Soft-tissue sarcoma of the head and neck after puberty

Malignant peripheral nerve sheath tumour of the maxilla

A 38-year-old man was diagnosed with malignant peripheral nerve sheath tumour of the maxilla. He was treated with total maxillectomy. Histopathological examination of the resected specimen revealed a close resection margin. The tumour was of high grade with an MIB-1 labelling index of almost 60%. At six weeks following the surgery, he developed local tumour relapse. The patient succumbed to the disease at five months from the time of diagnosis. The present report underlines the locally aggressive nature of malignant peripheral nerve sheath tumour of the maxilla which necessitates an early therapeutic intervention. A complete resection with clear margins is the most important prognostic factor for malignant peripheral nerve sheath tumour in the head and neck region. Adjuvant radiotherapy may be considered to improve the local control. Future research may demarcate the role of targeted therapy for patients with malignant peripheral nerve sheath tumour.

Malignant peripheral nerve sheath tumours of the infraorbital nerve: case report and literature review

Objective:

We report a case of malignant peripheral nerve sheath tumour seen in our department.

Method:

We present case reports and a review of the world literature concerning malignant peripheral nerve sheath tumour.

Results:

A 38-year-old Caucasian woman was diagnosed with malignant peripheral nerve sheath tumour of the infraorbital nerve. She underwent a wide enbloc resection followed by a course of radiotherapy. A five-year post-operative magnetic resonance imaging scan revealed no evidence of recurrence.

Conclusion:

Malignant peripheral nerve sheath tumours are rare in the head and neck. An awareness of their occurrence is important for early diagnosis. Management involves: accurate histological diagnosis; radiological imaging to define tumour extent and plan resection; wide surgical excision with histologically negative margins; reconstruction of the tissue defect; and post-operative radiotherapy.

Malignant peripheral nerve sheath tumour of the paranasal sinuses and the anterior skull base

BACKGROUND

Malignant peripheral nerve sheath tumours (MPNSTs) are highly aggressive neoplasms with a marked propensity for local recurrence and metastatic spread. The management of MPNSTs continues to challenge pathologists and surgeons. As MPNSTs of the paranasal sinuses and the skull base are rare, prognostic factors and treatment modalities have not been consistently identified.

PATIENTS AND METHODS

We present a case of MPNST of the anterior skull base and provide an overview of all MPNSTs reported since 1970, in which the tumour location was the anterior skull base or the paranasal sinuses.

RESULTS

Literature review revealed 33 well-documented cases of MPNSTs in this anatomic location. These cases were analysed with emphasis on age, gender, affected site, therapy, outcome, presence of neurofibromatosis, local recurrence and metastases.

CONCLUSIONS

Despite multimodal therapy and advances in surgical techniques, the prognosis of MPNST located in the paranasal sinuses and the anterior skull base remains dismal. Outcome is mainly a function of local control by surgical resection. Adjuvant radiochemotherapy has shown no benefit. It may therefore be advisable to abstain from radiochemotherapy in order to improve chances for surgical intervention in case of recurrent disease. Close follow-up investigations are indispensable.

Malignant peripheral nerve sheath tumors of the head and neck: management of 10 cases and literature review

BACKGROUND

This study analyzes the management and outcomes of a series of 10 malignant peripheral nerve sheath tumors (MPNST) of the head and neck.

METHODS

From 1984 to 2004, 10 patients underwent surgical treatment of a MPNST. We retrospectively reviewed presenting symptoms, radiological findings, surgical management, and follow-up status and performed a literature review.

RESULTS

Eight tumors were located at the lateral skull base; 2 involved the vagus nerve in isolation. Two lesions were growing within the sinonasal tract. The most common presenting symptom was a rapidly enlarging cervical mass. Seventy percent of the tumors could be resected completely. Long-term follow-up showed a 2-year disease-specific survival rate of 50% and 5-year survival rate of 20%. Negative prognostic indicators were advanced tumor stage, early recurrence, and presumably also the presence of von Recklinghausen's disease. Postoperative adjuvant radiotherapy was found to make no difference in outcome.

CONCLUSIONS

Although rare, MPNST is one of the most aggressive tumors in the head and neck area. Complete tumor removal is the mainstay of treatment and most important prognostic factor of MPNST. Adjuvant radiotherapy should be used to assist surgical excision in local control. The role of adjuvant chemotherapy remains controversial.

Solitary Malignant Schwannoma of the Nasal Cavity and Paranasal Sinuses: Report of Two Rare Cases

Malignant schwannomas of the paranasal sinuses are extremely uncommon tumors, as only 18 well-documented cases have been previously published in the English-language literature. We report two new cases of solitary malignant schwannoma—one in a 23-year-old man and the other in a 45-year-old woman. Neither was associated with von Recklinghausen's disease. These tumors involved the maxillary sinus, nasal cavity, and orbit and extended intracranially. Following surgery, both patients experienced recurrences. The male patient developed a slowly enlarging intranasal mass at the same site 8 years following excision of the original tumor and postoperative radiotherapy. Microscopic examination of the recurrent tumor revealed that its features were similar histologically to those of the original. The female patient experienced a recurrence 1 year following her first operation.

Management of Malignant Schwannomas of the Paranasal Sinuses and Anterior Skull Base

The evolution of skull base surgery has facilitated the extirpation of previously unresectable tumors. As experience with skull base surgery increases, the feasibility of resection and long-term outcomes is becoming apparent for the more common lesions. Neoplasms such as malignant schwannomas are rare and, therefore, defy single-institution analysis. The treatment and four-year follow-up of a malignant paranasal sinus and anterior skull base schwannoma is described. Analysis of the literature confirms the low incidence of this tumor and supports the efficacy of skull base surgery in its treatment.

Soft tissue sarcoma of the head and neck in children and adolescents

BACKGROUND

The experience of one institution in treating soft tissue sarcomas of the head and neck in a pediatric population is presented.

METHODS

Case materials of 134 patients younger than 20 years who were referred to the University of Texas M. D. Anderson Cancer Center between 1970 and 1989 for treatment of sarcoma of the head and neck were retrospectively reviewed. Patients with rhabdomyosarcoma underwent multimodality treatment consisting of surgery, irradiation, and chemotherapy. Wide resection was the treatment used for patients with nonrhabdomyosarcomatous soft tissue sarcomas (NRSTS). Adjuvant chemotherapy and irradiation were used to treat high grade neoplasms and residual disease. The clinical response to therapy was measured in terms of the disease-specific survival rate.

RESULTS

Seventy-nine of 134 patients presented with untreated or biopsy-proven disease. Fifty-six had rhabdomyosarcoma and 23 had

NRSTS

At 2 and 5 years, the disease-specific survival rates for patients with rhabdomyosarcoma were 74% and 63%, respectively, and patients with NRSTS had 80% and 75% disease-specific survival rates at 2 and 5 years, respectively.

CONCLUSIONS

Rhabdomyosarcoma of the head and neck in children is effectively treated with multimodality therapy. Prognostic indicators for rhabdomyosarcoma include completeness of tumor resection and the development of recurrent disease. Aggressive surgical resection is the treatment of choice for patients with

NRSTS

Prognostic indicators for NRSTS include completeness of tumor resection and the development of recurrent disease.

Malignant schwannoma located in the retroauricular region

There have been no reports about malignant Schwannoma located retroauricularly in the medical literature we reviewed. Malignant Schwannoma is a very malignant tumor, which is rare. For diagnosis, microscopic and immunohistochemical studies are needed. It is often seen together with neurofibromatosis. The prognosis is very poor and the only available treatment is surgical excision. Although it is known that both radiotherapy and chemotherapy are not effective, we achieved good outcome with this combination applied postoperatively.

Prognostic factors in head and neck soft tissue sarcomas: analysis of 128 cases

Soft tissue sarcomas make up a heterogenous group of rare malignant tumors originating from mesodermal tissues. Although there have been several improvements in diagnostic methods, staging, and treatment over the past few years, the prognosis of head and neck sarcomas remains worse than those sited at the trunk or extremities. The purpose of this retrospective study was to report the survival results of 128 consecutive patients with soft tissue sarcomas of the head and neck treated from 1953 to 1985. Of the 93 patients submitted to surgical resection, the procedure was considered radical in 67 patients. Of the operated group, 46 patients (49.5%) developed recurrence of disease. Thirty-two patients underwent further treatment (surgery, radiotherapy, or chemotherapy), and 14 patients were salvaged, giving the ultimate result of 65.6% disease control rate in the operated group. The univariate survival analysis showed no statistical difference (P > 0.05) according to age, race, sex, and site or histologic type of the tumor. Radicality of surgery was an important prognostic factor affecting survival (P = 0.0014 for disease-free interval and P = 0.0183 for overall survival). The multivariate analysis showed that the radicality of surgery and tumor histology were independent prognostic factors affecting recurrence. The same variables and age group were related to the risk of death. Every effort must be made to make an early diagnosis and a radical surgical resection of these tumors must be tried (except for embryonal rhabdomyosarcoma), because it offers the best chance for cure.

Malignant sinonasal epithelioid schwannoma

Malignant schwannomas are rare neoplasms that are seldom found in the head and neck. Few cases have been reported involving paranasal sinuses and none of them was of the "epithelioid" type. In this report, an unusual case of epithelioid malignant schwannoma involving the maxillary sinus, nasal cavity and orbit is presented. The patient was a 27-year-old male with a history of headache, nasal obstruction and epistaxis. Histologically, the tumour had a biphasic pattern with spindle and epithelioid elements which led to a differential diagnosis with malignant melanoma. It had also to be distinguished from other neoplasms, such as squamous cell carcinoma and olfactory neuroblastoma because of it location. Immunohistochemical positivity for S-100 protein, glial fibrillary acidic protein and vimentin together with negativity for HMB-45 and cytokeratins, as well as mesaxon formation detected with electron microscopy were conclusive in the diagnosis. The patient was treated with surgical excision and radiotherapy but local recurrence and metastases occurred, and he died within 1 year after initial diagnosis.

Malignant schwannoma arising in a paranasal sinus

A case of malignant schwannoma arising in a paranasal sinus is reported. In this case, histological hallmarks were lost because of the poorly differentiated nature of the tumour. Immunohistological techniques were applied to the diagnosis, confirming the neural origin of this tumour. Malignant schwannoma is a relatively rare disease in the nasal cavity and paranasal sinuses. For the treatment of this tumour, wide resection is recommended. In this patient, radical resection of the maxilla with orbital and ethmoid exenteration was performed. The patient recovered uneventfully with no evidence of disease three years after surgery.

Head and neck synovial cell sarcoma

Our experience with 14 patients treated for synovial cell sarcoma during the past 30 years is described. These tumors were manifested in young people whose ages ranged from 12 to 43 years. The diagnosis of synovial cell sarcoma proved difficult because approximately one third of the patients initially received incorrect pathologic diagnoses. A painless neck mass was the most common presenting symptom. Initial treatment included surgical excision in five patients and surgical excision and radiation therapy in nine. Recurrent or metastatic tumor occurred from 4 months to 62 months later; thus, long-term followup is important. Four of the nine patients who were followed more than 5 years died of their disease. Favorable prognostic findings included early diagnosis and the performance of wide surgical removal.

Leiomyosarcoma of the skull base-a diagnostic challenge

Soft tissue sarcomas often present a frustrating diagnostic challenge for the pathologist as well as the surgeon. Despite the development of better defined criteria for histopathologic and immunohistochemical evaluation, definitive diagnosis may not be immediately apparent. We report two cases of leiomyosarcoma of the skull base that presented with the clinical diagnosis of schwannoma, a diagnosis confirmed on initial histopathologic examination. It was only after closer review and special immunohistochemical studies that the diagnosis of leiomyosarcoma was made. The methods for diagnosing such tumors using both standard histopathologic criteria and immunohistochemical methods are reviewed. We suggest that all extracranial soft tissue tumors of the skull base be examined by both techniques to avoid delayed or missed diagnosis.

Head and neck sarcoma: report of the Head and Neck Sarcoma Registry. Society of Head and Neck Surgeons Committee on Research

A Head and Neck Sarcoma Registry was established by the Society of Head and Neck Surgeons to review treatment results of a rare tumor by surgeons with special interest in this anatomic site. Two hundred fourteen patients were analyzed. There were 194 adult tumors and 20 pediatric tumors. The major sites included parotid and neck, 20%; face and forehead, 18%; maxilla and palate, 13%; scalp, 12%; mandible, 11%; paranasal sinuses, 7%; larynx, 2%; and oral cavity, 5%. Eighty-four percent were resectable. The disease-free survival was 56%; overall survival was 70% at 5 years. Major determinants of survival were adequacy of resection (margins free of tumor) and tumor type. Survival differed according to tumor cell type (tumor grade was not available). Patients with chondrosarcoma and dermatofibrosarcoma had survival approaching 100%. Patients with malignant fibrous histiocytoma (MFH) and fibrosarcoma (FSA) had intermediate survival of 60% to 70%. The worst survival, less than 50% at 5 years, occurred in patients with osteosarcoma, angiosarcoma, and rhabdomyosarcoma in decreasing order. This suggests a rationale for identifying high-risk patients for prospective adjuvant protocols. This study emphasizes the value of recording uncommon tumors to provide relevant information for future study and possibly therapy.

Maxillofacial malignant peripheral nerve sheath tumours

The clinical and pathological features of 7 patients with MPNST in the maxillofacial area are reviewed. They occurred in five men and two women; ages ranged from seven to eighty years. The parotid area and infratemporal fossa were the commonest sites (two cases each), followed by the lower lip, cheek and central mandible (one case each). Two had the antecedent of an excised neurofibroma, one with von Recklinghausen's disease and radiotherapy, that had recurred many times. Pathological slides were revised. Immunohistochemistry with S-100 protein was positive in 6 of 7 cases; electron microscopy confirmed the diagnosis in 3 cases. None showed divergent differentiation. Surgical treatment was performed in all, with or without radiotherapy. Surgical margins were positive in five cases. Recurrence took place in six and was multiple in three. Surgical salvage of the local recurrences produced satisfactory results in 3 of the 6 cases. One patient developed lung metastasis.

Soft tissue sarcomas of the head and neck in adults

We reviewed the clinical records and pathologic material of 176 adults with primary soft tissue sarcomas treated at Memorial Sloan-Kettering Cancer Center between 1950 and 1985. Seventy-two patients (41%) had low-grade sarcomas and 104 (59%) had high-grade sarcomas. All but 18 patients underwent some form of excision as initial therapy. Adjuvant radiotherapy and chemotherapy combined with surgical excision showed no significant effect. A significantly increased risk of treatment failure was associated with large tumor size, positive surgical margins, bone involvement, local recurrence, metastatic spread, and high histologic grade. Except for recurrence, the p value by univariate analysis in the log-rank test for comparison of survival according to these clinical and pathologic characteristics was p less than 0.0001. Although the overall survival was 75% at 2 years, 55% at 5 years, and 46% at 10 years, only 20% of the patients with high-grade sarcomas were alive 10 years after treatment. Most patients with rhabdomyosarcoma, high-grade peripheral nerve tumor, and high-grade fibrous histiocytoma and all patients with high-grade angiosarcoma died of disease less than 5 years after diagnosis. New therapeutic strategies are needed to improve the survival of adult patients with high-grade soft tissue sarcomas of the head and neck.

Soft-tissue sarcomas of the head and neck

We reviewed the charts of 352 patients at the Mayo Clinic who were diagnosed and treated for primary soft-tissue sarcomas of the head and neck from 1962 to 1982. The age at diagnosis ranged from 6 weeks to 91 years; 28 percent were pediatric patients. Regional or distant metastases were present at the time of primary diagnosis in 8 percent of patients. Nonorbital rhabdomyosarcoma was the most common tumor type (17 percent), and neuroblastoma was the rarest (2 percent). In children, rhabdomyosarcomas were proportionally more common, as was overall involvement of the orbit. Surgical excision was the sole method of tumor control in 49 percent of patients; excision with adjuvant radiotherapy or chemotherapy was used in 33 percent. In those with localized disease, overall survival was 81 percent at 2 years, 68 percent at 5 years, and 60 percent at 10 years postoperatively. Patients with angiosarcoma and nonorbital rhabdomyosarcoma experienced the poorest survival rates.

Malignant nerve sheath tumors of the head and neck

Malignant nerve sheath tumors comprise approximately 5% of all soft tissue sarcomas; only 8% to 15% of these tumors arise in the head and neck. Most tumors appear as a rapidly expanding nonpainful mass in the face or lateral neck. Reported association with Von Recklinghausen's disease varies from 26% to 70%. Wide surgical excision is generally the recommended primary treatment. Recently, there has been a trend to include postoperative radiation therapy as a primary modality.

Chemotherapy of bilateral acoustic neuromas

In patients with bilateral acoustic neuromas, it is not unusual for the tumors to be of unequal size. At the time of the first examination, the smaller tumor may have already destroyed the hearing, while the ear with residual hearing may harbor a large acoustic neuroma. The remaining hearing is then at great risk if surgical removal of the tumor is attempted. Chemotherapy of bilateral acoustic neuromas is here presented as a possible alternative to surgery in those patients whose prognosis for conservation of hearing is poor.

Combined modality treatment of adult soft tissue sarcomas of the head and neck

Between 1975 and 1985, 16 adult patients high grade soft tissue sarcomas arising in the head and neck were treated with combined modality therapy at the National Cancer Institute. Fifteen patients underwent an attempt at gross resection, while only a biopsy was performed in 1 patient. All patients received conventionally fractionated, high-dose, post-operative irradiation. Twelve of 16 patients received adjuvant chemotherapy with cyclophosphamide and adriamycin, given concomitantly with radiation therapy. With a median follow-up of 43 months from diagnosis (range 11-116 months), 10 patients (64%) are disease-free. Of these 10 patients, 1 presented with pulmonary metastases and 2 patients later failed in the lung; all pulmonary disease was resected and these patients are disease-free at 80, 115, and 116 months following presentation. Local control was maintained in 12 patients (75%). An analysis of the iso-effect lines for local control shows a slope of 0.32. The median NSD for local control was 1720 ret. We conclude that aggressive local management of high grade sarcomas which combines gross resection and high-dose post-operative irradiation results in excellent local control. The role of adjuvant chemotherapy is less well defined in this small patient series. The acute and late complications of this combined modality approach are manageable.

Soft tissue sarcomas of the head and neck in adolescents and adults

Between 1960 and 1982, 188 patients were treated for soft tissue sarcomas of the head and neck. These patients had a heterogeneous group of neoplasms whose biologic behavior was determined by histologic classification, differentiation, and size. Histologic classification of these tumors was important and had prognostic significance. Differentiation affected local control and the propensity for distant metastases. Tumor size also contributed to outcome: patients with tumors of more than 5 cm had a worse survival than those with smaller sarcomas. Wide surgical excision with an adequate margin of normal tissue offered the best means of local control. The addition of postoperative radiotherapy was utilized for patients with positive margins or high grade aggressive sarcomas. Finally, despite multimodality therapy, achieving local control and prevention of distant disease in high grade sarcomas remains a major therapeutic challenge.

Soft tissue sarcomas of the adult head and neck

From 1969 to 1983, 53 adult patients with head and neck soft tissue sarcomas were evaluated and treated by the Division of Surgical Oncology at the University of Illinois. The most common anatomic location was the neck (36%), and these patients had the highest 5-year disease-free survival rate (67%). Fibrosarcoma was the most common histologic type (26%); patients with aggressive fibromatosis had the longest mean survival time (93 months). The mean overall survival time was 58.7 months, and the disease-free 2-year, 5-year, and 10-year survival rates were 68%, 54%, and 28%, respectively. Wide excision was the treatment of choice, with adjuvant radiotherapy or chemotherapy, or both, used in selected patients. In all of the long-term survivors, the tumors were either well-differentiated or less than or equal to 5.0 cm in diameter. It is apparent that aggressive therapy of such tumors can provide good long-term results.

Squamous cell carcinoma and liposarcoma of the larynx occurring metachronously

A case of liposarcoma arising in a larynx previously irradiated for carcinoma is reported. Treatment was by wide local excision. The previous radiotherapy was probably incidental in this case.

Intrinsic malignant schwannoma of the larynx. A case report

The first case of an intrinsic laryngeal malignant schwannoma is reported. The diagnosis of a malignant schwannoma is difficult to establish without gross evidence of its origination in a nerve. Although surgery remains the mainstay of treatment, a combination of surgery and radiotherapy appears promising. The prognosis in most cases is poor, with death usually resulting from persistent or locally recurrent disease.

Malignant schwannoma of the vagus nerve: a case report and review of the literature

A case of neuroectodermal tumor, a malignant schwannoma, of the cervical vagus nerve is presented. It had been previously misdiagnosed and was a recurrence. A review of the literature reveals this to be the sixth such case reported. The difficulties in establishing a diagnosis and the principals of adequate therapy are discussed; these include wide surgical resection and postoperative radiotherapy to the tumor bed. The correct recognition of their malignant potential is essential for long-term disease-free survival.

[Neurogenic sarcoma of the head and neck with contact to the skull base (author's transl)]

The neurogenic sarcoma is a neoplasm found seldom. It descends from the sheaths of peripheric nerves. If this tumor develops from a solitary or multiple neurofibroma, it might also be called a neurofibrosarcoma. All other synonyms, especially that of the malignant schwannoma, should better be abandoned for histogenetic reasons. Today the classification of all tumors of the peripheral nervous system is based on a suggestion of the WHO from 1969. The tabular summary of the literature shows that only a little more than a hundred cases of neurogenic sarcoma of the head and neck were reported during the last 50 years. Differential diagnosis of this malignant tumor includes nearly all other malignant neoplasms of soft tissue, sometimes even anaplastic carcinoma. Histopathology, including electron microscopy, is described in general and also in detail with regard to three cases. Three forms of micro-morphological variants are dealt with, too. For diagnosis histological examination will be absolutely successful only in cases of neurofibromatosis or in cases where the nerve from which the tumor originates may be identified. Otherwise, conventional and computerized X-ray tomography may be helpful. Finally, some therapeutic and prognostic principles are discussed.

Analysis of staging and management of patients with sarcoma: a ten-year experience

Over ten years, 70 patients with soft tissue sarcoma were treated for their primary tumors at the hospital of The Fox Chase Cancer Center. The clinical characteristics of these tumors are correlated with the outcome of various management efforts. The results of these evaluations identify three groups that can provide the basis for future treatment decisions and stratification for randomized studies of management options. The first group of patients, those with small well differentiated tumors, have no systemic spread regardless of the treatment modality used. The second group, those with large (greater than 5 cm) tumors that are moderately or poorly differentiated, do uniformly poorly despite the management techniques used. An intermediate group, those with high grade or large size but not both, have outcomes which may be correlated to treatment modalities.

Clinical course of unusual malignant sarcomas of head and neck

The clinical manifestations of 29 recently encountered sarcomas of the head and neck were analyzed in an attempt to define more accurately the diagnostic characteristics and therapeutic responses of these unusual tumors. The host factors of age, sex distribution, race, habits and associated features differ sufficiently to distinguish the sarcoma from the carcinoma population. In addition, the clinical course of sarcoma patients as monitored by mode of presentation, site of involvement, tumor histology, diagnostic features and certain elements of management and outcome, further indicates that these tumors can be defined and managed as a distinct group of lesions. A review of the recent literature supports the major conclusions of this study.