Multiple primary soft tissue sarcomas

A case report of 2 distinct primary sarcomas arising in an extremity in rapid succession

A 59-year-old male presented with a primary synovial sarcoma around his knee. Two months after resection, he presented with a new, rapidly-growing mass in the ipsilateral proximal thigh. A biopsy of the new mass demonstrated a pleomorphic liposarcoma, distinct from the prior synovial sarcoma. He underwent neoadjuvant radiation, followed by wide resection. He is now undergoing surveillance for recurrence. While 2 distinct primary sarcomas developing in rapid succession is rare, this case emphasizes the need for a complete work-up, including obtaining a tissue diagnosis for suspected recurrent lesions as this may alter treatment and follow-up recommendations.

Coincidence of Undifferentiated Pleomorphic Sarcoma and Epithelioid Leiomyosarcoma in a Patient; A Case Report

Introduction: Soft tissue sarcoma (STS) is a rare tumor with mesodermal origin. There are more than 100 different types of histology in sarcoma, which present different clinical behaviors. Liposarcoma, leiomyosarcoma, and undifferentiated pleomorphic sarcoma are among the most common pathologies Case Presentation: The patient was a 46-year-old man with 2 masses. The pathology of chest-wall mass (250 × 187 mm) was compatible with undifferentiated pleomorphic sarcoma (UPS). Arm mass (42 × 29 mm) pathology was suggestive of low-grade epithelioid leiomyosarcoma with smooth muscle differentiation. He received two cycles of mesna and doxorubicin and ifosfamide (MAI) regimen chemotherapy due to large and multiple masses, but the tumor size did not change. After consultation with an orthopedic oncosurgeon, wide masses resection was done. Adjuvant chemotherapy with an MAI regimen was continued for a total of 6 courses and radiation with a 60 Gy total dose to the posterior aspect of the chest wall. No recurrence or complications was observed after 4 months of follow-up. Conclusions: Multiple STS is rare; nevertheless, its probability, either synchronous or metachronous, should be considered during patient examine and follow-up. In the case of a secondary lesion, different histology is probable, and the patient should be biopsied and imaged.

Gastrointestinal stromal tumors (GISTs) and synchronous intra-abdominal malignancies: case series of a single institution's experience

Background: Gastrointestinal stromal tumors (GISTs) quite often co-exist with other primary tumors, as seen in up to 33% of cases. In the literature such occurrences have primarily been described through case reports and rarely through case series, which is not sufficient to prove if there is an association between these two entities.

Materials and Methods: We conducted a retrospective study using medical and pathological records from sixty-nine patients who underwent surgical treatment for GIST in a single university surgical department between 2011 and 2019. Seven cases of GIST accompanying a synchronous primary tumor were identified and included in the study.

Results: Survival analysis comparing the overall survival of patients with single GIST versus patients with concurrent GIST and another primary tumor, has shown no statistically significant difference between these two groups (p = 0.19). However, when comparing the recurrence rate, patients with synchronous GISTs and another primary tumor have a statistically significant increased possibility for recurrence (p = 0.02). Statistical analysis comparing the size of GISTs between the two groups has shown that patients with single GIST have larger tumors than patients with synchronous tumors (p = 0.048).

Conclusions: The synchronous occurrence of GISTs and other intra-abdominal tumors is more common than previously considered, though it is not yet clear if there is a causal association for the concomitant occurrence. Further studies are required to elucidate the genetic and molecular mechanisms of carcinogenesis and progression associating GIST and synchronous tumors.

Multiple Soft Tissue Sarcomas in a Single Patient: An International Multicentre Review

Developing multiple soft tissue sarcomas (STSs) is a rare process, sparsely reported in the literature to date. Little is known about the pattern of disease development or outcomes in these patients. Patients were identified from three tertiary orthopaedic oncology centres in Canada and the UK. Patients who developed multiple extremity STSs were collated retrospectively from prospective oncology databases. A literature review using MEDLINE was also performed. Six patients were identified in the case series from these three institutions, and five studies were identified from the literature review. Overall, 17 patients were identified with a median age of 51 years (range: 19 to 77). The prevalence of this manifestation in STS patients is 1 in 1225. The median disease-free interval between diagnoses was 2.3 years (range: 0 to 19 years). Most patients developed the secondary STS in a metachronous pattern, the remaining, synchronously. The median survival after the first sarcoma was 6 years, and it was 1.6 years after the second sarcoma. The 5-year overall survival rate was 83.3% and 50% following the first and second STS diagnoses, respectively. A diagnosis of two STSs does not confer a worse prognosis than the diagnosis of a single STS. Developing a second STS is a rare event with no identifiable histological pattern of occurrence. Presentation in a metachronous pattern is more common. A high degree of vigilance is required in patients with a previous STS both to detect both local recurrence and to identify new masses remote from the previous STS site. Acquiring an early histological diagnosis should be attempted.

Extremity soft tissue sarcoma with multiple primary malignancies--Characteristics and outcome

BACKGROUND

Understanding the incidence and characteristics of multiple primary malignancies (MPM) has implications for guiding appropriate treatment and surveillance of extremity soft tissue sarcoma (STS).

OBJECTIVES

We sought to examine the incidence of MPM in STS (MPM-STS), and compare their clinicopathologic characteristics and survival to those with STS only.

METHODS

585 patients who underwent surgery for extremity STS were reviewed. Logistic regression analyses to identify factors contributing to the development of MPMs and a 1:2 matched case-control analysis to compare survival outcome were performed.

RESULTS

Of the 585 patients analyzed, 34 (6%) with MPM were identified. On univariate logistic regression analysis, older age (>49 years) at STS diagnosis (p = 0.008) and histologic types of undifferentiated pleomorphic sarcoma or myxofibrosarcoma (p = 0.033) were significant. In multivariate analysis, only older age at STS diagnosis remained significant (OR = 2.5, p = 0.029). Cancer-specific survival of the MPM-STS group was significantly lower than that of the STS-only group (p = 0.031). However, there was no significant difference in STS-specific survival between the two groups (p = 0.208).

CONCLUSION

Our study suggests that MPM is not uncommon in extremity STS and older age at STS diagnosis is associated with risk of MPM. Prognosis of STS in the MPM-STS group seems similar to that of the STS-only group.

Metachronous Bilateral Extremity Soft Tissue Sarcomas

BACKGROUND

Soft tissue sarcomas (STS) account for approximately 1% of adult malignancies, with 50 to 60% occurring in the extremities. Liposarcoma is the most common type of STS and represent about 20% of total adult sarcomas. There are rare syndromes associated with increased risk of developing STS. Further, chemical compounds such as chlorinated phenols and a few chemotherapeutic drugs have been linked to STS, along with ionizing radiation. Nevertheless, the etiology is uncertain for most of these lesions.

CASE REPORT

This report details 2 cases of metachronous bilateral STS of the lower extremities. The first of these presented as a local recurrence of a previously resected right thigh liposarcoma and a new liposarcoma in the left thigh. As mentioned above, among the different subtypes of STS, liposarcoma has the highest tendency for multifocality. The second patient had multifocal metachronous leiomyosarcoma with lung metastases occurring simultaneously with the second presentation. Leiomyosarcoma is another subtype reported to present with multifocal disease.

CONCLUSIONS

Despite the rarity of bilateral lesions, their occurrence should not be overlooked in the initial diagnosis and follow-up of the initially detected tumor. Early detection can affect patient survival because their presence predicts unfavorable outcomes.

Patient With Slow-Growing Mediastinal Mass Presents With Chest Pain and Dyspnea

A 52-year-old white woman presented with severe pain over the right upper abdomen and nonpleuritic, right-sided, lower chest-wall pain. Her pain had progressively gotten more frequent and severe over the last 5 months. It was also associated with a nonexertional, pressure-like sensation in the central chest. The patient denied any shortness of breath, fevers, cough, or any sputum production. She was taking levothyroxine for hypothyroidism and was a 30-pack-year current smoker; there was no history of drug abuse or occupational exposure. Previous chest radiographs dating back to 5 years consistently showed an elevated right-sided hemidiaphragm without any infiltrates or effusions; cardiomediastinal structures were unremarkable. She had not had a previous workup for these abnormal findings.

Successful resection of a huge mediastinal liposarcoma extended to the bilateral thorax

Liposarcoma arising in the mediastinum is extremely rare. Herein we present a case of a 47-year-old man with a huge posterior mediastinal tumor that extended to the bilateral thorax. The patient underwent a complete resection of the tumor and experienced an uneventful recovery. Postoperative pathology finally revealed liposarcoma. The patient underwent follow-up for 25 months, during which time no recurrence was found.

Metachronous myxofibrosarcoma and osteosarcoma: case report and review of the literature

The occurrence of multiple primary sarcomas in one individual is very uncommon and the development of osteosarcoma as a second tumor following a soft tissue sarcoma is extremely rare. We report a case of a 62-year-old man who developed 2 histologically distinct sarcomas: a soft tissue myxofibrosarcoma and vertebral osteosarcoma. This unusual case highlights the critical role of careful histopathological evaluation in distinguishing synchronous or metachronous neoplasia from metastatic tumor. To the best of the authors' knowledge, this is the first reported case of metachronous soft tissue myxofibrosarcoma and osteosarcoma.

Soft tissue sarcoma diagnosed subsequent to lymphoma is associated with prior radiotherapy and decreased survival

BACKGROUND

Cancer survivors are at increased risk for second malignancies, and vigilance is thus required. The authors sought to determine whether there was an association among lymphoma, sarcoma, and the associated treatments for these diseases.

METHODS

From the authors' prospective soft tissue sarcoma (STS) database of 8240 patients, they identified 112 patients with STS and lymphoma treated from 1982 to 2009 who had complete follow-up data. They examined the importance of the initial diagnosis in patients with both STS and lymphoma, in addition to determining the role of radiation therapy, a known inducer of sarcoma.

RESULTS

Review of their sarcoma, gastric, urology, breast, and gynecology databases revealed that lymphoma (95%) or leukemia (5%) occurred in 1.6% of STS patients in comparison to 0.5% of patients in the other databases (P < .01; odds ratio, 3.1; 95% confidence interval, 2.6-3.8). Patients diagnosed with STS only were more likely to die of disease at 10 years compared with those with STS and lymphoma (P = .006), but this difference was not significant when patients presenting with recurrence or metastases were excluded. Among patients with lymphoma and STS, lymphoma was the first diagnosis in 71% of patients. Median survival after STS diagnosis was shorter when lymphoma was the initial diagnosis (67 vs 170 months, P = .002), and these patients were more likely to have radiation-associated STS (44% vs 3%, P < .001).

CONCLUSIONS

There was a 3-fold higher incidence of lymphoma in STS patients compared with other solid tumors. The poor prognosis of those diagnosed with both STS and lymphoma was most likely a consequence of prior irradiation.

Bilateral symmetrical metachronous myxofibrosarcoma: a case report and review of the literature

Soft tissue sarcomas (STS) are rare. Affected patients are at increased risk of developing a second primary malignancy, particularly another primary STS. These rarely affect the extremities, tending to occur in the abdomen, head or neck. We describe a patient with myxofibrosarcoma of the buttock who developed a second primary tumour of the same histological type in the contralateral buttock thirty months after excision. Remarkably, the second tumour was symmetrical and there were no predisposing factors or evidence of metastatic spread. The second tumour was a significant size at presentation with encasement of the sciatic nerve. Awareness of the sarcoma patient's increased risk of developing a second tumour could lead to earlier diagnosis and improved outcome. A review of the literature on multiple soft tissue sarcomas is also presented.

Synchronous presentation of uterine leiomyosarcoma and retroperitoneal liposarcoma: analysis by comparative genomic hybridization and review of the literature

Multiple primary malignant neoplasms are not uncommon, whereas 2 different types of primary sarcomas simultaneously presenting in 1 individual is quite unusual. We encountered a patient presenting with a uterine sarcoma and another retroperitoneal mass at the same time. These 2 tumors showed distinct pathologic and immunohistochemical features. The diagnosis of a synchronous presentation of a uterine leiomyosarcoma and a retroperitoneal sclerosing well-differentiated liposarcoma was rendered. Further study by comparative genomic hybridization showed unrelated genomic alterations of these 2 tumors. Nevertheless, other common genetic alterations such as balanced translocations, point mutations, or epigenetic modifications could still exist because of the limitation of findings by comparative genomic hybridization. In conclusion, both metastasis and multiple primary tumors should always be taken into consideration in differential diagnosis while encountering synchronous sarcomas.

Radiation-induced sarcoma: 25-year experience from the Norwegian Radium Hospital

BACKGROUND

The aim of this study was to determine the prevalence and outcome of radiation-induced sarcomas (RISs) among sarcoma patients referred to the Norwegian Radium Hospital (NRH).

MATERIAL AND METHODS

Ninety patients were identified from the institutional sarcoma data base. Medical records and histological and cytological material from both primary and secondary tumours were reviewed.

RESULTS

RIS represented 3.0 % of the sarcomas in the data base. The median latency time from radiotherapy of the primary tumour to the diagnosis of RIS was 13.6 years (range 2.5-57.8 years). Gynaecological, breast and testicular cancers were the most common primary diagnoses. For the RISs 13 different histological types were identified including 25 malignant fibrous histiocytomas (28% of all) and 22 osteosarcomas (24%). The sarcoma-related 5-year crude survival was 33% (95 % CI 23-43 %). Unfavourable prognostic factors were metastases at presentation, incomplete surgery and presence of tumour necrosis.

CONCLUSION

Radiation-induced sarcoma is rare and harbours an aggressive clinical behaviour. Complete surgical resection is mandatory for cure.

Genetic profiling differentiates second primary tumors from metastases in adult metachronous soft tissue sarcoma

Purpose. Patients with soft tissue sarcomas (STS) are at increased risk of second primary malignancies, including a second STS, but distinction between metastases and a second primary STS is difficult. Patients and Methods. Array-based comparative genomic hybridization (aCGH) was applied to 30 multiple STS of the extremities and the trunk wall from 13 patients. Different histotypes were present with malignant fibrous histiocytomas/undifferentiated pleomorphic sarcomas being the predominant subtype. Results. aCGH profiling revealed genetic complexity with multiple gains and losses in all tumors. In an unsupervised hierarchical cluster analysis, similar genomic profiles and close clustering between the first and subsequent STS were identified in 5 cases, suggesting metastatic disease, whereas the tumors from the remaining 8 patients did not cluster and showed only weak pairwise correlation, suggesting development of second primary STS. Discussion. The similarities and dissimilarities identified in the first and second STS suggest that genetic profiles can be used to distinguish soft tissue metastases from second primary STS. The demonstration of genetically different soft tissue sarcomas in the same patient suggests independent tumor origin and serves as a reminder to consider development of second primary STS, which has prognostic and therapeutic implications.

Primary mediastinal liposarcoma: a case report

Introduction

Liposarcoma is the most commonly diagnosed soft tissue sarcoma in adults and occurs predominantly in the lower limbs and retroperitoneum. Primary mediastinal liposarcomas are rare.

They are often asymptomatic and when growing to large size the presenting symptoms are related to direct invasion or compression of other thoracic organs such as the heart, great vessels and lung.

Case presentation

A case of a 68-year-old man with primary mediastinal liposarcoma involving the diaphragm and pericardium and successfully managed by complete surgical excision is presented. The patient's postoperative course was uneventful with no evidence of recurrence 9 months after the operation.

Conclusion

Surgical removal is the optimal treatment for a mediastinal liposarcoma. If the entire tumor can not be resected, surgical debulking often results in symptomatic relief. International literature has demonstrated that recurrent disease occurs and therefore a long-term careful follow up is required.

Coexistence of gastrointestinal stromal tumor (GIST) and colorectal adenocarcinoma: A case report

Background

Gastrointestinal stromal tumors (GIST) represent the most common mesenchymal tumors of the digestive tract. Over the last ten years the management of GISTs has dramatically altered but their coexistence with other gasrointesinal tumors of different histogenesis presents a special interest. The coexistence of GISTs with other primaries is usually discovered incidentally during GI surgery for carcinomas.

Case presentation

We present here, a case of a 66-year-old patient with intestinal GIST and a synchronous colorectal adenocarcinoma discovered incidentally during surgical treatment of the recurrent GIST. Immunohistochemical examination revealed the concurrence of histologically proved GIST (strongly positive staining for c-kit, vimentin, SMA, and focal positive in S-100, while CD-34 was negative) and Dukes Stage C, (T3, N3, M0 according the TNM staging classification of colorectal cancer).

Conclusion

The coexistence of GIST with either synchronous or metachronous colorectal cancer represents a phenomenon with increasing number of relative reports in the literature the last 5 years. In any case of GIST the surgeon should be alert to recognize a possible coexistent tumor with different histological origin and to perform a thorough preoperative and intraoperative control. The correct diagnosis before and at the time of the surgical procedure is the cornerstone that secures the patients' best prognosis.

Occurrence of other malignancies in patients with gastrointestinal stromal tumors

Almost one-third of gastrointestinal stromal tumors (GISTs) are discovered incidentally during investigative or therapeutic procedures for unrelated diseases. In this regard, GISTs may coexist with different types of cancer, either synchronously or metachronously. The frequency of this association and the spectrum of neoplasms involved have not been sufficiently analyzed. We conducted a review of the literature and our own records for cases with sporadic GISTs and other malignancies, with emphasis on solid tumors. Neurofibromatosis 1 and Carney triad-associated tumors were excluded. Based on these data, there were 518 cancers in 486 GIST patients among 4813 cases with informative data. The overall frequency of second tumors in different series varied from 4.5% to 33% (mean, 13%). A total of 29 patients had multiple malignancies. GISTs of gastric location were most commonly involved with other neoplasms, reflecting their overall high frequency (60%) of all GISTs. The major types of GIST-associated cancers were gastrointestinal carcinomas (n=228; 47%), lymphoma/leukemia, (n=36; 7%), and carcinomas of prostate (n=43; 9%), breast (n=34; 7%), kidney (n=27; 6%), lung (n=26; 5%), female genital tract (n=25; 5%), and carcinoid tumors (n=13; 3%). Other cancers included soft tissue and bone sarcomas (n=15; 3%), malignant melanoma (n=12; 2%), and seminoma (n=6; 1%). Occurrence of collision tumors and metastases of carcinoma or sarcoma into a GIST (the latter noted in 4 cases) can be challenging diagnostic problems. The potential nonrandom association and causal relationship between GIST and other neoplasms remain to be investigated.

Metachronous bilateral soft tissue sarcoma of the extremities

BACKGROUND AND AIMS

Synchronous and heterochronous multiple soft tissue sarcoma of the extremities is very rare. Out of 1,201 of our patients, 4 patients presented with symmetrical bilateral soft tissue sarcoma of the extremities. The aim of this study was to identify possible reasons for this unusual manifestation of sarcomas.

MATERIALS AND METHODS

The patients' data was acquired by review of the patients' charts and follow-up information was gathered by phone calls to the patients or their relatives and their general practitioners.

RESULTS

All tumours were located at the extremities and were diagnosed as leiomyosarcoma in two patients, malignant fibrous histiocytoma and clear cell sarcoma in one patient each. No other individual or family history of cumulation of neoplasms was known in the patients. The median interval between the diagnoses was 3 1/2 years (range: 4 months to 9 1/2 years). In two patients a second primary sarcoma of the same entity was considered the most likely diagnosis, whereas in one patient a contralateral lymph node metastasis and in one other patient an atypical soft tissue metastasis had to be taken into account. A positive family history with a father with malignant fibrous histiocytoma may indicate a hereditary predisposition in one patient. Aside from irradiation effects, exposition to other carcinogenic agents or genetic predisposition, the reasons for the clustering of soft tissue sarcoma in one same patient remain still unclear. Only one patient, although suffering from disseminated metastatic disease was living at follow-up time, the other three patients had already died.

CONCLUSION

The interpretation of the bilateral manifestation of soft tissue sarcoma remains open, but predicts an unfavourable outcome.

Increased risk of malignancies in a population-based study of 818 soft-tissue sarcoma patients

Soft-tissue sarcomas (STS) have been associated with various rare cancer syndromes and occur at increased frequencies in survivors of childhood cancer. Also adult patients with STS have been suggested to be at an increased risk of additional malignancies. After exclusion of syndrome-associated and radiation-induced sarcomas, we studied multiple primary malignancies in a population-based cohort of 818 patients with primary STS of the extremities and the trunk wall. In total, 203 other malignancies developed in 164 (20%) patients median 10 (0-32) years before and median 4 (0-35) years after the sarcoma diagnosis. Standardised morbidity ratios (SMRs) were determined for primary malignancies following a STS. Hereby individuals who had developed a STS were identified to be at increased risk of second primary malignancies (SMR for all malignant tumours=1.3; 95% CI=1.0-1.5; P=0.02) with STS being the only specific tumour type that occurred at an increased risk (SMR=17.6; 95% CI=8.1-33.5; P<0.001). Hence, this population-based series demonstrates a high frequency of second primary tumours among STS patients and indicates a particularly increased risk of developing a new STS.

Second primary malignancies among patients with soft tissue tumors in Sweden

Survival from soft tissue tumors (STTs) has been improved because of the successful treatment. One of the late sequelae in STT survivors is the development of a second malignancy. The present study aimed at quantifying risks for second malignancies in patients with STTs, and risks for second STTs after other primary malignancies. Adjusted standardized incidence ratios (SIRs), calculated from the Swedish Family-Cancer Database, were used as a measure of risk. Among 6,671 primary STT patients, a total of 650 second malignancies occurred. Besides second STTs, other cancer sites with an increased SIR were the nervous system, endocrine glands, skin (melanoma and squamous cell carcinoma) and prostate; the risk for non-Hodgkin lymphoma (NHL) was also increased. The overall risk of second malignancies decreased in the following order: fibrosarocma (1.63) > myxosarcoma (1.48) > leiomyosarcoma (1.44) > liposarcoma (1.21). An increased risk of second STTs after primary cancers of the bone, ovary, nervous system, cervix, thyroid gland, skin, endometrium, breast, upper aerodigestive tract, and after Hodgkin disease, NHL and leukemia was also noted. This study showed that the incidence of second primary malignancies in patients with STTs was increased, but the SIRs varied among specific cancer sites. Besides therapeutic effects, the associations between STTs and bone and nervous system tumors suggested that cancer syndromes, such as neurofibromatosis type 1 and Li-Fraumeni syndrome, may partly explain the excesses. The associations of STTs with cancers of the skin (squamous cell carcinoma and melanoma) and with NHL may be related to immunodeficiency.