Lymph node metastasis from soft tissue sarcoma in adults. Analysis of data from a prospective database of 1772 sarcoma patients

Is there a role for sentinel lymph node biopsy in the management of sarcoma?

Is there a role for sentinel lymph node (SLN) biopsy in the management of sarcoma? Sentinel node biopsy has dramatically changed the management of melanoma and breast cancer, helping surgeons avoid radical lymphadenectomies in node negative patients who would previously have undergone a more morbid operation with little benefit, or remained pathologically unstaged. Many investigators have explored the use of lymphatic mapping for malignancies other than breast cancer or melanoma. Lymphatic mapping and sentinel node biopsy has not been investigated in the management of sarcomas, which is not surprising given that the majority of sarcomas spread by local extension or hematogenously. Regional lymph node metastases are rare; developing in about 3-10% of patients with localized disease. However, among certain subtypes of high-grade sarcomas there is a propensity for regional lymph node metastases. These include rhabdomyosarcoma, epithelioid sarcoma, clear cell sarcoma, synovial sarcoma, and vascular sarcomas. It is in these particular subtypes that there may be a benefit to SLN biopsy.

Incidence of lymph node and ovarian metastases in leiomyosarcoma of the uterus

OBJECTIVE

The purpose of this study was to determine the incidence of lymph node and ovarian metastases in newly diagnosed uterine leiomyosarcoma (LMS), and to describe possible predictive factors.

METHODS

We used our prospectively acquired databases to identify 275 consecutive patients with uterine LMS treated from 7/82 to 12/01. Patients were included if there was clear documentation of lymph nodes and/or ovarian tissue in the pathologic reports. Clinical data were extracted from electronic medical records. Statistical analysis using the Fisher exact test was used to determine prognostic factors.

RESULTS

There were 108 patients (39.2%) identified in whom an oophorectomy and 37 patients (13.5%) in whom lymph node sampling was performed as part of the initial surgical management of uterine LMS. Bilateral oophorectomy was performed in 102 (94.4%) of the 108 patients. The median numbers of pelvic, para-aortic, and total lymph nodes acquired were 5 (range, 1-27), 3 (range, 1-9), and 6 (range, 1-34), respectively. Ovarian metastases were found in 4 (3.9%) out of 108 patients. Two (2.8%) of the 71 patients with disease confined to the uterus and/or cervix (stage I/II) and 2 (5.4%) of the 37 patients with gross extrauterine disease had ovarian metastases (P = 0.43). Positive lymph nodes were seen in 3 (8.1%) of 37 patients. No patients with stage I/II disease had positive lymph nodes (P = 0.015). None of the factors analyzed predicted for metastases to the ovary. Only the presence or absence of gross extrauterine disease correlated with lymph node metastasis. In addition, all three of these cases had clinically suspicious (enlarged) lymph nodes.

CONCLUSIONS

The incidence of ovarian and lymph node metastases in uterine LMS is very low and is most commonly associated with extrauterine disease. Lymph node dissection for uterine LMS should be reserved for patients with clinically suspicious nodes.

Radiation therapy for soft tissue sarcoma

Sarcomas are relatively uncommon tumors of mesenchymal origin. They may arise anywhere within the musculoskeletal system and are typically classified by clinical behavior into benign, borderline, or malignant. This article focuses primarily on the role of radiation for malignant soft tissue sarcoma and selected borderline tumors.

Combined-modality treatment of localized soft tissue sarcomas of the extremities

Over the past 20 years, considerable progress has been made in the treatment of patients with extremity soft tissue sarcomas. There has been a migration away from amputation toward treatment by excision plus radiation for most patients with localized tumors. Decisions about the optimal use and sequencing of surgery and radiation remain complex. Whereas it is clear that local control is probably not impacted significantly by the treatment sequence, rates of wound complication, fibrosis, and edema are affected by the treatment sequence. In addition, recent single-institution reports indicate that some carefully selected patients can be treated by surgery alone. The recent data evaluating treatment by surgery alone and treatment sequencing variables do not lead to a situation in which clear, uniform recommendations for treatment can be made for many patients with extremity soft tissue sarcomas. Indeed, treatment planning for patients with extremity soft tissue sarcoma in the new millennium is infinitely more complex than it was in the era when amputation was the primary treatment for these patients. Considerable clinical experience and multidisciplinary input are required for optimal treatment planning for these patients. Future research should be directed at refining the indications for specific therapies, reducing the toxicities of local therapies, and developing more effective systemic therapies.

Extra-nodal lymphoma presenting as a mimic of soft-tissue sarcoma

BACKGROUND

A variety of soft-tissue tumours result in soft-tissue masses, which are all differential diagnoses of soft-tissue sarcomas. A rare cause is extra-nodal lymphoma which, unlike a soft-tissue sarcoma which it mimics, should not be excised, but rather treated by chemotherapy and/or radiotherapy. The aim of the present study was to identify clinical, radiological, biopsy and management features of lymphoma when presenting as a soft-tissue mass.

METHODS

A review of 17 cases of soft-tissue lymphoma presenting as a soft-tissue mass from a total database of 295 soft-tissue tumours was undertaken. Lymphomas arising in cervical, axillary and inguinal nodes were excluded.

RESULTS

All patients presented with a soft-tissue mass but none had the symptoms of lymphoma. Computed tomography scanning identified seven (54%) of 13 with regional lymphadenopathy, six (46%) of 13 with encasement of major vascular structures and three with invasion across major soft-tissue boundaries. Core biopsy established a diagnosis in 13 patients (sensitivity 93%). All patients were treated with either chemotherapy and/or radiotherapy and all are alive with a mean follow up of 19 months. None underwent major resectional surgery.

CONCLUSION

The present series highlights a rare subgroup of patients with extra-nodal soft-tissue lymphoma mimicking soft-tissue sarcoma. Core biopsy is accurate in their diagnosis. Computed tomography scanning may show features suggesting the diagnosis.

Management of malignant gastrointestinal stromal tumours

Gastrointestinal stromal tumours (GISTs) are the most common form of mesenchymal tumour of the gastrointestinal tract. Clinically, they range from small indolent tumours curable with surgery alone to aggressive cancers. Making a distinction between an indolent and a malignant GIST is unreliable with conventional histopathological techniques. The presence of metastases at the time of diagnosis confirms malignancy, but all GISTs should be regarded as having malignant potential. GISTs characteristically express the KIT protein, a transmembrane tyrosine kinase receptor for stem-cell factor. Most GISTs have a mutation in the KIT proto-oncogene that translates into a gain-of-function constitutive activation of the KIT kinase. KIT activation seems to be an early tumour-promoting event in pathogenesis. Commonly, malignant GISTs show high-level primary resistance to conventional chemotherapy. Imatinib mesylate is an orally administered selective inhibitor of certain tyrosine kinases including KIT. Most patients with advanced malignant GISTs achieve clinical benefit and significant antitumour responses with imatinib mesylate. Responses have been durable, and most patients tolerate the drug well at clinically effective doses. Imatinib mesylate is the first effective systemic therapy for advanced GIST.

Clinical presentation of gastrointestinal stromal tumors and treatment of operable disease

Gastrointestinal stromal tumors (GISTs) are generally found in the stomach or small intestine and less commonly in the colon, rectum or an intra-abdominal site. The patients symptoms on presentation are most commonly gastrointestinal bleeding. Surgery remains the standard treatment for nonmetastatic GISTs, but rates of disease recurrence are significant--5% in primary disease and 90% in locally advanced disease. Five-year survival following surgical resection varies between 35% and 65% on the basis of several published studies. Clinical knowledge of the prognosis of patients with GISTs remains rather limited--small tumor size, low-grade mitotic index and stomach location are factors associated with a more favorable prognosis.

Cutaneous angiosarcoma complicating morbid obesity

Herein, we report a case of cutaneous angiosarcoma in a 35-year-old, morbidly obese woman. The tumor arose in the most dependent portion of the lower abdominal panniculus and showed typical changes of chronic lymphedema. The patient underwent a radical resection of her lower abdominal wall panniculus, which showed a multicentric, high-grade angiosarcoma with bilateral superficial inguinal lymph node metastases. Histologically, conventional vasoformative areas were admixed with poorly differentiated sheets of spindle and epithelioid cells. Factor VIII was focally positive (membranous), whereas CD31 showed robust, diffuse positivity (membranous and cytoplasmic). The initial margins of resection were negative, and no follow-up radiation or chemotherapy was given. Following a recurrence at the previous excision site, the patient died 7 months after the surgery. Postmortem examination revealed a widely metastatic tumor that involved multiple organ systems. We believe this is the second report of cutaneous angiosarcoma occurring in a chronically lymphedematous abdominal panniculus due to morbid obesity.

Fine-needle aspiration biopsy of metastatic soft-tissue sarcomas to lymph nodes

This paper highlights the role of fine-needle aspiration cytology (FNAC) in 15 cases of metastatic soft-tissue sarcomas involving lymph nodes. Histopathology reports of the primary tumor were available in all cases. Histological diagnoses correlated well with the cytology reports. The most common type of sarcoma to involve the lymph node was embryonal rhabdomyosarcoma (6 cases), followed by synovial sarcoma (2 cases), leiomyosarcoma (2 cases), malignant fibrous histiocytoma (2 cases), fibrosarcoma (1 case), malignant peripheral nerve sheath tumor (1 case), and rhabdomyosarcoma (1 case). FNAC was thus helpful in the early diagnosis, proper staging, and management. Importantly, it obviated a lymph node biopsy in the majority of cases.

Primary Gastrointestinal Sarcomas

Gastrointestinal (GI) sarcomas are uncommon tumors with the majority of previous studies performed over long time intervals. The purpose of this review is to analyze our single-institution experience with primary GI sarcomas. Between January 1990 and June 1998,27 adult patients with primary GI sarcomas were identified in the tumor registry at the University Hospital, School of Medicine of University of Alabama at Birmingham and retrospectively reviewed. Patient, tumor, and treatment factors as well as expression of p53 and Ki-67 were analyzed with overall survival as the main outcome variable. Statistical analysis was performed by log rank test and Cox regression. Significance was defined as P < 0.05. Median age was 55 years (range 36–80 years). The stomach was the most common site of presentation (59%) followed by small bowel (29%). The average tumor size was 15 cm (range 2–46 cm). A complete resection was performed in 22 patients (81.5%). Fifteen tumors were classified as low grade (55.5%). Actuarial 3-year survival was 43 per cent with a median follow-up of 16 months. Overexpression of p53 and Ki-67 correlated with a trend to decreased survival but it did not reach statistical significance. Multivariate analysis found incomplete resection ( P = 0.00001) and high grade ( P = 0.003) to be significant negative prognostic factors. We conclude that GI sarcomas tend to be large tumors with most arising in the stomach and proximal GI tract. Complete surgical resection is associated with prolonged survival and despite the large size of these tumors should be attempted whenever possible.

Routine bone scintigraphy in primary staging of soft tissue sarcoma; Is it worthwhile?

BACKGROUND

The incidence of bone metastases in soft tissue sarcoma (STS) patients seems to be low but has not been studied separately. In this study, the authors aimed to determine the value of routine radionuclide bone scanning in preoperative staging of STS patients.

METHODS

Preoperative bone scans were evaluated retrospectively in 109 consecutive patients (median age, 44 years; range, 1-86) with intermediate or high grade STS. Scans were scored in 3 categories: 1, metastases very likely; 2, equivocal; and 3, normal or benign lesions.

RESULTS

Category 1 scans were found in 8 of 109 patients (7%); in all 8 patients, bone metastases were confirmed. Six of these eight patients reported pain, and all had additional lung, bone marrow, or lymph node metastases. The highest rate (17%) was found in the rhabdomyosarcoma subgroup (n = 18). Category 2 (equivocal) scans were present in 12 of 109 patients (11%), in all of which bone metastases were excluded through additional investigations. Category 3 (normal) scans were found in 81%. Bone metastases were at least as frequent as lung metastases (4%) and were the single site of systemic disease in 4%. The rate of bone metastases was 55% in patients with bone pain versus 2% in patients without pain.

CONCLUSIONS

Bone metastases in primary STS patients are rare (7%) yet in this study at least as frequent as lung metastases. The low rate in asymptomatic patients versus the high rate in symptomatic patients supports the use of bone scanning in symptomatic patients only. The yield of routine bone scanning is low.

Soft-tissue sarcomas

Sarcomas of the soft tissues are challenging lesions for the surgical oncologist. Careful planning must be done at all stages of diagnosis and treatment, because every sarcoma is unique with respect to histologic type, size, and location. Pretreatment discussions in a multidisciplinary format are useful to ensure appropriate and effective management of these tumors.

Epithelioid sarcoma: the clinicopathological complexities of this rare soft tissue sarcoma

BACKGROUND

Epithelioid sarcoma is a rare high grade soft tissue sarcoma with a known propensity for locoregional recurrence. The literature is limited on other characteristics such as frequency of multifocal disease at presentation, the relationship of presenting size of the primary lesion to prognosis, and the ability of current staging systems to predict prognosis.

METHODS

Review of the Royal Marsden National Health Service Trust (RMH) experience of 37 cases over 21 years.

RESULTS

The mean age was 29 years, with male predominance (2.7:1), and distal limb locations were most common (56%). Five patients presented with multifocal local disease. Median follow-up was 88 months in the 19 patients still alive. The 5- and 10-year actuarial overall survival was 70% and 42%, respectively. Tumors deep to the investing fascia had a worse prognosis than superficial tumors. Regional metastasis events were also associated with significantly worse overall survival. Local recurrence, size of 5 cm or larger, and regional metastasis events were predictive of worse distant metastasis-free survival. Tumor size (<5 cm vs. > or =5 cm), local recurrence events, sex, and site were not significant predictors of survival. The American Joint Committee on Cancer/International Union Against Cancer staging systems and the recently proposed RMH staging system of the Royal Marsden National Health Service Trust provided poor differentiation of prognosis in epithelioid sarcoma. The 5-year actuarial local recurrence rate was 35%. The 5-year actuarial regional nodal metastasis rate was 23%. The actuarial 5-year distant metastasis rate was 40%, with pleuropulmonary metastases the most common site of metastatic disease, and 35% of pleuropulmonary metastases presented with pleural effusion. Median post-distant metastasis survival was 8 months.

CONCLUSIONS

Epithelioid sarcoma has unusual clinical behavior compared with other high grade soft tissue sarcoma. It has a propensity for multifocal disease at presentation, local recurrence, regional metastasis, and particularly poor prognosis after regional or distant metastatic disease. Size and stage according to the American Joint Committee on Cancer/International Union Against Cancer are unreliable predictors of prognosis.

Role of surgery in the management of postmastectomy extremity angiosarcoma (Stewart-Treves syndrome)

Stewart-Treves syndrome (STS) is the rare occurrence of angiosarcoma in a setting of postmastectomy upper extremity lymphedema. A collective comparison of outcomes following various initial treatment options in STS has not previously been reported. We reviewed 160 cases of STS reported in the literature since 1966. We analyzed the relationship between initial treatment and survival in all 92 of these patients for whom detailed treatment and outcome data had been reported. There was no significant difference in survival comparing those initially treated with wide excision (n = 16) and those treated with amputation (n = 45) (P = 0.40). Even in the setting of initial surgical treatment, overall long-term survival was poor (<40%). There have been even fewer long-term survivors among those treated initially with regional chemotherapy (n = 7) or radiation therapy (n = 24). An update on STS and a discussion of recent advances in the understanding of its molecular pathogenesis that may result in future treatment improvements are presented.

Two hundred gastrointestinal stromal tumors: recurrence patterns and prognostic factors for survival

OBJECTIVE

To analyze the outcome of 200 patients with gastrointestinal stromal tumor (GIST) who were treated at a single institution and followed up prospectively.

SUMMARY BACKGROUND DATA

A GIST is a visceral sarcoma that arises from the gastrointestinal tract. Surgical resection is the mainstay of treatment because adjuvant therapy is unproven.

METHODS

Two hundred patients with malignant GIST were admitted and treated at Memorial Hospital during the past 16 years. Patient, tumor, and treatment variables were analyzed to identify patterns of tumor recurrence and factors that predict survival.

RESULTS

Of the 200 patients, 46% had primary disease without metastasis, 47% had metastasis, and 7% had isolated local recurrence. In patients with primary disease who underwent complete resection of gross disease (n = 80), the 5-year actuarial survival rate was 54%, and survival was predicted by tumor size but not microscopic margins of resection. Recurrence of disease after resection was predominantly intraabdominal and involved the original tumor site, peritoneum, and liver.

CONCLUSIONS

GISTs are uncommon sarcomas. Tumor size predicts disease-specific survival in patients with primary disease who undergo complete gross resection. Tumor recurrence tends to be intraabdominal. Investigational protocols are indicated to reduce the rate of recurrence after resection and to improve the outcome for patients with GIST.

Two hundred gastrointestinal stromal tumors: recurrence patterns and prognostic factors for survival

OBJECTIVE

To analyze the outcome of 200 patients with gastrointestinal stromal tumor (GIST) who were treated at a single institution and followed up prospectively.

SUMMARY BACKGROUND DATA

A GIST is a visceral sarcoma that arises from the gastrointestinal tract. Surgical resection is the mainstay of treatment because adjuvant therapy is unproven.

METHODS

Two hundred patients with malignant GIST were admitted and treated at Memorial Hospital during the past 16 years. Patient, tumor, and treatment variables were analyzed to identify patterns of tumor recurrence and factors that predict survival.

RESULTS

Of the 200 patients, 46% had primary disease without metastasis, 47% had metastasis, and 7% had isolated local recurrence. In patients with primary disease who underwent complete resection of gross disease (n = 80), the 5-year actuarial survival rate was 54%, and survival was predicted by tumor size but not microscopic margins of resection. Recurrence of disease after resection was predominantly intraabdominal and involved the original tumor site, peritoneum, and liver.

CONCLUSIONS

GISTs are uncommon sarcomas. Tumor size predicts disease-specific survival in patients with primary disease who undergo complete gross resection. Tumor recurrence tends to be intraabdominal. Investigational protocols are indicated to reduce the rate of recurrence after resection and to improve the outcome for patients with GIST.

Two hundred gastrointestinal stromal tumors: recurrence patterns and prognostic factors for survival

OBJECTIVE

To analyze the outcome of 200 patients with gastrointestinal stromal tumor (GIST) who were treated at a single institution and followed up prospectively.

SUMMARY BACKGROUND DATA

A GIST is a visceral sarcoma that arises from the gastrointestinal tract. Surgical resection is the mainstay of treatment because adjuvant therapy is unproven.

METHODS

Two hundred patients with malignant GIST were admitted and treated at Memorial Hospital during the past 16 years. Patient, tumor, and treatment variables were analyzed to identify patterns of tumor recurrence and factors that predict survival.

RESULTS

Of the 200 patients, 46% had primary disease without metastasis, 47% had metastasis, and 7% had isolated local recurrence. In patients with primary disease who underwent complete resection of gross disease (n = 80), the 5-year actuarial survival rate was 54%, and survival was predicted by tumor size but not microscopic margins of resection. Recurrence of disease after resection was predominantly intraabdominal and involved the original tumor site, peritoneum, and liver.

CONCLUSIONS

GISTs are uncommon sarcomas. Tumor size predicts disease-specific survival in patients with primary disease who undergo complete gross resection. Tumor recurrence tends to be intraabdominal. Investigational protocols are indicated to reduce the rate of recurrence after resection and to improve the outcome for patients with GIST.

Angiosarcoma of the scalp

An 82-year-old woman was seen at our Dermatology Department for a plaque on the right parietal scalp that had recently increased in size, and bled. The lesion had been present for 3 months. The patient had a previous diagnosis of chronic bronchitis, noninsulin-dependent diabetes mellitus, and hypertension, but no previous history of cancer. Physical examination revealed a 7 x 10 cm plaque, composed of a central necrotic and bleeding surface, surrounded by small purple-red satellite nodules. A biopsy showed an ill-defined infiltrative intradermal mass with a pattern of hypercellular sheets of large cells alternating with areas of dilated, irregular, blood-filled channels, dissecting the collagen bundles. The endothelial cells lining these channels were plump and pleomorphic, surrounded by other spindle-shaped cells with pleomorphic and atypical nuclei. The diagnosis of angiosarcoma was made, and the patient was sent to an oncology center for further evaluation and treatment, where a computed tomography head scan was taken revealing no erosion of the skull. The patient refused surgery, so radiotherapy was proposed. One month later, she developed lymph node enlargement of the left anterior cervical nodes. A needle aspiration biopsy was consistent with sarcoma. Two weeks later, she was started on palliative radiotherapy: a programmed dose of 4500 cGy was proposed of which she only received 3000 cGy because of treatment withdrawal and loss to follow-up. During this time, she showed partial initial response, but despite treatment the disease relentlessly progressed, with hemorrhage and severe pain being the most striking features.

Soft tissue sarcoma of the hand

A retrospective review of our institute's tumor registry from January 1972 to January 1996 revealed 24 patients with a diagnosis of primary soft tissue sarcoma of the hand, from a total of 570 extremity soft tissue sarcomas (4%). The most frequent histologic type was malignant fibrous histiocytoma, which occurred in 9 (38%) of the 24 patients. The second most common histologic type was epithelioid sarcoma, which occurred in 6 (25%) patients. There was a statistically significant difference in the rate of local recurrence based on the type of treatment in which amputation was superior to the other forms of treatment. There was no statistically significant difference in the rate of distant failures between treatment groups. The estimated cumulative 5- and 10-year overall survival rates for all patients were 59% and 53%, respectively. Stage II patients had estimated cumulative 5- and 10-year survival rates of 68% and 59%, respectively. Stage III patients had a cumulative 5-year survival rate of 20%. Factors that were statistically significant in predicting survival were the size of the primary tumor, with tumors smaller than 5 cm having a better prognosis, and stage of the tumor at presentation, with stage I and II tumors having the highest survival rate. In selected patients with a primary hand sarcoma, aggressive limb-sparing surgery with adjuvant therapy offered equivalent survival compared with amputation.

Effective follow-up strategies in soft tissue sarcoma

The value of surveillance for detection of recurrences in patients with soft tissue sarcoma (STS) after definitive surgical resection of the primary tumor is based on the premise that early recognition and treatment of local or distant recurrence can prolong survival. Surveillance strategies should meet the criteria of easy implementation, accuracy, and cost-effectiveness. Although guidelines have been proposed for follow-up of patients with STS, there are few data in the medical literature on the effectiveness of these recommendations. We reviewed the effectiveness of a surveillance program for primary extremity STS in an effort to provide an evidence-based rationale for follow-up of STS. We concluded that clinical assessment of patient symptoms, chest X-ray imaging, and physical examination are effective strategies for follow-up of extremity STS. Chest X-ray imaging also appears to be cost-effective, at least for high-grade extremity STS. Imaging of the primary extremity site by computed tomography (CT) scan or magnetic resonance imaging (MRI) on an annual basis and routine laboratory blood tests were ineffective strategies for recurrence detection. However, certain patient characteristics such as body habitus, previous radiation therapy, and location of the primary tumor site may require the use of CT scans and MRI for adequate clinical assessment. The role of specific surveillance strategies for recurrence detection for sarcomas of the trunk, head and neck, retroperitoneum, and viscera has yet to be defined.

Adult soft tissue sarcoma

BACKGROUND

Soft tissue sarcomas (STS) are a group of anatomically and histologically diverse tumours. They account for about 1% of adult malignancies, and about 50% of patients diagnosed with sarcoma eventually die of the disease. These tumours are grouped together because of shared biological characteristics and treatment responses.

METHODS

A review of the key literature on STS was undertaken, complemented by data taken from the prospectively accumulated database of 3442 patients treated for STS at Memorial Sloan-Kettering Cancer Center (MSKCC) from July 1982 to December 1997.

RESULTS

Despite advances in knowledge of the molecular genetics of STS, the aetiology in most cases remains elusive. Management has been gradually refined over the last two decades. Core biopsy usually provides enough material for diagnosis. Computed tomography and magnetic resonance imaging provide a similar amount of information, which is usually adequate for surgical planning. Amputation as standard treatment for extremity lesions has been replaced by limb-sparing surgery in about 90% of patients. The role of adjuvant radiation has been further defined: it has been shown to be unnecessary for completely excised tumours less than 5 cm in diameter, but effective in decreasing local recurrence for others. Adjuvant chemotherapy has been controversial for many years. Recent meta-analysis of randomized trial results has found a small reduction in local and distant relapse, and a trend to better overall survival. Recurrent or metastatic disease should be completely excised if possible.

CONCLUSIONS

Soft tissue sarcoma requires multidisciplinary care tailored to the individual patient and tumour for optimal results.

Multifocal Angiosarcoma of the Scalp: A Case Report and Review of the Literature

Multifocal angiosarcoma of the scalp is uncommon. Its risk factors include a history of radiotherapy and possibly sun exposure. Angiosarcoma is an aggressive tumor with a high propensity for both local recurrence and distant metastasis. Overall, the prognosis is poor. The size of the lesion is an important prognostic factor. Treatment modalities include surgery with wide margins (with or without adjuvant therapy) and multidrug chemotherapy, followed by radiotherapy. The local failure rate is high.

Angiosarcoma of the bladder: a review

OBJECTIVES

To present a new case of angiosarcoma of the bladder, review 9 other previously reported cases, and discuss the unique features of our case with regard to presentation, treatment, and clinical course of patients with this exceedingly rare tumor. The utility of multimodality therapy is emphasized.

METHODS

We report the latest case of angiosarcoma of the bladder. We also reviewed the world literature (MEDLINE) and discovered 9 previously reported cases of angiosarcoma of the bladder. Presentation, treatment, and clinical course were analyzed.

RESULTS

Of the 10 cases, 2 were considered to have arisen from a preexisting bladder hemangioma. Two patients had a history of prior gynecologic malignancies treated with external beam radiotherapy, with subsequent sarcoma formation within the past treatment field. Two other patients presented with skin lesions that predated the discovery of bladder lesions. Only 4 patients presented with primary bladder lesions and no preexisting disease or previous carcinogenic exposure (except for tobacco use). Hematuria was a universal presentation, and treatment was widely variant. Of the 10 patients, 8 died during a period of follow-up of 23 months. Five patients died of tumor-related causes. Mean survival of these 5 was 10.6 months. The 2 most recent patients (including ours) were alive and tumor free at 8 and 32 months, respectively. Both of these patients underwent multimodality oncologic approaches as part of their treatment regimen.

CONCLUSIONS

Angiosarcoma of the bladder is exceedingly rare and usually fatal. Prognosis is poorer than that of angiosarcomas in more traditional sites. Regional lymph nodes are typically spared, but local recurrence with eventual distant metastasis is the rule. Optimal therapy has not been determined, but it most likely should involve a multimodal approach combining radical surgery with chemotherapy and radiotherapy.

Distant skin and soft tissue metastases from sarcomas

BACKGROUND AND OBJECTIVES

This small series documents the clinical and pathological features and the rarity of distant skin and soft tissue metastases from sarcomas.

MATERIALS AND METHODS

Five cases of sarcomas from different anatomical locations that had metastasized to skin and subcutaneous soft tissue were identified in three women and two men. The age range was 41-77 years. The primary tumors had wide excisions, followed by either radiation or chemotherapy, or both. The histological types were epithelioid sarcoma, malignant fibrous histiocytoma, malignant peripheral nerve sheath tumor, and leiomyosarcoma. Metastases occurred to the skin and soft tissue of the chest wall, leg, breast, and abdominal wall. The diagnosis was established by excision biopsies for three cases and by needle biopsy and fine-needle aspiration for two cases.

RESULTS

Three patients died within 7 months of the diagnosis of soft tissue metastases that were always histologically high grade and never solitary. One patient is alive with lung metastasis discovered 17 months after excision of primary. Lung metastases occurred either simultaneously or within a short period after soft tissue metastases.

CONCLUSION

Distant skin and soft tissue metastases from sarcomas are very rare and often occur as a terminal event.

Combined modality treatment of extremity soft tissue sarcomas

BACKGROUND

Substantial progress has been made in the multimodality treatment of soft tissue sarcoma over the past decade. This review summarizes current state-of-the-art management for patients with extremity soft tissue sarcoma.

METHODS

Literature-based review of combined modality treatment of extremity sarcoma.

RESULTS

The revised staging system of the International Union Against Cancer/American Joint Committee on Cancer (UICC/AJCC) for this disease is described and a practical approach to diagnosis, evaluation, management, and follow-up of patients is presented. Brief summaries of the roles of surgical therapy, pre- and postoperative radiotherapy, pre- and postoperative chemotherapy, and concurrent chemoradiation in the management of extremity soft tissue sarcoma are provided, with summaries of the available data from randomized prospective trials. The data referenced and discussed herein provide the basis for stage-specific treatment recommendations for the management of patients with localized soft tissue sarcoma of the extremities.

CONCLUSIONS

Soft tissue sarcoma remains a challenging disease to treat. The majority of patients require an integrated combined modality approach. Future research should be directed at developing more effective systemic therapies and minimizing the toxicities of local therapies.

Primary angiosarcoma of the breast

We report a case of a 44-year-old woman with primary angiosarcoma of the left breast. An excisional biopsy was performed initially and the mass was interpreted as angiosarcoma. The pre-operative staging provided no evidence of metastasis. The patient then underwent a left mastectomy with the placement of an expandable prosthesis. For 3 months the prosthesis was progressively expanded to the desired size and it was then replaced with a permanent one. Primary angiosarcoma of the breast is a rare and often misdiagnosed disease. Treatment options are numerous and conflicting. The diagnostic approach and treatment options from the literature are presented and discussed.

Survival in primary soft tissue sarcoma of the extremities and trunk

BACKGROUND

Soft tissue sarcomas (STS) of the extremities are rare. The purpose of this study was to identify prognostic risk factors associated with survival in patients with primary extremity and truncal STS.

METHODS

Patient, tumor, and pathologic data from 149 consecutive patients with localized primary STS of the extremities and trunk were analyzed using Kaplan-Meier and Cox regression techniques to identify univariate and multivariate risk factors. A subgroup analysis was performed to compare factors predictive of survival in patients who received treatment before (n = 50) and after (n = 99) treatment was standardized in 1988.

RESULTS

The 5-year survival rate was 76.5% with an average follow-up of 6 years. Local recurrence occurred in 23% of all patients, 40% before 1988 and 15% after 1988 (P < 0.0001). Risk factors associated with survival included resection quality (R0 vs. R1; P < 0.0001), era of operation (P = 0.002), local recurrence (P < 0.001), UICC stage (P < 0.0001), tumor size (P < 0.001), tumor depth (P = 0.002), regional lymph nodes (P < 0.0001), and histology (P < 0.0001). Multivariate analysis revealed that tumor size, tumor depth, and resection quality were independent risk factors of survival.

CONCLUSIONS

These results indicate that management of STS in a specialized institution improves overall survival. Resection quality is the most important risk factor of survival. Therefore, effort should be made during primary treatment of STS to achieve wide, tumor-free resection margins.

Epithelioid sarcoma: clinical behavior and prognostic factors of survival

BACKGROUND

Epithelioid sarcoma is a rare histologic subtype of sarcoma. The clinical behavior and prognostic factors influencing survival in this disease are examined.

METHODS

A review of clinicopathologic features of patients with epithelioid sarcoma prospectively followed between July 1982 and July 1995 at Memorial Sloan-Kettering Cancer Center was performed. Kaplan-Meier and log-rank analysis were used.

RESULTS

Eleven men (69%) and five women (31%) were treated during this period. Mean age at diagnosis was 33 years, and length of symptoms before diagnosis was 18 months. Tumors presented in the trunk in 44% of patients, the lower extremity in 31%, and the upper extremity in 25%. Median follow-up time was 45 months. At least one local recurrence was experienced by 69% of patients. Metastases to regional lymph nodes during the course of the disease developed in 44% of patients and to the lungs in 44%. Median survival was 88.8 months, with a 66% 5-year survival rate. Pulmonary metastasis was correlated with decreased survival.

CONCLUSIONS

A delay in diagnosis of epithelioid sarcoma is common. Epithelioid sarcoma differs from other sarcoma subtypes in propensity for nodal spread and local recurrence. Careful follow-up evaluating local recurrence, nodal spread, and pulmonary metastases is warranted.

Immunohistochemical and clinical evaluation of cathepsin expression in soft tissue sarcomas

Lysosomal proteases are known to enhance the spread of epithelial tumour cells, but little is known of the possible role of proteases in the growth of soft tissue sarcomas (STS). We investigated the expression of cathepsins D, B, S, H, L and procathepsin L in frozen sections of 34 STS from 34 patients by immunohistochemistry (IHC). Cathepsins D, B and H were relatively highly expressed in STS (77-91%). The expression rate of cathepsins S and L and of procathepsin L was lower (40-66%). Cathepsin S and L expression showed a moderate (P = 0.078 and P = 0.019) and procathepsin L a strong (P = 0.00001) correlation with the survival rate of STS patients. Cathepsin S expression is also correlated with the local recurrence rate (P < 0.01). Lysosomal proteases may play a role in STS progression, and cathepsin expression may also have significance as a prognostic factor in STS.

Primary hemangiosarcoma of the mediastinum

A case of a 44-year-old female who had an intrathoracic mass that was found to be a hemangiosarcoma of the anterior mediastinum is reported. Radical surgical incision through a right anterior thoracotomy was performed, followed by post-operative radiotherapy. Since this is a rare tumor at this location, the clinical and radiological findings, the histopathological appearances and its therapeutic management are discussed. Radiologists, surgeons and oncologists should in the differential diagnosis of a mediastinal mass include that of a tumor of vascular origin, even if it is rare. Radical excision followed by post-operative radiotherapy, especially in cases where the tumor has been partially excised, is the treatment of choice.

Management of soft tissue sarcomas of the extremity in adults

Concepts of the current management of soft tissue sarcomas (STS) of the extremities in adults are presented. The role of surgery, radiation, and chemotherapy as well as the combination of these modalities are reviewed. The addition of radiation therapy to less than radical surgery has resulted in higher rates of limb preservation and acceptable local control. A multidisciplinary approach will help achieve optimal functional results with less morbidity. Treatment of systemic disease is poor with current methods. Innovative uses of existing systemic modalities or new modalities will be important to improve results in the management of these difficult tumors.

Soft tissue sarcoma of the extremity. Limb salvage after failure of combined conservative therapy

PURPOSE

To assess the results of salvage therapy using surgery alone or surgery and re-irradiation for patients with locally recurrent extremity soft tissue sarcoma (STS) following conservative surgery and radiotherapy.

MATERIALS AND METHODS

25 patients with locally recurrent STS after conservative surgery and irradiation were assessed between 1990 and 1995. Two patients with concurrent systemic relapse were treated palliatively. Seven patients were not candidates for conservative re-excision and underwent amputation, 11 patients underwent conservative resection without irradiation. Seven of these patients relapsed, and five went on to receive combined conservative surgery and re-irradiation. A further five patients initially received combined retreatment, for a total of ten patients treated with combined conservative surgery and re-irradiation. Six of these ten patients were treated with brachytherapy alone, one with brachytherapy and external beam therapy, and three with external beam therapy alone. The median retreatment dose was 49.5 Gy (range 35-65 Gy), and the median cumulative soft tissue dose was 100 Gy (range 93-120 Gy).

RESULTS

The median follow-up from the most recent treatment is 24 months (range 7-42 months). At the last follow-up 14 patients are alive and disease free; two are alive with local disease and four with systemic disease, and five are dead of disease. Overall local control is 19/23 (91%). The local control for patients treated with conservative excision without irradiation is 4/11 (36%) and for conservative excision with re-irradiation 10/10 (100%). Six (60%) of these patients experienced significant post-irradiation would-healing complications, but three have recovered fully. Functional scores for the entire treated group are significantly lower after treatment, as are those for patients undergoing combined surgery and re-irradiation, but 70% of those treated with conservative surgery and re-irradiation and a good or excellent post-treatment functional score.

CONCLUSIONS

Combined conservative surgery and re-irradiation provided superior local control to local re-excision alone and a functional outcome superior to amputation. Combined treatment with re-irradiation should be considered the primary salvage therapy for patients who fail combined therapy and who are suitable for conservative re-excision. Systemic relapse is a significant problem, and optimal therapy should minimize the risk of local relapse after the initial therapy. Eighteen patients (72%) had a history of intralesional excision as their initial intervention, and suggests that inappropriate initial management is a risk factor for relapse after combined conservative therapy. Improvements in therapy must include the appropriate education of the primary care physicians.

Soft tissue sarcomas

Soft tissue sarcomas are relatively rare tumors with an annual incidence of 5000 to 6000 in the United States. The primary therapy is surgical resection with an adequate margin of normal tissue. For patients at high risk local control is improved with postoperative adjuvant radiation. Local recurrence rates vary depending on the anatomic site. In extremity lesions one third of patients will have locally recurrent disease with a median disease-free interval of 18 months. Treatment results for extremity local recurrence may approach those for primary disease. Isolated pulmonary metastases may be resected with 20% to 30% 3-year survival rates. Patients with sarcomas in other sites present similar but more difficult problems in terms of local control and management of disseminated disease. Patients with unresectable pulmonary metastases or extrapulmonary metastatic sarcoma have a uniformly poor prognosis and are best treated with systemic chemotherapy.

Soft tissue sarcoma of the extremity

A retrospective review of 33 cases of soft tissue sarcoma of the extremity presenting over a 10 year period was undertaken. The history, patterns of referral, diagnostic investigations, procedures undertaken and outcomes were studied. We found there was a frequent delay in diagnosis and sometimes misinterpretation of biopsy specimens. Patients were seen by a variety of specialists from disciplines such as general surgery, plastic surgery, orthopaedic surgery and rheumatology. Considerable progress has been made in the treatment of soft tissue sarcomas, often allowing local control of the tumour without amputation. We believe there should be early referral of patients having these tumours to a centre where a combined multidisciplinary approach can be undertaken.

Breast sarcoma

Primary sarcoma of the breast is a rare problem and accounts for less than 5% of all soft-tissue sarcomas and less than 1% of all breast malignancies. As experience with breast sarcoma has increased, the perceived differences with other soft-tissue sarcomas has decreased. Outcome is predicated upon histologic type, degree of differentiation, and tumor size. Recurrences are primarily local as an early event and distant to the lung somewhat later in the course of the disease.

Treatment of soft-tissue sarcomas of the hand

We studied the clinical features, radiographic and pathological findings, treatment, and results for twenty-three patients who had been managed for a soft-tissue sarcoma of the hand between 1982 and 1990. The ages of the patients ranged from sixteen to seventy-six years (median age, thirty-one years). The most common clinical finding was a small, painless soft-tissue mass. Twenty of the tumors were high-grade, and eighteen were less than five centimeters in diameter. The most common diagnosis was synovial sarcoma, which was identified in eight patients. Leiomyosarcoma, rhabdomyosarcoma, and malignant fibrous histiocytoma developed in three patients each; epithelioid sarcoma, in two patients; and angiosarcoma, liposarcoma, neuroectodermal tumor, and clear-cell sarcoma, in one patient each. Curative wide excision or amputation was attempted in twenty-two patients; the margins were positive for tumor cells in eight, and local recurrence was seen in nine. Of the twenty-three patients, fourteen had survived, without evidence of disease, after a median duration of follow-up of forty-nine months, and nine had died of disease. The median rate of survival did not differ significantly on the basis of the size or grade of the tumor or the use of adjuvant treatment. However, the rate of survival of the patients who had a soft-tissue sarcoma of the hand that was less than five centimeters in diameter was significantly lower (p = 0.0008) than that of 152 patients who had a similar tumor at another site in an extremity.(ABSTRACT TRUNCATED AT 250 WORDS)

Primary gastrointestinal sarcomas: analysis of prognostic variables

BACKGROUND

Primary gastrointestinal sarcomas are uncommon, and the clinicopathological determinants of survival remain unclear. In order to correlate clinical presentation, pathological assessment, and treatment with outcome, we have analyzed our institution's recent experience with these tumors.

METHODS

Records of adult patients admitted to our institution between July 1982 and December 1991 were reviewed.

RESULTS

During this period, 38 adult patients (> 16 years of age) were admitted to our institution with a primary gastrointestinal sarcoma. They accounted for 2% of all adult sarcoma admissions during that period. The study population was composed of 26 men and 12 women. Ages ranged from 29 to 82 years (mean 59). Disease was localized to the primary site in 30 patients (81%). The stomach was the most frequent site of disease (20 cases). The small bowel was affected in nine cases (five duodenum, four jejunum) and the large bowel in nine cases (two colon, seven rectum). Ninety-two percent of patients were symptomatic at presentation. A complete resection was performed in 27 cases, incomplete resection in seven cases, and biopsy only in the remaining three patients. Nine patients received doxorubicin-based chemotherapy. Leiomyosarcoma (n = 35) was the predominant histological diagnosis. Twenty-six tumors were classified as high grade (68%) and 12 as low grade (32%). Overall actuarial 5-year survival was 28% (median follow-up 26 months). Weight loss (p = 0.02) and pain at presentation (p = 0.05) were adverse prognostic factors. Histological grade (p = 0.0002), completeness/extent of surgical resection (p = 0.005), or small bowel primary site were significant determinants of overall survival. The resection of contiguous organs did not affect survival if the primary tumor was completely excised (p = 0.422). Age, race, sex, presentation (prior surgery), tumor size, or adjuvant therapy were not significant prognostic factors. Recurrence was noted in 44% after complete resection, and mean time to recurrence was 9 months (median 7, range < 1-37). Hepatic metastases (42%) and local recurrence (42%) were the predominant sites of initial failure. For patients with a complete resection, grade was the major prognostic determinant (5-year survival: high grade/complete resection 18% vs. low grade/complete resection 72%, p = 0.002).

CONCLUSION

The prognosis of gastrointestinal sarcomas is poor. Complete surgical excision is the optimal therapy. However, our results suggest that surgery alone is inadequate for high-grade tumors. We believe that these patients should be considered candidates for investigational adjuvant therapies.

Post-radiation primary intranodal leiomyosarcoma

An unusual case of post-radiation primary intranodal leiomyosarcoma of the cervical lymph node is presented. The patient was a 32-year-old white man who was treated in 1986 with hemiglossectomy and right neck dissection, followed by radiation therapy, for squamous cell carcinoma of the tongue. Six years later, he presented with an enlarged left cervical lymph node which on biopsy showed a high grade spindle cell malignant neoplasm. Immunohistochemistry and electron microscopic study verified the smooth muscle origin of the tumour. Extensive work-up for a second primary lesion was negative. Primary intranodal leiomyosarcoma is extremely rare. We briefly discuss the histological differential diagnosis of spindle cell lesions of lymph nodes, leiomyosarcoma of the vessel wall and radiation-associated sarcoma.

Diagnostic procedures and pretreatment evaluation of soft tissue sarcomas

The diagnosis and preoperative evaluation of patients with a suspected soft tissue sarcoma involve several important considerations to ensure optimal treatment outcomes. Biopsy techniques must involve the retrieval of adequate tissue to establish the histologic diagnosis and grade of the tumor without compromising the subsequent definitive surgical resection. CT or MRI techniques represent the gold standard to evaluate the local extent of disease which is necessary to ascertain surgical resectability and/or the need for radiation therapy. CT scanning of the lungs is mandated for all patients with sarcomas to evaluate for metastatic disease and, for patients with abdominal or retroperitoneal tumors, scanning of the liver should also be included. Accurate staging of these patients will help define overall survival.