The prognostic value of histologic subtypes in primary extremity liposarcoma

Radiotherapy, volume reduction, and short-term surgical outcomes in the treatment of large myxoid liposarcomas

Purpose

While tumor volume reduction following radiation has been documented in myxoid liposarcomas, it is unclear whether large tumors experience similar volume reduction to smaller tumors.

Materials and Methods

MRI studies performed before and after completion of pre-operative radiation therapy (RT) were examined. Tumor sizes were noted and categorized as large versus small based on size >10 cm. Tumor volumes were calculated, and operative duration and major wound complications were recorded.

Results

The median largest tumor dimension was 12.4 cm before RT and 8.7 cm after RT. The median tumor volume was 298.9 cm3 before RT and 106.9 cm3 after RT. There was no significant difference in the mean percent tumor volume reduction between large tumors and small tumors (p = 0.11, 56.3% vs. 64.5%). Operative duration most strongly correlated to post-RT MRI volume (R2=0.674, p<0.001). Despite volume reduction, tumors that were large on presentation were more likely to experience major wound complications post-operatively.

Conclusion

Radiation appears to be as effective at reducing myxoid liposarcoma tumor volume in large and small tumors. However, large tumors on presentation appear more likely to experience wound complications despite tumor volume reduction. Future studies should investigate disease-related outcomes as a factor of volume reduction in myxoid liposarcoma.

Management of myxoid liposarcoma of the extremity

Myxoid liposarcoma (MLPS) is the second most common type of LPS after the well differentiated LPS. MLPS is primarily localized to the extremities. The incidence of LPS is ~2 per million worldwide. MLPS accounts for ~30% of all LPS cases. MLPS is usually encountered in adults, but can also occur in younger individuals more than other types of LPS. MLPS can be divided into low- and high-grade subtypes, which present with differences in patient prognosis and outcome. Methods of tumor management include surgery, radiotherapy and chemotherapy; however, there is no unified treatment based on tumor characteristics alone. The present manuscript reviews the surgical management, radiotherapeutic and chemotherapeutic approaches reported in the literature for different types of MLPS in the extremities, as well as the post-treatment outcomes. In addition, the present review provides an evidence-based management plan for MLPS in the form of an organogram based on specific tumor and patient parameters.

Prognostic factors of metastatic myxoid liposarcoma

BACKGROUND

Myxoid liposarcoma (MLS) has the tendency to metastasize extrapulmonary. Although prognostic factors at the initial diagnosis of MLS have been reported, those at diagnosis of metastasis remain unclear. The purpose of this study was to investigate the prognostic factors for disease-specific survival at the initial diagnosis of metastasis.

METHODS

This retrospective observational study was conducted at three cancer centers and two university hospitals in Japan. Of 274 MLS patients pathologically diagnosed between 2001 and 2015, 48 metastatic patients were examined.

RESULTS

Lung metastases were detected in nine patients (18.8%) and extrapulmonary metastases in 45 (93.8%). Interval from primary diagnosis to the first metastasis was significantly shorter in patients with lung metastases than without (p = 0.007). Median disease-specific survival after diagnosis of metastases was 52.5 months in all patients. In multivariable analysis, liver metastasis (hazard ratio (HR), 2.71 [95% confidence interval (CI), 1.00-7.09]) and no evidence of disease (NED) achieved by radical treatment (resection with or without radiation therapy, or radiation therapy ≥60 Gy) or semi-radical (radiation therapy ≥40 Gy) treatment were significantly related to survival (HR, 0.36; 95%CI [0.13-0.95]). The number of metastases (odds ratio (OR), 0.44; 95%CI [0.25-0.78]) and abdominal/retroperitoneal metastases (OR, 0.09; 95%CI [0.008-0.95]) were the significant inhibitory factors of achieving NED.

CONCLUSIONS

This is the first study to statistically demonstrate the importance of achieving NED with surgical resection or radiation therapy for longer survival in metastatic MLS patients. As number of metastases was a significant factor for achieving NED, early detection of metastases might be important.

Metastatic Liposarcoma of the Skull Base: A Case Report and Review of Literature

BACKGROUND AND IMPORTANCE

Myxoid liposarcoma is not an uncommon form of sarcoma. However, it usually affects the lower extremity long bones. Scapular involvement is extremely rare, as is a metastasis to the parasellar region. We present a case of liposarcoma of the skull base originating in the scapular region and metastasizing to the sellar and parasellar regions and provide a review of the pertinent literature.

CLINICAL PRESENTATION

A 43-year-old female patient diagnosed with left scapular myxoid liposarcoma was treated with surgical resection. She had clear resection margins and was treated pre- and postoperatively with radiotherapy to the region. She remained asymptomatic for 2 years following surgery, after which she abruptly developed diplopia with right lateral gaze. There were no symptoms of raised intracranial pressure or impaired vision. Her examination was normal apart from complete right sixth nerve palsy. Imaging studies of the brain showed a large mass in the clivus eroding into the floor of the sella, encircling the right internal carotid artery in the cavernous sinus. The mass also displaced the sellar contents superiorly. An endonasal, endoscopic skull base approach was undertaken, and a subtotal resection was performed in an effort to avoid multiple cranial nerve pareses.

CONCLUSION

Our literature search revealed that this case report is the first to document liposarcoma metastasis to the skull base originating from the scapular region. Subtotal surgical resection resulted in minimal improvement of the patient's sixth nerve palsy. Postoperative radiation was undertaken. A multidisciplinary approach on an individual patient basis is recommended.

Recent advances in the management of liposarcoma

Liposarcoma is the most common soft tissue sarcoma. With its various subtypes, the natural history of this disease can vary significantly from a locally recurrent tumor to a highly malignant one carrying a poor prognosis. Progress in the understanding of the specific molecular abnormalities in liposarcoma provides greater opportunity for new treatment modalities. Although surgical resection and radiation therapy remain the keystones for the management of primary liposarcoma, the inclusion of novel agents that target known abnormalities in advanced liposarcoma enhances the potential for improved outcomes.

Myxoid liposarcoma of the foot: a study of 8 cases

INTRODUCTION

Myxoid liposarcoma is the only translocation-associated liposarcoma subtype. It classically originates in the deep soft tissues of the thigh. At distal sites of the extremities, this tumor is exceedingly rare. We present a series of 8 cases occurring in the foot/ankle.

RESULTS

Two female and 6 male patients, aged between 32 and 77 years (mean, 54.3 years), were identified. Tumor size ranged from 1.1 to 10 cm (mean, 6.8 cm). Two lesions eroded bone. All tumors were treated by excision and 7 by (neo)adjuvant radiotherapy. R0 status was reached in 2 cases with 1 case followed by metastasis in the groin. All other cases were documented with R1 (n=2) or R2 (n=4) resection status. In 1 patient, the follow-up status was unknown. All other patients were alive 15-135 (mean, 55.8) months after initial diagnosis. We conclude that myxoid liposarcoma at acral sites are exceedingly rare, and in this series, prognosis was good irrespective of resection status. Clinicians and pathologists have to be aware because this sarcoma type shows a peculiar clinical behavior with high radio- and chemosensitivity and metastatic spread to extrapulmonary sites.

Pathological characterization of primary splenic myxoid liposarcomas in three dogs

Non-angiomatous-non-lymphomatous sarcomas (NANLs) represent 23%-34% of canine primary splenic sarcomas. Splenic liposarcomas account for 2%-6% of NANLs but myxoid variants are rarely reported and information on their behaviour is fragmentary. An 8-year-old male crossbreed (case 1), a 12-year-old female French bulldog (case 2), and an 11-year-old crossbreed (case 3) underwent splenectomy after the detection of a splenic nodule. Histology, histochemistry, immunohistochemistry, and transmission electron microscopy (TEM) were performed. Bundles of spindle-to-polygonal cells containing occasional cytoplasmic oil-red-O positive vacuoles embedded in an Alcian blue-positive extracellular matrix were observed. Aggregates of round cells were detected in cases 1 and 3. All tumours were vimentin positive and actin, desmin, Factor VIII, and S100 negative. The TEM evidenced different maturational stages of adipose cells (lipoblasts, intermediate, and undifferentiated). All the cases developed hepatic metastases and were euthanized. Disease free interval was 2 months in cases 1 and 3, and 21 months in case 2. The presence of a neoplastic embolus in case 1 and areas of round cell differentiation in cases 1 and 3 represented the sole prognostic indices.

Well-differentiated liposarcoma arising in the parapharyngeal space: a case report and review of the literature

BACKGROUND

Liposarcomas rarely occur in the parapharyngeal space and only a few case reports exist. For curative therapy of liposarcoma, surgical excision remains the dominant modality. Although a wide surgical margin is important to prevent local recurrence, wide excision is often difficult in the head and neck region.

CASE REPORT

We report a case of a 19-year-old female with a well-differentiated liposarcoma arising in the parapharyngeal space. We removed the tumour surgically utilising a cervical-parotid approach. The histological diagnosis was well-differentiated sclerosing liposarcoma. There is no recurrence after five years and nine months of follow up.

CONCLUSION

The patient's age and the tumour site made it difficult for us to make a quantitative diagnosis before the operation. Well-differentiated liposarcoma rarely develop distant metastasis, but often recur locally. The benefit of adjuvant radiotherapy for well-differentiated liposarcoma is still not clear and careful and long-term follow up is necessary.

Liposarcoma: a soft tissue tumor with many presentations

Liposarcoma is an uncommon connective tissue tumor arising from lipoblast cells. The lesion is located in body soft parts and rarely arises from the bones. The tumors are variable in presentation ranging from benign well-differentiated tumors to myxoid and round cell-dedifferentiated and pleomorphic forms which can present with metastases. The lesions are most often treated by surgical resection. Chemotherapy and radiation may be added to the treatment of the more malignant variants with some success.

Pleomorphic liposarcoma: a cytologic study of five cases

Pleomorphic liposarcoma represents one of the rarest variants of liposarcoma. It has a poor prognosis and unlike other variants of liposarcoma, lacks a molecular or genetic signature. Histologic studies of pleomorphic liposarcoma have defined this lesion as a high grade sarcoma, which contains a variable number of lipoblasts. We describe the cytologic features of five cases of pleomorphic liposarcoma, all of which had histologic confirmation. We consistently identified numerous lipoblasts as well as micro and macrovesicular fat vacuoles in the background of cellular, pleomorphic sarcomatoid neoplasms. The appearance of the aspirates differs substantially form other variants of liposarcoma.

The first case report of a metastatic myxoid liposarcoma invading the left atrial cavity and pulmonary vein

Myxoid liposarcoma (MLS) is the most commonly encountered liposarcoma subgroup, accounting for about 50% of all cases. Metastatic MLS of the heart is extremely rare. Herein we describe for the first time metastasis of MLS to the left atrium and left upper pulmonary vein in a 54-year-old woman who was admitted with shortness of breath and cough persisting for 2 weeks. The patient reported that a total surgical excision of MLS of the left thigh followed by radiotherapy was performed 4 years ago. An emergency operation was performed due to rapidly progressive worsening of clinical condition and echocardiographic determination of left atrial mass protruding into the left ventricle and obstructing the mitral inflow throughout the diastole. The mass could not be totally excised because it was tightly adhered to the surrounding tissue. Postoperative magnetic resonance imaging (MRI) showed a 5 × 3 cm residual tumor deforming the posterior wall of the left atrium entirely and extending into the left upper pulmonary vein. Histopathological examination was consistent with MLS. In conclusion, considering probable cardiac metastasis in patients presenting with respiratory symptoms with medical history of soft tissue sarcomas would be life saving. The case is discussed, and a review of the literature in relation to the metastatic involvement of the heart by MLS is presented.

Prognostic factors and metastatic patterns in primary myxoid/round-cell liposarcoma

Background. This study aimed to investigate prognostic factors for patients with myxoid/round-cell liposarcoma (MRCLS), in particular the significance of the round cell component, and to identify metastatic patterns as well as possibly suggest a suitable strategy for followup. Methods. Clinical, morphologic, and follow-up data from 160 patients with MRCLS was reviewed and statistically analysed. Results. Of 130 tumours with the round cell component evaluated, 61 had no round cell component, 27 had <5% round cell component, and 42 had >5%. All patients underwent surgical excision, 15 requiring amputation. 107 patients received adjuvant radiotherapy. Local recurrence occurred in 19 patients (12%), predominantly in patients with marginal or intralesional margins and a round cell component. Overall disease specific survival was 75% at 5 years and 56% at 10 years and was related to the proportion of round cell component. Of 52 patients who developed metastases, 38 (73%) had purely extrapulmonary metastases. We could not identify any factors predicting the site of metastases developing. Conclusions. The occurrence of any round cell component is the most important adverse prognostic factor for patients with MRCLS; patients with >5% round cell component are at higher risk of local recurrence, metastasis and tumour-related death and should be considered for adjuvant radiotherapy and possibly chemotherapy. The best method of monitoring extrapulmonary metastases remains to be established.

Feasibility of whole-body MRI for detecting metastatic myxoid liposarcoma: a case series

No feasible method currently exists to evaluate systemic metastasis in patients with myxoid liposarcoma. The purpose of this study was to determine the feasibility of performing whole-body magnetic resonance imaging (MRI) to detect metastatic myxoid liposarcoma. From June 2008 to May 2010, all patients who were newly diagnosed with myxoid liposarcomas at our institution underwent whole-body MRI along with other conventional imaging methods. We divided the whole body into 38 sections (7 soft tissue sections and 31 bone tissue sections). In total, there were 570 regions (105 soft tissue regions and 465 bony regions) in 15 patients (10 men and 5 women) who underwent whole-body MRI.Of 105 soft tissue regions, there were 4 true positives, 3 false positives, 1 false negative, and 97 true positives. Of 465 bone tissue regions, there were 11 true positives, 5 false positives, 2 false negatives, and 447 true negatives. In soft tissue, whole-body MRI for the detection of metastatic lesion showed a sensitivity of 80%, a specificity of 97.0%, a positive predictive value of 57.1%, and a negative predictive value of 99.0%. In bone tissue, whole-body MRI had a sensitivity of 84.6%, a specificity of 98.9%, a positive predictive value of 68.8%, and a negative predictive value of 99.6%.Whole-body MRI is feasible and effective for detecting bone and soft tissue metastasis in patients with myxoid liposarcoma.

Integrin α6(high) cell population functions as an initiator in tumorigenesis and relapse of human liposarcoma

The relapse and resistance to chemo- and radiotherapy are main problems in the treatment of human liposarcoma. It is important to find a functional marker existing in the liposarcoma cells for targeting. In this article, we established a new sub-cell line SW872-S cells with high tumorigenicity from human liposarcoma SW872 cells by repeated inoculation approach. The characteristic of the sub-cell line is linked to the high levels of integrin α6 on the surface. The integrin α6(high) cells show much higher tumor initiation and self-renewal potential in vivo than integrin α6(low) cells do. Targeting integrin α6 with its specific short interfering RNA and antibody significantly inhibits the cell adhesion to laminin and the tumor growth in vitro and in vivo, respectively. Interestingly, integrin α6 marks almost all of the surgical biopsy specimens of patients with liposarcoma relapse. Moreover, integrin α6 is found to coexpress with CD13, which might contribute to the antiapoptosis ability of integrin α6(high) cells. Consistently, integrin α6(high) cells are more sensitive to the CD13 inhibitor bestatin, and 61% of 23 other human tumor cell lines also contain integrin α6(high) CD13(high) subgroup. These results provide evidence, for the first time, to our knowledge, that integrin α6 and CD13 can serve as functional markers of the tumor-initiation subcell population in human liposarcoma as well as other cancers for therapeutic targeting.

Primary liposarcoma of the heart

The author reports a case of a 64-year-old man, who presented with a 4-week history of dyspnoea and dizziness suffering from a large mass in the pericardium. CT of the chest showed a lobulated mass in the pericardial sac located between the pulmonary veins and the ascending aorta reaching the superior vena cava. The tumour was completely resected and histopathological analysis revealed the tumour to be a well-differentiated lipoma-like and focal sclerosing liposarcoma, which was composed predominantly of adipocytes with hyperchromatic nuclei and eosinophilic-to-vacuolated cytoplasm disrupted by fibrous septa. Two years after initial tumour diagnosis the patient is still alive without signs of tumour recurrence.

New frontiers in the treatment of liposarcoma, a therapeutically resistant malignant cohort

The adipogenic origin-derived liposarcoma (LPS) family is the most common soft tissue sarcoma histological subtype. This group is composed of three categories as per the 2002 WHO guidelines: (1) well-differentiated and dedifferentiated liposarcoma (WDLPS/DDLPS); (2) myxoid and round cell liposarcoma (MLS and RCL); and (3) pleomorphic liposarcoma (PLS). While clustered together, these histological subtypes are widely diverse in their clinical, pathological, and molecular characteristics. In general, surgery still remains the mainstay of LPS therapy and the only approach offering the potential of cure. Effective therapeutic strategies for locally advanced and metastatic disease are currently lacking and are crucially needed. With the current gradually increasing knowledge of LPS genetic- and epigenetic-associated deregulations, the ultimate goal is to develop drugs that can specifically eliminate LPS cells while sparing normal tissues. This tumor-tailored target-orientated approach will hopefully result in a significant improvement in the outcome of patients suffering from these poor prognosis malignancies.

Multi-level total en bloc spondylectomy for solitary lumbar metastasis of myxoid liposarcoma

This article reports a case of solitary lumbar metastasis of myxoid liposarcoma treated by multi-level total en bloc spondylectomy. Myxoid liposarcoma has a predisposition to initial metastasis at an extrapulmonary site including bone. However a bone scan and FDG-PET, which are generally used for a whole-body screening of metastasis, are not sensitive to bone metastasis from myxoid liposarcoma. These situations make it difficult to achieve curative resection of a bone metastasis, especially in the spine. The patient was a 54-year-old man who had an intralesional excision of soft tissue tumor in the right thigh. He had an additional expansive excision due to the histological diagnosis of myxoid liposarcoma at the initial surgery. Four years postoperatively, L3 metastasis expanding to the adjacent vertebrae was detected using magnetic resonance imaging. Plain radiographs and computed tomography showed no evidence of the tumor involving the lumbar spine. A bone scan was false-negative although FDG-PET showed mild uptake. There was no other metastasis on the further examination. Multi-level total en bloc spondylectomy was performed using a combined posterior-anterior approach. The lumbar nerves were dissected and preserved. The vertebral bodies of L2, 3 and the upper half of L4, which had been invaded by the tumor, were removed en bloc using an anterolateral extraperitoneal approach. He had no local recurrence or further metastasis until he died of ischemic cardiac disease 14 months postoperatively.

Primary mediastinal liposarcoma, with 6 years of follow-up to autopsy, revealed histopathological features of primary and metastatic lesions

Primary mediastinal liposarcoma was observed in a 73-year-old man. Because of tight adhesions to adjacent tissues, neither complete resection nor surgical debulking of the tumor was possible. A T-tube was inserted into the patient's trachea for severe dyspnea, and he was treated with radiotherapy and an oral peroxisome proliferator-activated receptor-gamma agonist. The patient died 6 years after the initial diagnosis. Autopsy revealed liposarcoma composed of 3 subtypes in the primary tumor: well-differentiated, dedifferentiated, and round cell components. Round cell and dedifferentiated liposarcomas were predominantly observed in the metastatic nodules.

[A case of liposarcoma arising in the mesentery]

A liposarcoma is the most common soft tissue sarcoma in adults with an incidence of about 20% of all soft tissue sarcomas. Although incidence differs from a region of origination, a case arisen from mesentery has rarely been reported. We experienced a case of liposarcoma arising from the mesentery of a 51-year-old male patient. He was treated by wide excision. Histologically, the tumor was composed of a mixed well-differentiated liposarcoma with myxoid and spindle cell type.

Radiosensitivity translates into excellent local control in extremity myxoid liposarcoma: a comparison with other soft tissue sarcomas

BACKGROUND

Myxoid liposarcoma has been reported to be more radiosensitive compared with other soft tissue sarcomas (STS). The authors report the results of multidisciplinary treatment of extremity myxoid liposarcoma compared with a contemporary cohort of other STS subtypes with an emphasis on the role of radiotherapy (RT) in improving local control.

METHODS

Between 1989 and 2004, 691 patients were identified from a prospective STS database who underwent combined management for localized extremity STS and were followed for a minimum of 12 months or until death. All patients underwent surgery together with pre or postoperative RT, depending on their presenting characteristics and resection margins. Demographics and outcomes were compared between patients with myxoid liposarcoma and other STS subtypes (other-STS).

RESULTS

Of 691 patients, 88 patients had myxoid liposarcoma and 603 had other STS subtypes (other-STS). Median age was 48 and 60 years for the myxoid liposarcoma and other-STS groups, respectively. Median follow-up was 86 and 61 months, respectively. For myxoid liposarcoma and other-STS groups, preoperative RT was used in 57% versus 61% of patients and postoperative RT in 43% versus 39%, respectively. The 5-year local recurrence-free survival was 97.7% for patients with myxoid liposarcoma compared with 89.6% for patients with other-STS tumors (P = .008). High-grade tumors were present in 7% and 59% of myxoid liposarcoma and other-STS patients, respectively (P = .0003). Two myxoid liposarcoma patients with local recurrence had positive resection margins, whereas only 33% of patients in the other-STS group who developed a local recurrence had positive resection margins. No patients with myxoid liposarcoma required amputation as primary management, whereas 8 (1.3%) required amputation as primary management in the other-STS group. Systemic disease control was superior in myxoid liposarcoma compared with other-STS patients, with 5-year overall and metastasis-free survival rates of 93.9% versus 76.4% (P = .0008) and 89.1% versus 66.0% (P = .0001) respectively. Of 12 myxoid liposarcoma patients with distant metastases, 7 appeared in nonpulmonary sites. In comparison, 205 (34%) patients with other-STS tumors developed systemic disease but 78% had pulmonary metastases.

CONCLUSIONS

Multidisciplinary management of extremity STS achieves high rates of local control. Myxoid liposarcoma is associated with higher rates of local control compared with other STS subtypes, after combined surgery and radiation, suggesting a particular radiosensitivity that can be exploited to improve oncologic outcome in appropriate cases.

Prognostic factors and expression of MDM2 in patients with primary extremity liposarcoma

OBJECTIVE

The objective of this study was to investigate MDM2 (murine double minute 2) protein expression and evaluate its relationship with some anatomical and pathological aspects, aiming also to identify prognostic factors concerning local recurrence-free survival, metastasis-free survival and overall survival in patients with primary liposarcomas of the extremities.

MATERIALS AND METHODS

Of 50 patients with primary liposarcomas of the extremities admitted to a Reference Service, between 1968 and 2004, 25 were enrolled in the study, following eligibility and exclusion criteria.

RESULTS

The adverse factors that influenced the risk for local recurrence in the univariant analysis included male sex (P = 0.023), pleomorphic histological subtype (P = 0.027), and high histological grade (P = 0.007). Concerning metastasis-free survival, age less than 50 years (P = 0.040), male sex (P = 0.040), pleomorphic subtype (P < 0.001), and high histological grade (P = 0.003) had a worse prognosis. Adverse factors for overall survival were age under 50 years (P = 0.040), male sex (P = 0.040), pleomorphic subtype (P < 0.001), and high histological grade (P = 0.003).

CONCLUSIONS

There was no correlation between immunohistochemically observed MDM2 protein expressions and the anatomical and pathological variables studied. The immunohistochemical expression of MDM2 protein was not considered to have a prognostic value for any of the surviving patients in this study (local recurrence-free survival, metastasis-free survival, or overall survival). The immunoexpression of MDM2 protein was a frequent event in the different subtypes of liposarcomas.

Metastatic myxoid liposarcomas: imaging and histopathologic findings

OBJECTIVE

The objective was to describe the imaging and histopathologic characteristics of metastatic myxoid liposarcomas.

MATERIALS AND METHODS

This retrospective study was approved by the institutional review board and complied with HIPAA guidelines. The study group comprised 12 patients with metastatic myxoid liposarcoma who underwent MRI, CT, or FDG-PET. The location and imaging characteristics of the metastatic lesions were recorded, and the histopathology of all metastatic lesions was reviewed.

RESULTS

There were 23 histologically proven metastases in 12 patients. Based on imaging criteria, there were 41 metastases. The mean time from the diagnosis of primary tumor to the first metastasis was 4.4 years. Sixty-seven percent of patients had bone and soft tissue metastases, 33% had pulmonary metastases, 33% had liver metastases, 25% had intra-abdominal, and 16% retroperitoneal metastases. CT demonstrated well-defined lobulated masses with soft tissue attenuation in all cases, without macroscopic fat component. In cases of osseous metastases, CT showed mixed lytic and sclerotic foci, with bone destruction in advanced cases. MRI demonstrated fluid-like signal intensity with mild heterogeneous enhancement in cases of soft tissue metastases. In osseous metastases, MRI showed avid heterogeneous enhancement. FDG-PET showed no significant FDG uptake for all metastases. MRI was the most useful imaging modality for osseous and soft tissue metastases.

CONCLUSION

Myxoid liposarcomas are soft tissue sarcomas, with a high prevalence of extrapulmonary metastases. The bones and soft tissues were the most common site of involvement, followed by the lungs and liver. MRI was the most sensitive modality in the detection of osseous and soft tissue metastases, and is the recommended modality for the diagnosis and follow-up of bone and soft tissue involvement.

Sarcoma

Sarcomas comprise a heterogeneous group of mesenchymal neoplasms. They can be grouped into 2 general categories, soft tissue sarcoma and primary bone sarcoma, which have different staging and treatment approaches. This review includes a discussion of both soft tissue sarcomas (malignant fibrous histiocytoma, liposarcoma, leiomyosarcoma, synovial sarcoma, dermatofibrosarcoma protuberans, angiosarcoma, Kaposi sarcoma, gastrointestinal stromal tumor, aggressive fibromatosis or desmoid tumor, rhabdomyosarcoma, and primary alveolar soft-part sarcoma) and primary bone sarcomas (osteosarcoma, Ewing sarcoma, giant cell tumor, and chondrosarcoma). The 3 most important prognostic variables are grade, size, and location of the primary tumor. The approach to a patient with a sarcoma begins with a biopsy that obtains adequate tissue for diagnosis without interfering with subsequent optimal definitive surgery. Subsequent treatment depends on the specific type of sarcoma. Because sarcomas are relatively uncommon yet comprise a wide variety of different entities, evaluation by oncology teams who have expertise in the field is recommended. Treatment and follow-up guidelines have been published by the National Comprehensive Cancer Network (www.nccn.org).

Risk assessment in liposarcoma patients based on FDG PET imaging

PURPOSE

Tumor grade and subtype are considered standard parameters for risk assessment in patients with liposarcoma. The aim of this study was to assess the clinical value of [(18)F]fluorodeoxyglucose (FDG) PET-derived maximum standardized uptake value (SUV(max)) for prediction of outcome in liposarcoma patients.

METHODS

(18)F-FDG PET was performed in 54 patients with liposarcoma prior to therapy. SUV(max) was calculated for each tumor and results were correlated with tumor grade, subtype, and relapse-free survival.

RESULTS

SUV(max) ranged from 0.4 to 15.9 (mean 3.6) and was significantly lower in grade I than in grade II and grade III tumors. SUV(max) was 2.3+/-1.7, 3.5+/-1.5, 4.8+/-2.5, and 5.6+/-5.8 in well-differentiated, myxoid/round cell, dedifferentiated, and pleomorphic subtypes, respectively. Borderline differences (p=0.059) were found between tumor SUV(max) in patients with and without relapse. Using a SUV of 3.6 as cut-off, the accuracy in predicting a relapse was 75%. Tumor grade yielded a lower accuracy for predicting relapse (50%), as did tumor subtype (35%). In Kaplan-Meier survival analysis, patients with a SUV(max) >3.6 had a significantly shorter disease-free survival of 21 months compared with 44 months in patients with a SUV(max) </=3.6. Tumor grading and tumor subtype did not yield significant differences.

CONCLUSION

Pretherapy tumor SUV obtained by FDG PET imaging was a more useful parameter for risk assessment in liposarcoma than tumor grade or subtype. A SUV(max) of more than 3.6 resulted in a significantly reduced disease-free survival and identified patients at high risk for developing early local recurrences or metastatic disease.

Epineural dissection is a safe technique that facilitates limb salvage surgery

Epineural dissection has been used in our center for the past 19 years as a means of preserving the sciatic nerve when it is closely applied to a soft tissue sarcoma. Our aim in doing this study was to establish if this technique resulted in increased local or systemic recurrence of the tumor. In addition, we assessed functional outcomes. Forty-three patients had an epineural dissection done during primary resection of a malignant thigh tumor. These patients were compared with 44 patients with tumors that were of similar size and grade but distant from the nerve. We also analyzed seven patients who required nerve resection. There was no difference in local or systemic recurrence rates or functional outcomes when epineural dissection was done. Those with nerve resection had worse Musculoskeletal Tumor Society scores but equivalent Toronto Extremity Salvage Scores to those with an epineural dissection. We conclude that epineural dissection (when combined with radiotherapy in a planned multidisciplinary approach to limb salvage) is both a safe and effective procedure to preserve the sciatic nerve and that nerve resection should be limited to situations where the nerve is completely encased in tumor.

LEVEL OF EVIDENCE

Prognostic study, Level II-2 (retrospective cohort study). See the Guidelines for Authors for a complete description of levels of evidence.

Soft tissue sarcoma: Advances in understanding and management

Soft tissue sarcomas are a rare group of neoplasms readily dispersed throughout the body with different histopathologies and different outcomes. The present review summarizes advances made in biology, distribution and natural history, and emphasises predictive models for outcome. Complete resection remains the major factor in providing cure, with limited benefits in the control of the local disease by radiation therapy and only minimal benefit of systemic therapy for metastatic disease. Identification of targeted therapy utilising direct specific molecular targets raises hope that future progress in control, if not cure, is realistic.

Differential gene expression in liposarcoma, lipoma, and adipose tissue

Malignant transformation is thought to be associated with changes in the expression of a number of genes, and this alteration in gene expression is felt to be critical to the development of the malignant phenotype. Sarcomas represent a diverse group of tumors derived from cells of mesenchymal origin. Marked heterogeneity exists in the biological behavior of sarcomas, even within histologic subtypes of sarcomas. In an effort to better understand the biology of liposarcomas, gene expression in normal adipose tissue, lipomas, and liposarcomas was examined using the Affymetrix microarray technology. Differences in gene expression were quantified as the fold change in gene expression among the sample sets. Differences in gene expression among normal adipose tissue, lipomas, and liposarcomas were observed. In addition, genes expressed uniquely in liposarcoma among these and 18 other tissue sample sets were identified. Gene sets were devised that allowed the separation of liposarcomas from other samples, and most normal adipose tissue from most lipomas using the Eisen clustering software "Cluster." We conclude that differences in gene expression can be identified among different tumors derived from the adipocyte series. Such differences in gene expression may help differentiate among subtypes of sarcomas, and may also yield clues to the pathophysiology of this heterogeneous group of tumors.

Primary pleomorphic liposarcoma of the parotid gland: a case report and review of the literature

Although liposarcomas are the most common type of sarcoma in adults, they are rare in the head and neck region. Pleomorphic liposarcoma is the least common histologic subtype in all locations. To our knowledge, there have been only 11 reported cases of primary liposarcomas of the major salivary glands, and the pleomorphic variant arising in the parotid gland has been reported only once before. Only 2 of the 11 reported cases of liposarcoma of the major salivary glands in the literature have died of disease, and both cases were of the pleomorphic subtype. We report a case of pleomorphic liposarcoma arising in the left parotid gland of an 80-year-old woman. This case report highlights that, despite conservative surgery followed by 2 local recurrences, our patient is doing well with minimal local morbidity and no demonstrable metastases 30 months after the initial diagnosis. We also present a review of the literature on the subject.

Pleomorphic Liposarcoma

Pleomorphic liposarcoma is an uncommon form of liposarcoma that only recently has been properly characterized. A series of 57 cases is presented. Patient age at presentation ranged from 27 to 95 years (median, 54 years), and there was a slight male predilection (male/female ratio = 1.2:1). Tumors most frequently involved the lower limb (47% of cases) or upper limb (18%). Other anatomic sites, including trunk (14%), retroperitoneum (7%), head and neck (5%), abdomen/pelvis (5%), and spermatic cord (4%), were less frequently involved. Tumor size ranged from 1.5 to 21 cm (median, 8 cm), with deep (subfascial) locations (39 cases) being more frequent than subcutaneous (11 cases) or dermal sites (5 cases). All lesions showed features of pleomorphic sarcoma and at least focally contained typical multivacuolated lipoblasts. Although there was considerable overlap, tumors fell into three broad categories: high-grade pleomorphic/spindle cell sarcoma with scattered lipoblasts or sheets of lipoblasts (60%), high-grade pleomorphic sarcoma with epithelioid areas and scattered lipoblasts (28%), and intermediate- to high-grade sarcoma predominantly resembling myxofibrosarcoma except for the presence of lipoblasts (12%). Immunohistochemistry revealed focal staining for smooth muscle actin in 13 of 29 cases (45%), S-100 protein positivity in lipoblasts in 15 of 45 cases (33%), focal staining for keratin in 6 of 28 cases (21%), including 5 of 13 (38%) with epithelioid morphology, and focal staining for desmin in 4 of 30 cases (13%). Follow-up data, available in 50 patients (88%) (median, 33 months), showed local recurrence in 34% of patients, systemic metastases in 32%, and tumor-related death in 32%. Only 2 of the 16 superficial (dermal or subcutaneous) lesions metastasized. Five-year overall, local recurrence-free, metastasis-free, and disease-free survivals were 63%, 58%, 58%, and 39%, respectively. By univariate analysis, central (nonextremity) location, deep situation, tumor size > or =10 cm, mitotic rate > or =10 per 10 HPF, necrosis, and epithelioid morphology were associated with a worse prognosis. However, by multivariate analysis, only age > or =60 years, central location, tumor size, and mitotic rate remained independent predictors for an adverse outcome. By multivariate analysis, wide local excision or amputation and postoperative radiotherapy protected against local recurrence.

The impact of chemotherapy on the survival of patients with high-grade primary extremity liposarcoma

OBJECTIVE

To determine if chemotherapy offers a survival benefit to patients with large, high-grade, primary extremity liposarcoma.

SUMMARY BACKGROUND DATA

The impact of chemotherapy on the survival of patients with primary extremity soft tissue sarcoma is controversial and its effect on individual histologic subtypes is not defined.

PATIENT AND METHODS

Two prospectively collected sarcoma databases were used to identify all patients with >5 cm, high-grade, primary extremity liposarcoma that underwent surgical treatment of cure from 1975 to 2003 (n = 245). Clinical, pathologic and treatment variables were analyzed for disease-specific survival (DSS), distant recurrence-free survival (DRFS) and local recurrence-free survival (LRFS).

RESULTS

Sixty-three (26%) patients were treated with ifosfamide based chemotherapy (IF), 83 (34%) with doxorubicin based chemotherapy (DOX) and 99 (40%) received no chemotherapy (NoC). To assess the impact of DOX, a contemporary cohort analysis of patients treated from 1975 to 1990 was performed. The 5 year DSS of the DOX treated patients was 64% (53%-74%) compared with 56% (51%-79%) for the NoC patients (log-rank P value = 0.28). To assess the impact of IF, a contemporary cohort analysis of patients treated from 1990 to 2003 was performed. The 5 year DSS of the IF treated patients was 92% (84%-100%) compared with 65% (51%-79%) for the NoC patients (log-rank P value = 0.0003). Independent prognostic factors for improved DSS were smaller size (HR = 0.7, P = 0.01), myxoid/round cell histologic subtype (HR = 0.3, P = 0.03) and treatment with IF (HR = 0.3, P = 0.01). The five-year DRFS of the IF treated patients was 81% (70%-92%) compared with 63% (50%-76%) for the NoC patients (log-rank P value = 0.02). The 5 year LRFS of the IF treated patients was 86% (76%-96%) compared with 87% (77%-97%) for the NoC patients (log-rank P value = 0.99).

CONCLUSIONS

In patients with large, high-grade, primary extremity liposarcoma; DOX is not associated with improved DSS and IF is associated with an improved DSS. Treatment with IF should be considered in patients with high-risk primary extremity liposarcoma.

Liposarcomas in dogs: 56 cases (1989–2000)

OBJECTIVE

To determine the biological behavior of liposarcomas in dogs and identify clinical signs, the effect of treatment on survival time, and potential prognostic factors.

DESIGN

Retrospective study.

ANIMALS

56 dogs with histologically confirmed liposarcoma.

PROCEDURE

Information was obtained on signalment, tumor size, location of the tumor, stage of disease, remission duration, overall survival time, cause of death, type of surgery (incisional biopsy, marginal excision, or wide excision), and any additional treatments given.

RESULTS

Surgery consisted of incisional biopsy in 6 dogs, marginal excision in 34, and wide excision in 16. Twenty-five dogs had histologic evidence of tumor cells at the surgical margins and 28 did not (status of the margins was unknown in 3 dogs). Twelve of 43 dogs had local recurrence. Median survival time was 694 days, and the only factor significantly associated with survival time was type of surgery performed. Median survival times were 1,188, 649, and 183 days, respectively, for dogs that underwent wide excision, marginal excision, and incisional biopsy. Factors that were not found to be significantly associated with survival time included tumor size, status of the margins, tumor location, and histologic subtype.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that in dogs, liposarcomas are locally invasive neoplasms that rarely metastasize and occur primarily in appendicular or axial locations and that wide excision is preferred to marginal excision when feasible.

Experimental approaches to treatment of soft tissue sarcoma

The experimental approaches described in this article represent potential new approaches for targeted therapy. Thus far, none of the preclinical data have demonstrated a cure for sarcomas; however, the antitumor effects of many of these new agents seem to be enhanced when the agents are combined with chemotherapeutic agents. The combination of novel therapeutics with conventional chemotherapy may be the most effective strategy in terms of maximization of tumor killing and minimization of toxicity and the risk of drug resistance. Not only are new drugs being developed for treatment of sarcomas but new ways of delivering drugs are also being investigated. The angiogenic, or metronomic, schedule of drug delivery may be preferable to conventional schedules in achieving optimal tumor inhibition. In addition, isolated limb perfusion is a unique approach to delivery of drugs, such as TNF and melphalan, for sarcomas and melanomas [137, 138]. The advantages of this method of drug delivery include the ability to administer therapeutic agents in high concentrations to a specific region of the body without systemic toxicity. Further advances in the understanding of the biology of sarcomas along with novel approaches to delivery of drugs are crucial to the development of new and effective therapies.

Pediatric soft tissue sarcomas

Many of the soft tissue sarcomas that occur in children are of the same histology as those in adults; however, the relative prevalence of these sarcomas is different between children and adults. In some cases, the biologic behavior of pediatric sarcomas is more benign than that in adults. Treatment for sarcomas in children is also different. Pediatric sarcomas are more commonly responsive to chemotherapy. Furthermore, in children who are still growing, surgery and radiation are associated with higher morbidity than in adults. This article discusses the diagnosis and treatment of rhabdomyosarcoma and undifferentiated sarcomas, with an emphasis on surgical considerations, and the diagnosis and treatment of nonrhabdomyosarcomatous soft tissue sarcomas in children.

Metastatic patterns of extremity myxoid liposarcoma and their outcome

BACKGROUND AND OBJECTIVES

Extremity myxoid liposarcomas have a unique extrapulmonary metastatic potential. We studied the metastatic pattern of extremity liposarcomas to determine what types of posttreatment imaging may be of value in the follow-up these patients.

METHODS

Twenty-two patients from a total of 128 patients with primary extremity liposarcoma were treated at a tertiary care institution for subsequent metastases from January 1981 to January 2000. Median follow-up was 45 months (range: 6-270 months). Data on these patients was prospectively collected and then retrospectively analyzed for effect of metastatic pattern and treatment on outcome.

RESULTS

Of these 22 patients, extrapulmonary metastases developed in 10, combined pulmonary and extrapulmonary metastases developed in 6, and isolated pulmonary metastases developed in 6. Of the 16 patients with extrapulmonary metastases, 13 were of the myxoid subtype. Of the 49 patients with extremity myxoid liposarcomas, metastases developed in 14 (29%). The most common sites of metastases among these 14 patients include: the retroperitoneum, 10 patients (71)%; intra-abdominal extra-hepatic, 7 patients (50%); spinal/paraspinal, 6 patients (43%). Only 3 of the patients are alive and disease free and all 3 of these patients are from the subgroup of 10 patients with only extra-pulmonary metastases (2 intra-abdominal and 1 retroperitoneal).

CONCLUSIONS

Extremity myxoid liposarcomas have an unusually high predilection for extra-pulmonary metastases, frequently without any pulmonary metastases. After treatment of the primary tumor, these patients should be followed with periodic chest X-ray and abdominal/pelvic computed tomography (CT) scans. Any back or neurologic complaints should prompt additional imaging of the appropriate spinal area. Consideration should be given to surgical and adjuvant treatment of metastatic disease when appropriate.

Pleomorphic liposarcoma: clinicopathologic, immunohistochemical, and follow-up analysis of 63 cases: a study from the French Federation of Cancer Centers Sarcoma Group

The clinicopathologic and immunohistochemical features of 63 pleomorphic liposarcomas are presented. There were 35 men and 28 women (median age 63 years; range 18-93 years). Tumor size ranged from 2 to 23 cm (median 10 cm). Tumor locations included lower extremity (36.5%), especially the thigh (28.5%), limb girdles (17.5%), upper extremity (16%), thoracoabdominal wall (9.5%), and internal trunk (20.5%). A total of 75% were deep seated and/or extracompartmental. Histologically, lesions show a varying combination of lipogenic and nonlipogenic areas characterized by malignant fibrous histiocytoma-like, round cell liposarcoma-like, and/or epithelioid/carcinoma-like features. A pericytic pattern was focally present in 15 (24%) tumors. Eighteen (29%) lesions were grade 2, and 45 (71%) were grade 3 sarcomas. Tumor necrosis was observed in 51 (81%) cases, vascular invasion in three, and mitotic counts ranged from 3 to 124 per 10 high power fields (median 25). Lipogenic areas were S-100 protein immunoreactive, at least focally, in 20 of 42 (48%) cases. Nonlipogenic areas showed focal reactivity for smooth muscle actin (24 of 49; 49%), desmin (9 of 48; 19%), CD34 (18 of 45; 40%), S-100 protein (5 of 49, 10%), CD68 (6 of 46, 13%), and epithelial membrane antigen (13 of 49, 26.5%). Epithelioid areas showed epithelial membrane antigen (4 of 11; 36%) but not cytokeratin (0 of 11) reactivity. Treatment procedures in 51 patients consisted of simple tumorectomy (16) and wide excision (33). Five and 31 patients received neoadjuvant and adjuvant chemotherapy and/or radiation therapy, respectively. Follow-up (48 patients, range 7-276 months; median 38 months) showed a 45% local recurrence rate and a 42.5% metastasis rate, metastases occurring mostly in lungs and pleura. Seventeen patients (35%) died of disease, of whom none was metastatic at diagnosis. Five-year overall, metastasis-free, and local recurrence-free survivals were 57%, 50%, and 48%, respectively. Patient age > or =60 years, truncal tumor location, deep situation, tumor size >5 cm, vascular invasion, and incomplete tumor excision were significant adverse prognostic factors. Tumor grade and histology did not affect patient outcome. In conclusion, pleomorphic liposarcoma is a rare, often deep-seated and limb-based aggressive and metastasizing neoplasm of late adulthood. It shows a wide range of morphologic appearances, but tumor grade and histology have no effect on patient outcome.

Expression of the FUS domain restores liposarcoma development in CHOP transgenic mice

Fusion proteins created by chromosomal abnormalities are key components of mesenchymal cancer development. The most common chromosomal translocation in liposarcomas, t(12;16)(q13;p11), creates the FUS-CHOP fusion gene. In the past, we generated FUS-CHOP and CHOP transgenic mice and have shown that while FUS-CHOP transgenic develop liposarcomas, mice expressing CHOP, which lacks the FUS domain, display essentially normal white adipose tissue (WAT) development, suggesting that the FUS domain of FUS-CHOP plays a specific and critical role in the pathogenesis of liposarcoma. To test the significance of FUS and CHOP domain interactions within a living mouse, we generated mice expressing the FUS domain and crossed them with CHOP-transgenic mice to generate double-transgenic FUSxCHOP animals. Here we report that expression of the FUS domain restores liposarcoma development in CHOP-transgenic mice. Our results provide genetic evidence that FUS and CHOP domains function in trans for the mutual restoration of liposarcoma. These results identify a new mechanism of tumor-associated fusion genes and might have impact beyond myxoid liposarcoma.

Pleomorphic rhabdomyosarcoma in adults: a clinicopathologic study of 38 cases with emphasis on morphologic variants and recent skeletal muscle-specific markers

Pleomorphic rhabdomyosarcoma (PRMS) is a rare and controversial tumor of skeletal muscle phenotype. Diagnostic criteria for PRMS by combined histology and currently available immunohistochemistry have not been clearly defined. We report 38 pleomorphic rhabdomyosarcomas in adults, explore morphologic variants, and discuss our experience with both specific and nonspecific skeletal muscle markers in these tumors. Clinical data, morphology, and immunohistochemistry were reviewed. Electron microscopy was performed. Of 38 cases, there were 28 males and 10 females. Patient ages ranged from 21 to 81 years (median = 54 y; mean = 51 y). Tumors were located in the lower extremity (n = 18), abdomen/retroperitoneum (n = 6), chest/abdominal wall (n = 5), spermatic cord/testes (n = 4), upper extremity (n = 3), and one each in the mouth and orbit. Tumor sizes ranged from 1.5 to 15.0 cm (mean = 7.3 cm; median = 6.8 cm). The cases were divided into three variants, each with large, atypical, pleomorphic polygonal rhabdomyoblasts (PRMB) with abundant eosinophilic cytoplasm in varying numbers and different morphologic backgrounds of round or spindled rhabdomyoblasts (RMB). 1. Classic PRMS: Predominantly atypical PRMB in sheets (n = 8). 2. Round cell PRMS: Clusters of PRMB throughout the tumor with a background of slightly atypical, medium-sized, round, blue RMB (n = 13). 3. Spindle cell PRMS: Scattered PRMB in a predominance of atypical spindled RMB arranged in a storiform growth pattern (n = 17). Immunohistochemistry revealed the following: myoglobin (37/38), MyoD1 (19/36), skeletal muscle myogenin (myf4; 19/34), fast skeletal muscle myosin (4/5), desmin (36/38), muscle-specific actin (MSA; 25/35), smooth muscle actin (SMA; 15/33), and muscle specific myogenin (myf3; 25/35). Immunohistochemistry was supportive of skeletal muscle differentiation with at least one positive skeletal muscle-specific marker (myoglobin, MyoD1, fast skeletal muscle myosin, or myf4). In addition, all cases had some positivity for nonspecific muscle markers (desmin, MSA, SMA, myf3). Electron microscopy (EM), performed on eight selected cases from all three morphologic groups, demonstrated definitive skeletal muscle differentiation in all cases. Follow-up, available on 30 (79%) cases, revealed that 70% of patients died of disease (mean 20 months, range 1 month-108 months), 3% were alive with disease at 12 months (n = 1); and 27% had no evidence of disease (mean, 83 mo; range, 18 to 108 mo). PRMS, a tumor of predominantly middle-aged adult males in the lower extremity, can be diagnosed by the morphologic presence of scattered PRMB with immunohistochemical evidence of at least one skeletal muscle-specific marker. There are three morphologic variants of PRMS. The appropriate diagnosis of PRMS is significant as it is a high-grade sarcoma, with an aggressive clinical course.

Predictive value of grade for metastasis development in the main histologic types of adult soft tissue sarcomas: a study of 1240 patients from the French Federation of Cancer Centers Sarcoma Group

BACKGROUND

Histologic grade is said to be the most important prognostic factor in adult soft tissue sarcomas (STS), but most grading systems have been tested in the overall sarcoma group and the predictive value of histologic grade needs to be assessed specifically for each of the histologic categories.

METHODS

From 1980 to 1994, 1240 nonmetastatic patients were entered in the French STS database. The following parameters were studied: patient's age and gender, previous history, tumor location, size and depth, neurovascular or bone involvement (NBI), histologic type and subtype, and grade (the French Federation of Cancer Centers [FNCLCC] system). Median follow-up for the survivors was 88 months; only 5% of patients were lost to follow-up. The authors performed univariate and multivariate analyses for metastasis-free survival for the overall sarcoma group and for every main histologic type.

RESULTS

In order of importance, parameters were respectively retained as independent predictors of metastasis as follows: grade, tumor size, NBI and tumor depth for the overall group, grade and NBI for malignant fibrous histiocytomas (n = 349), tumor size, histologic subtype and grade for liposarcomas (n = 188), NBI, grade and tumor size for leiomyosarcomas (n = 148), grade and NBI for synovial sarcomas (n = 125), grade for unclassified sarcomas (n = 140), and sarcomas of other types (n = 158). No parameter was significant for malignant schwannomas (n = 72) or for rhabdomyosarcomas (n = 60).

CONCLUSION

In this study, histologic grade appeared as an independent predictor of metastasis development in the main histologic types of adult STS, with the exception of malignant schwannomas and rhabdomyosarcomas.

Malignant fibrous histiocytoma: an institutional review

BACKGROUND

A thorough understanding of malignant fibrous histiocytoma (MFH), the most common subtype of soft tissue sarcoma, will lead to improved histologic-specific protocols.

METHODS

126 patients with histologically confirmed MFH were analyzed. The median follow-up was 42 months (range 1-233 months).

RESULTS

Overall survival was 58% at 5 years and 38% at 10 years. Grade significantly influenced prognosis, with 10-year survival of 90%, 60%, and 20% for low, intermediate, and high grade tumors, respectively (p = 0.0007). Distant metastases at initial presentation (p = 0.0002) and size of the primary tumor (p = 0.0007) influenced outcome. Neither anatomic site nor depth of the primary tumor were significant prognostic factors. Positive microscopic margins were associated with a decreased disease-free survival (p = 0.006).

CONCLUSIONS

Tumor grade, size, and distant metastases at initial presentation remain the most important prognostic factors for MFH. Resection with negative microscopic margins decreased the incidence of local recurrence.

Pleomorphic liposarcoma: a clinicopathologic analysis of 19 cases

Pleomorphic liposarcoma is a variant of liposarcoma defined morphologically by the presence of pleomorphic lipoblasts. Because of its rarity, there are limited studies with long-term follow-up information. Nineteen pleomorphic liposarcomas were studied. Unequivocal pleomorphic lipoblasts were required for inclusion. In each case, the following features were noted: tumor site; tumor size; tumor depth; predominant histologic pattern (epithelioid or malignant fibrous histiocytoma [MFH]-like); extent of necrosis (absent, less than 15%, or at least 15%); mitotic counts; treatment and clinical follow-up. Patients were 11 females and 8 males, aged 33-87 years (mean, 64.5 y; median, 70 y). Tumors involved the extremities (13 patients: intramuscular in 10, subcutaneous in 2, depth unknown in 1), retroperitoneum (4 patients), mediastinum (1 patient), and paratesticular region (1 patient). Size ranged from 4.5--31 cm (mean, 11.9 cm; median, 12.0 cm). Predominant pattern was epithelioid in 7 and MFH-like in 12. Necrosis was present in 15 (79%) and was extensive (36 15%) in 14 patients. Mitotic counts ranged from 0.2--3.4/10 high-power fields (mean, 1.4; median, 1.4) by the average-count method and from 1--6/10 high power fields by the highest count method (mean, 2.9; median, 3.0). All patients were treated surgically; 10 patients received adjuvant chemotherapy and/or radiation therapy. On follow-up of 18 patients (range, 2--129 mo; mean, 35.4 mo; median, 23 mo) nine (50%) were dead of disease (range, 2--48 mo; mean, 20.1 mo; median, 12 mo), one died of other causes 2 months after diagnosis, two were alive with disease, five were disease free, and one was alive at 129 months (tumor status unknown). Five had recurrences (range, 3--28 mo; mean, 14.4 mo; median, 8 mo), and four of five (80%) with recurrences were dead of disease. Metastases developed in eight patients (range, 4--48 mo; mean, 19.5 mo; median, 11.5 mo), most commonly to the lungs. In conclusion, pleomorphic liposarcoma is a rare tumor of adulthood that occurs most commonly in the deep, soft tissues of the extremities. It behaves as a high-grade sarcoma that frequently metastasizes, most commonly to the lungs. Although this tumor has a wide range of histologic appearances, no clinical or pathologic feature is predictive of a more aggressive clinical course.

Brain metastasis from a primary liposarcoma of the digit: case report

Soft-tissue sarcomas of the digit are uncommon. We herein report on a patient with a de-novo subungual right thumb liposarcoma with subsequent failure in the brain. The pertinent literature and recommendations for management are presented.