Distant skin and soft tissue metastases from sarcomas

Leiomyosarcoma Invading the Vena Cava: A Case Report

Leiomyosarcoma is an aggressive soft tissue tumor originating from smooth muscle cells typically of the uterus, gastrointestinal, or genitourinary system. The most common site of leiomyosarcoma of soft tissue is the retroperitoneum, accounting for 50% of all cases. The majority of patients are asymptomatic, which may be due to the large retroperitoneal cavity. However, when symptoms do occur, they are vague in nature. The most common growth pattern is an entirely extravascular mass. We are presenting an interesting case of a 65-year-old lady, who was referred to our hospital as a case of large left retroperitoneal mass with left renal vein thrombosis. She was biopsied and diagnosed with leiomyosarcoma with invasion into descending colon and the left renal vein, which led to renal vein thrombus. In the last few decades, there is a lack of studies about leiomyosarcoma invading the renal vein and Inferior Vena Cava (IVC). As far as we know, the leiomyosarcoma of a major blood vessel is extremely rare. Since leiomyosarcoma often has a late presentation with the advanced stage when detected, a high index of suspicion is needed to be detected early and avoid such a complication.

Ablation of soft tissue tumours by long needle variable electrode-geometry electrochemotherapy: final report from a single-arm, single-centre phase-2 study

Standard electrochemotherapy (ECT) is effective in many tumour types but is confined to the treatment of small superficial lesions. Variable electrode-geometry ECT (VEG-ECT) may overcome these limitations by using long freely-placeable electrodes. Patients with bulky or deep-seated soft-tissue malignancies not amenable to resection participated in a single-arm phase-2 study (ISRCTN.11667954) and received a single course of VEG-ECT with intravenous bleomycin (15,000 IU/m²) and concomitant electric pulses applied through an adjustable electrode array. The primary outcome was radiologic complete response rate (CRR) per RECIST; secondary endpoints included feasibility, metabolic response, toxicity (CTCAE), local progression-free survival (LPFS) and patient perception (EQ-5D). During 2009–2014, we enrolled 30 patients with trunk/limb sarcomas, melanoma, Merkel-cell carcinoma, and colorectal/lung cancer. Median tumour size was 4.7 cm. Electrode probes were placed under US/TC guidance (28 and 2 patients, respectively). Median procedure duration was 80 minutes. Tumour coverage rate was 97% (29 of 30 patients). Perioperative side-effects were negligible; one patient experienced grade-3 ulceration and infection. One-month ¹⁸F-FDG-SUV decreased by 86%; CRR was 63% (95% CI 44–79%). Local control was durable in 24 of 30 patients (two-year LPFS, 62%). Patients reported an improvement in “usual activities”, “anxiety/depression”, and “overall health” scores. VEG-ECT demonstrated encouraging antitumour activity in soft-tissue malignancies; a single course of treatment produced high and durable responses, with low complications.

Malignant fibrous histiocytoma of the breast in young male patient: a case report and a review of the literature

Malignant Fibrous Histiocytoma (MFH) is a fairly common tumor in the deep soft tissues: the most frequent primary sites are the lower (49%) and upper (19%) limbs, but it has been reported even in the retroperitoneum and abdomen (16%), while localization in the breast is extremely rare (1-2). Breast cancer is rarely seen in males, accounts for approximately 1% of all breast cancer, and the breast sarcomas constitute less than 1% of breast tumors in both sexes. In the review of the literature, this is the third male and first young male with MFH. Here, we present a 37-years-old male patient who is diagnosed to have malignant fibrous histiocytoma in a variant of pleomorphic fusiform cell localized in the left breast. Following the wide local excision, the patient was given an adjuvant 50 Gy of external radiotherapy. He remained alive and well after 42 months of followup. We believe that reporting such few cases would contribute to forming treatment algorithms of rare tumors.

Uterine leiomyosarcoma manifesting as a tricuspid valve mass

Uterine leiomyosarcoma is a rare malignancy and carries a poorer prognosis when compared to endometrial carcinoma. It has been observed to metastasize to all the major organs. It presents with symptoms of abdominal distension, vaginal bleeding and may pass unnoticed until an advanced stage in patients with leiomyomas. Surgery is a viable option in patients with disease limited to the uterus, but metastasis to the heart may require surgery to prevent acute and catastrophic complications. The case described here involves metastasis to the tricuspid valve, which caused severe tricuspid regurgitation in the setting of acute pulmonary embolism. Surgical resection restored cardiac function and stabilized the patient. This case illustrates a rare site of metastasis of leiomyosarcoma which required immediate intervention and resulted in a favorable outcome.

Isolated cutaneous metastasis of uterine leiomyosarcoma: case report and review of literature

A 54 year old lady presented for routine excision of a scalp lesion thought clinically to represent a sebaceous cyst of the right occiput. 4 years earlier she underwent total abdominal hysterectomy and right salpingo-oophorectomy for 3 large uterine fibroids. Histo-pathological examination of the hysterectomy specimen revealed an incidental low-grade leiomyosarcoma. Staging imaging was negative for metastatic disease. She made an uneventful recovery and was treated further by adjuvant pelvic radiotherapy.She noticed an uncomfortable and unsightly cystic swelling on her occiput four years after hysterectomy and was referred for routine excision of what was believed to be a benign lesion. The lesion was excised and sent for histopathological examination. Microscopic analysis including immuno-histochemistry demonstrated an ER and PR positive metastatic deposit of leiomyosarcoma. The margins of excision were histologically clear of disease.At Multi-Disciplinary Team (MDT) discussion a diagnosis of metastatic scalp deposit from previous uterine leiomyosarcoma was made. Re-staging CT brain, thorax, abdomen and pelvis and MRI brain were negative for local recurrence or distant metastases. She is currently undergoing radiotherapy to the scalp and surrounding tissues and will be followed up closely by the involved teams.To the best of our knowledge, this is the first case described in the worldwide literature of isolated cutaneous metastasis to the scalp of uterine leiomyosarcoma without evidence of disseminated disease at other sites.

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The treatment and outcome of patients with soft tissue sarcomas and synchronous metastases

Introduction: There is a strong association between poor overall survival and a short disease-free interval for patients with soft tissue sarcomas (STS) and metastatic disease. Patients with STS and synchronous metastases should have a very dismal prognosis.The role of surgery in this subgroup of patients with STS has not been defined.

Patients and Methods: A single-institution retrospective review was performed of 48 patients with STS and synchronous metastases in regard to patient demographics, presentation, tumor characteristics, metastatic sites, treatment, follow-up, and survival over a 27-year period.

Results: Most primary tumors were ≥10 cm (58%), high-grade histology (77%), and located on the extremity (60%).The most frequent site of metastatic disease was the lung (63%); 27% of patients had metastases to ≥2 organ sites. Surgery to the primary tumor was performed in 94% of patients (n = 45) and 68% had additional radiation therapy (n = 32). Thirty- five percent of patients underwent at least one metastastectomy (n = 17). Chemotherapy was administered to 90% of patients (n = 43); 31% received ≥3 different regimens (n = 15) and 25% were given intra-arterial or intracavitary therapy (n = 12). Median overall survival was 15 months with a 21% 2-year survival. Local control of the primary tumor was achieved in 54% (n = 26), and metastastectomy was performed in 35% (n = 17). No analyzed factors were associated with an improvement in overall survival

Conclusions: Despite multiple poor prognostic factors, the survival of patients with STS and metastases is comparable to those who develop delayed metastatic disease. However, unlike patients who present with metachronous disease, there was no improved survival observed for patients treated with metastastectomy. Consequently, treatment for patients with STS and synchronous metastases should be approached with caution. Surgical management of STS with synchronous metastases must be considered palliative and should be reserved for patients requiring palliation of symptoms. Patients must also be well informed of the noncurative nature of the procedure.

Cutaneous and subcutaneous metastases of gastrointestinal stromal tumors: a series of 5 cases with molecular analysis

Gastrointestinal stromal tumors (GISTs) rarely metastasize to the skin. We describe 5 patients with GIST with subcutaneous and cutaneous metastases. The mean age at metastasis was 54 years (range 30-68 years) with a male predominance (4:1). Primary tumors occurred in the stomach (n = 3), small bowel (n = 1), and abdomen, not otherwise specified (n = 1). The average time from primary tumor resection to the resection of skin metastases was 59 months (range 11-155 months). The metastases occurred in the scalp (n = 2), cheek (n = 1), and abdomen (n = 2) with 3 patients presenting with solitary nodules and 2 patients with multiple nodules. The average size was 2 cm (range 0.6-4 cm). Histologically, 2 cases were spindled and 3 cases demonstrated mixed epithelioid and spindle cell morphology. All were confirmed to have CD117 reactivity. KIT genotyping was performed in 4 of 5 cases. Two cases harbored a mutation in exon 11, and the remaining 2 cases were wild type in exons 9, 11, 13, and 17. All 5 patients had multiple concurrent or subsequent abdominal and/or hepatic metastases. In 4 patients with an average follow-up of 32 months (range 6-75 months), after the resection of the metastases, 2 were alive with disease and 2 died of disease. Cutaneous metastases seem to be a late complication of GIST, but their presence does not necessarily herald a rapid demise of the patient.

Scalp metastasis from malignant fibrous histiocytoma of bone

Malignant fibrous histiocytoma (MFH) of bone is a relatively rare primary malignant neoplasm and an aggressive tumor, characterized by a high frequency of local recurrence and distant metastasis. The most common metastatic site is the lung (>80%), followed by bone and regional lymph node. Metastasis to other sites is extremely rare. In this report, we describe the skin as being the initial metastatic site for MFH of bone. A 42-year-old female presented with a bone tumor involving the right proximal tibia. She underwent tumor excision and knee joint reconstruction. Histologic examination confirmed a striform-pleomorphic type of MFH of bone. Six months postoperatively, the patient developed a scalp metastasis. Wide local excision was performed. Six months after the scalp operation, the patient was alive with no further relapse. We should keep the skin in mind as the possible initial site of metastatic MFH of bone.

Osteosarcoma with skeletal muscle metastasis

Osteosarcoma usually metastasizes to the lung or the bone, but very rarely to the soft tissue. There have been few reports of osteosarcoma patients with long-term survival after the soft tissue metastasis. We report a case of osteosarcoma in a 18-year-old man, who presented with a solitary skeletal muscle metastasis in the right vastus lateralis as the second relapse of the disease. The patient underwent excision surgery without adjuvant chemotherapy, and remains free of the disease for over 34 months after the surgery.

Epithelioid sarcoma of the hand

Twenty-eight patients were treated for a primary epithelioid sarcoma of the hand. Twenty-seven patients (96%) had excisions before evaluation, including 11 (39%) with multiple prior excisions with varying diagnoses before epithelioid sarcoma, and all had surgical treatment after referral. The patients' surgical management included three patients with amputation at the forearm, three patients with wide excision, and 21 patients with a partial amputation of the hand. The followup period averaged 120 months (range, 24-276 months). Eighteen patients have no evidence of disease at last followup. Treatment failures included one local recurrence, four regional metastases, and five distant metastases. Five patients died secondary to disease. Two patients are alive with disease, and three are alive with no evidence of disease after additional treatment. After aggressive surgical management with negative margins, 71% of the patients were alive without evidence of disease at the last followup, with a 5- and 10-year survivorship of 85%. Our goal is to review: (1) the effectiveness of preoperative imaging, (2) the role of adjuvant therapy, (3) survival after alternative resections, and (4) function after resection.

Epithelioid sarcoma metastatic to the tongue: a rare entity

Epithelioid sarcoma (ES) typically arises as a firm nodule on the extremities of young men. The tumor is remarkable for diagnostic difficulties both clinically and histopathologically resulting in a high frequency of initial misdiagnosis. ES is also known to have a high rate of recurrence and high rate of metastasis predominantly to the lymph nodes, lungs, and scalp. Herein, the second case of ES with metastasis to the tongue is reported.

Cutaneous metastatic malignant fibrous histiocytoma

Malignant fibrous histiocytoma is the most common soft tissue sarcoma, but cutaneous metastasis of this tumor is quite rare. A 30-year-old female patient had several brownish 0.5 x 0.5-cm papules on her right ankle. Histopathologic examination revealed spindle-shaped tumor cells with cellular pleomorphism and high mitosis (5 of 10 high-power fields), suggestive of malignant fibrous histiocytoma. She had a history of left subcutaneous breast mass that was diagnosed as malignant fibrous histiocytoma 3 years earlier. We report a case of malignant fibrous histiocytoma with pleomorphism mixed with spindle-shaped cells and multinuclear giant cells, which metastasized to the skin.