Tumor necrosis is an underappreciated histopathologic factor in the grading of chondrosarcoma

BACKGROUND

Cartilaginous neoplasms can be challenging to grade; there is a need to create an evidence-based rubric for grading. The goal of this study was to identify histopathologic features of chondrosarcoma that were associated with 5-year survival and to compare these to traditional patient, tumor and treatment variables.

METHODS

This was a retrospective review of all patients undergoing surgical resection of a primary chondrosarcoma with at least 2 years of follow up. All specimens were independently reviewed by two pathologists and histopathologic features scored. Univariate and multivariate analyses were performed utilizing Kaplan Meier and proportional hazards methods to identify variables associated with 5-year disease specific survival (DSS) and disease free survival (DFS).

RESULTS

We identified 51 patients with an average follow up of 49 months eligible for inclusion. 30% of tumors were low grade, 45% were intermediate grade, and 25% were high grade. In a univariate analysis considering histopathologic factors, higher tumor mitotic rate (HR 8.9, p < 0.001), tumor dedifferentiation (HR 7.3, p < 0.001), increased tumor cellularity (HR 5.8, p = 0.001), increased tumor atypia (HR 5.8, p = 0.001), LVI (HR 4.7, p = 0.04) and higher tumor necrosis (HR 3.7, p = 0.02) were all associated with worse 5-year DSS. In a multivariate analysis controlling for potentially confounding variables, higher tumor necrosis was significantly associated with disease specific survival survival (HR 3.58, p = 0.035); none of the factors were associated with DFS.

CONCLUSIONS

This study provides an evidence-based means for considering histopathologic markers and their association with prognosis in chondrosarcoma. Our findings suggest that necrosis and LVI warrant further study.

Sarculator is a Good Model to Predict Survival in Resected Extremity and Trunk Sarcomas in US Patients

BACKGROUND

Sarculator is an online validated nomogram that predicts overall survival of patients with resected, primary extremity sarcomas. However, its ability to accurately predict outcomes in US patients with sarcoma is unknown.

PATIENTS AND METHODS

Patients from the National Cancer Data Base (NCDB) (2006-2016) with resected stage I-III primary extremity or trunk sarcoma were included. Predicted overall survival (pOS) was calculated using the Sarculator algorithm, which includes patient age, tumor size (cm), grade (1-3), and histology, and compared with actual overall survival (aOS). Harrell's C-index was calculated to determine the discriminatory ability of Sarculator (0.7 = good, 0.8 = strong, 1.0 = perfect model), and calibration plots were created.

RESULTS

In total, 9738 patients were included. Five-year pOS was 73.7% compared with aOS of 68.9%. The C-index for the entire cohort was 0.726. By stage, the C-index was 0.730 for stage I, 0.708 for stage II, and 0.679 for stage III. By histology, C-indices were highest for leiomyosarcoma (0.745), myxofibrosarcoma (0.722), and other histologies (0.721). By sociodemographic variables, Sarculator performed better for patients < 50 years (C-index 0.722), of other/unknown race (C-index 0.781), with private insurance (C-index 0.715), treated at a center other than a community cancer programs (C-index > 0.7), and with no comorbidities (C-index 0.716). Outcomes by zip code educational attainment and income were not markedly different (all C-indices > 0.7).

CONCLUSIONS

Sarculator is overall a good predictor of aOS and useful tool for clinicians to aid in survival prognostication. However, clinicians should be aware of populations for whom Sarculator's predictions may be less accurate. Future work could focus on enhancing the Sarculator algorithm specifically for US patients by including demographic variables.

A seven-gene signature and the C-C motif chemokine receptor family genes are the sarcoma-related immune genes

Cells of the tumor microenvironment exert a vital influence on sarcoma prognosis. This study aimed to analyze and identify differentially expressed genes (DEGs) related to immunity and their significance as immune biomarkers for the accurate prediction of overall survival of patients with sarcoma. The Cancer Genome Atlas was adopted for obtaining sarcoma gene microarray and corresponding clinical information. ESTIMATE algorithm was used to calculate tumor immune microenvironment indices. Immune-associated DEGs were identified using the limma packages and were further analyzed using the ClusterProfiler package and STRING website. Based on the results of these analyses, we constructed a prognostic model. Furthermore, we assessed the prognosis prediction model through functional evaluation and analysis of GSE17674. The functional analysis revealed that the upregulated immune DEGs were related to immune-related aspects. Chemokine ligands/receptors and immune-related genes were found to be vital for sarcoma formation and progression. We established a prognostic signature of seven genes, which indicated that high-risk cases exhibit poor prognostic outcome. The prognostic signature constructed in this study can accurately predict the overall prognosis in patients with sarcoma. Moreover, the novel immune gene expression analysis may provide clinical guidance for predicting prognosis in patients with sarcoma.

Tumor necrosis: A synergistic consequence of metabolic stress and inflammation

Tumor necrosis is a common histological feature and poor prognostic predictor in various cancers. Despite its significant clinical implications, the mechanism underlying tumor necrosis remains largely unclear due to lack of appropriate pre-clinical modeling. We propose that tumor necrosis is a synergistic consequence of metabolic stress and inflammation, which lead to oxidative stress-induced cell death, such as ferroptosis. As a natural consequence of tumor expansion, tumor cells are inevitably stripped of vascular supply, resulting in deprivation of oxygen and nutrients. The resulting metabolic stress has commonly been considered the cause of tumor necrosis. Recent studies found that immune cells, such as neutrophils, when recruited to tumors, can directly trigger ferroptosis in tumor cells, suggesting that immune cells can be involved in amplifying tumor necrosis. This article will discuss potential mechanisms underlying tumor necrosis development and its impact on tumor progression as well as the immune response to tumors.

Late Local Recurrence and Metastasis in Soft Tissue Sarcoma of the Extremities and Trunk Wall: Better Outcome After Treatment of Late Events Compared with Early

Background

Approximately 80% of soft tissue sarcoma (STS) recurrences, local and metastatic disease, are diagnosed within the first 3 years after primary diagnosis and treatment. Recurrences, however, can present after a longer period of remission. Our goal was to identify factors that may predict the risk of late recurrence.

Methods

We identified 677 patients with STS of the extremities and trunk wall from a population-based sarcoma register. Of these, 377 patients were alive and event-free at 3 years and were included for analysis of possible risk factors for late recurrence.

Results

Fifty-five of 377 (15%) patients developed late recurrence: 23 local recurrence, 21 metastasis, and 11 both manifestations. With R0 wide surgical margin as reference, R0 marginal (hazard ratio [HR] 2.6; p = 0.02) and R1 (HR 5.0; p = 0.005) margins were risk factors for late local recurrence. Malignancy grade (HR 8.3; p = 0.04) and R0 marginal surgical margin (HR 2.3; p = 0.04) were risk factors for late metastasis. We could not find a statistically significant correlation of late recurrence with many of the generally known risk factors for local recurrence and metastasis in STS. Outcome after treatment of late recurrences was better compared with outcome after treatment of early events.

Conclusions

Late recurrences, albeit relatively rare, do occur. Outcome after treatment was good compared with outcome after early events. Long surveillance of all patients with high-grade STS, especially if R0 wide surgical margin is not achieved in the primary treatment, appear to be well justified.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-021-09942-8.

Is Microscopic Vascular Invasion in Tumor Specimens Associated with Worse Prognosis in Patients with High-grade Localized Osteosarcoma?

BACKGROUND

Other than metastases at diagnosis and histological response to preoperative chemotherapy, there are few reliable predictors of survival in patients with osteosarcoma. Microscopic vascular invasion (MVI) has been identified in the resection specimens of patients with osteosarcoma. However, it is unknown whether the MVI in resected specimens is associated with worse overall survival and higher cumulative incidence of local recurrence or metastasis in a large cohort of patients younger than 40 years with high-grade localized osteosarcoma.

QUESTIONS/PURPOSES

(1) Is MVI associated with worse overall survival and higher cumulative incidence of events (local recurrence or metastasis) in patients younger than 40 years with high-grade localized osteosarcoma? (2) What clinical characteristics are associated with MVI in patients with high-grade localized osteosarcoma?

METHODS

A total of 625 patients younger than 40 years with primary high-grade osteosarcoma between 1997 and 2016 were identified in our oncology database. We included patients younger than 40 years with primary high-grade osteosarcoma who underwent definitive surgery and preoperative and postoperative chemotherapy. The minimum follow-up period was 2 years after treatment. Patients with the following were excluded: metastasis at initial presentation (21%, n = 133), progression with preoperative chemotherapy precluding definitive surgery (6%, n = 38), surgery at another unit (2%, n = 13), lost to follow-up before 2 years but not known to have died (3%, n = 18), and death related to complications of preoperative chemotherapy (1%, n = 4). A retrospective pathologic and record review was conducted in the remaining 419 patients. The median follow-up period was 5 years (interquartile range [IQR] 3 to 9 years). The overall survival of the entire group (n = 419) was 67% [95% CI 63 to 72] at 5 years. Of the 419 patients, 10% (41) had MVI in their resection specimens. The Kaplan-Meier method was used to estimate overall survival. The cumulative incidence of events captured the first event of either metastasis or local recurrence. This analysis was completed with a competing risk framework: deaths without evidence of local recurrence or metastasis were regarded as a competing event. Clinical and histological variables (sex, age, tumor site, tumor largest dimension, surgical margin, chemotherapy-induced necrosis, type of surgery, histologic type of tumor, type of chemotherapy regimen, pathologic fracture, and MVI) were evaluated using the log-rank test or Gray test in the univariate analyses and Cox proportional hazard model or Fine and Gray model in the multivariate analyses.

RESULTS

After adjusting for other factors, multivariate analyses showed that the presence of MVI in resection specimens was associated with worse overall survival and higher cumulative incidence of event (hazard ratio 1.88 [95% CI 1.22 to 2.89]; p = 0.004 and HR 2.33 [95% CI 1.56 to 3.49]; p < 0.001, respectively). A subgroup analysis demonstrated that the relationship between MVI and survival applied only to patients with a poor response to chemotherapy (less than 90% necrosis; overall survival at 5 years, MVI [+] = 24% [95% CI 11 to 39] versus MVI [-] = 60% [95% CI 52 to 66]; p < 0.001 and cumulative incidence of events at 5 years, MVI [+] = 86% [95% CI 68 to 94] versus MVI [-] = 54% [95% CI 46 to 61]; p < 0.001). The MVI (+) group had a higher proportion of patients with a poor response to chemotherapy (85% [35 of 41] versus 53% [201 of 378]; p < 0.001), involved margins (15% [6 of 41] versus 5% [18 of 378]; p = 0.021), and limb-ablative surgery (37% [15 of 41] versus 21% [79 of 378]; p = 0.022) than the MVI (-) group did.

CONCLUSIONS

MVI is associated with lower overall survival and higher cumulative incidence of local recurrence or metastasis, especially in patients with a poor histologic response to preoperative chemotherapy. Future studies in patients treated for osteosarcoma should consider this observation when planning new trials.

LEVEL OF EVIDENCE

Level III, therapeutic study.

A nomogram to predict metastasis of soft tissue sarcoma of the extremities

Soft tissue sarcoma (STS) of the extremities are a rare tumor. Metastases develop in about 40%-50% of patients, most of whom die from their disease. We sought to identify potential risk factors associated with metastatic diseases upon presentation for patients with STS and established a reliable nomogram model to predict distant metastasis of STS at presentation. The current study retrospectively analyzed 3884 STS of the extremities or trunk patients from the Surveillance, Epidemiology, and End Results (SEER) database between 2010 and 2015. Based on patient registration, all patients were randomly allocated to training sets and validation sets (2:1). Then, univariate and binary logistic regression analysis was used to determine the significantly correlated predictors of metastasis. Finally, the nomogram model was established, using these predictors and validated it. 311 (8.21%) of the cases experienced distant metastatic disease was present at the time of presentation. The nomogram was developed from age, histology subtype, primary site, tumor size, grade and depth. Encouragingly, the nomogram showed favorable calibration with C-index 0.790 in the training set and 0.801 in validation set. The DCA showed that the novel model was clinically useful. This nomogram model had a high precision to predict the metastasis of soft tissue sarcoma of the extremities. We expect this model could be used in different clinical consultation and established risk assessment.

Clinical Significance of the Radiological Relationship between the Tumor and the main blood vessels in Enneking IIB Osteosarcoma of the extremities

Aim: Osteosarcoma is one of the most prevalent primary bone malignancies in children and adolescents. Magnetic resonance imaging (MRI) has been considered a very critical tool to provide anatomical information of tumor and surrounding main blood vessels. To evaluate the prognostic significance of the radiological vascular involvement according to the pre-treatment MRI in patients with Enneking IIB osteosarcoma. Methods: In this retrospective study, we included 482 patients younger than 50 years old with Enneking IIB primary osteosarcoma of the extremities with complete clinical records from 2005 to 2015.Univariate and multivariable analyses were conducted to identify the risk factors for OS (Overall survival) and EFS (Event-free survival). The correlations between the risk factors was performed using Spearman analysis. The Kaplan-Meier method was used to calculate survival curves. Based on the radiological relationship between the tumor lesion and the surrounding reactive area with the main blood vessels as shown on pretreatment MRI findings. Results: Radiological vascular involvement assessed via pretreatment MRI is an important risk factor for Enneking IIB primary patients with osteosarcoma (HR_OS=2.32/HR_EFS=1.81 P<0.01) according to the univariate and multivariable analyses. Enneking IIB patients with osteosarcoma were assigned to three subtypes based on the radiological relationship between the main blood vessels and the lesion or reactive area. The 5-year cumulative OS of patients classified by the three types were 81.6% (type I), 67.1% (type II) and 44.8% (type III)(P<0.01). The 5-year cumulative EFS of the three types were 60.2% (type I), 46.7% (type II) and 30.2% (type III)(P<0.05). The total 5-year cumulative OS and EFS for all patients were 68.3% and 48.3%, respectively. Conclusion: Vascular involvement according to radiological findings from pretreatment MRI is an independent risk factor for cumulative OS and EFS in patients with Enneking IIB primary osteosarcoma of the extremities. The new subtyping based on the relationship between the tumors and surrounding reactive area with the main blood vessels based on pretreatment MRI can predict the prognosis of patients with osteosarcoma and provide certain directive information for selecting the appropriate surgical procedure for individual patients.

High Recurrence Rate of Myxofibrosarcoma: The Effect of Radiotherapy Is Not Clear

Background

Myxofibrosarcoma (MFS) is one of the more common types of soft-tissue sarcoma (STS) in patients over 60 years of age. Local recurrence (LR) rates have been reported to be higher compared to other STS types.

Patients and Methods

Using a population-based series from the southern Sweden health care region, 56 consecutive patients with MFS and localized disease at diagnosis were analyzed with respect to LR and distant metastases after surgery ± adjuvant treatment.

Results

The overall local recurrence (n = 15) and metastasis (n = 13) rates were 27% and 21%, respectively; 6 patients had both. Surgical margin was the only statistically significant prognostic factor for LR. Patients operated with a marginal margin had an HR of 4.5 (CI 1.3–15.1, p=0.02) and those operated with an intralesional margin 9.4 (CI 2.0–43.5, p=0.004) compared to those operated with a wide surgical margin. There was no difference in the LR rate depending on radiotherapy or not, although the latter group had smaller and more superficial tumors. 23 patients received radiotherapy, 9 of whom developed LR, all within the irradiated field. A tumor size >5 cm and intralesional surgical margin were shown to be risk factors for distant metastases.

Conclusions

The rate of LR for patients with myxofibrosarcoma was high. The impact of RT on local tumor control was unclear. The surgical margin was important for both local and distant tumor control. Large tumor size was a risk factor for distant metastasis.

The Prognostic Value of Lymphovascular Invasion in Truncal and Extremity Soft Tissue Sarcomas: An Analysis from the National Cancer Database

OBJECTIVE

The aim of this study was to determine the association between lymphovascular invasion (LVI) and overall survival (OS) in truncal/extremity soft tissue sarcomas (STS).

METHODS

The National Cancer Database (NCDB) was queried for all patients, ages 18-85 years, who underwent resection of primary, truncal/extremity STS between 2010 and 2012, and had LVI data. The primary endpoint was OS.

RESULTS

Among 6169 patients identified, the most common histology groups were (1) liposarcoma (LPS, 24%), (2) undifferentiated pleiomorphic sarcoma (UPS, 19%), and (3) leiomyosarcoma (LMS, 15%); 449 patients (7%) were LVI-positive. There were no differences in demographics or comorbidities between the LVI groups. Compared with LVI-negative patients, LVI-positive patients were more likely to have larger (> 5 cm: 80% vs. 66%), deep (80% vs. 68%), and high-grade tumors (82% vs. 57%). They were also more likely to have positive margins (27% vs. 17%), nodal (16% vs. 2%) and metastatic disease (21% vs. 4%), and receive chemotherapy (37% vs. 18%; all p < 0.001). LVI was associated with worse median OS (39 months vs. MNR; p < 0.001), which persisted on stratum-specific analyses for all tumor grades, size categories, and stages I-III, but not stage IV. On multivariable Cox regression, LVI was associated with worse OS (hazard ratio [HR] 1.84, 95% confidence interval [CI] 1.39-2.44), while accounting for other significant prognostic factors. Among non-metastatic, curative-intent resections (n = 5696), LVI was still associated with worse OS (HR 1.79, 95% CI 1.28-2.49).

CONCLUSIONS

LVI appears to be an important adverse pathologic factor in truncal and extremity STS. Even when taking into account other established prognostic factors, LVI was predictive of worse OS. Knowledge of LVI status may help to better risk-stratify patients and guide management strategies, and should be considered in future prognostic classification schemes and nomograms.

Soft Tissue Sarcomas: Preoperative Predictive Histopathological Grading Based on Radiomics of MRI

RATIONALE AND OBJECTIVES

The purpose of this study is to develop a radiomics model for predicting the histopathological grades of soft tissue sarcomas preoperatively through magnetic resonance imaging (MRI).

MATERIALS AND METHODS

Thirty-five patients who were pathologically diagnosed with soft tissue sarcomas and their histological grades were recruited. All patients had undergone MRI before surgery on a 3.0T MRI scanner. Radiomics features were extracted from fat-suppressed T2-weighted imaging. We used the least absolute shrinkage and selection operator (LASSO) regression method to select features. Then three machine learning classification methods, including random forests, k-nearest neighbor, and support vector machine algorithm were trained using the 5-fold cross validation strategy to separate the soft tissue sarcomas with low- and high-histopathological grades.

RESULTS

The radiomics features were significantly associated with the histopathological grades. Quantitative imaging features (n = 1049) were extracted from fat-suppressed T2-weighted imaging, and five features were selected to construct the radiomics model. The model that used support vector machine classification method achieved the best performance among the three methods, with areas under the receiver operating characteristic curves Area Under Curve (AUC) values of 0.92 ± 0.07, accuracy of 0.88.

CONCLUSION

Good accuracy and AUC could be obtained using only five radiomic features. Therefore, we proposed that three-dimensional imaging features from fat-suppressed T2-weighted imaging could be used as candidate biomarkers for preoperative prediction of histopathological grades of soft tissue sarcomas noninvasively.

Marital status and survival in patients with soft tissue sarcoma: A population-based, propensity-matched study

Background

Marital status serves as an independent prognostic factor for survival in a variety of cancers. However, its prognostic impact on soft tissue sarcoma (STS) has not yet been established.

Objective

To investigate the impact of marital status on survival outcomes among STS patients.

Methods

A total of 18 013 STS patients diagnosed between 2004 and 2015 were extracted from Surveillance, Epidemiology, and End Results (SEER) database. The marital status was classified into married, divorced, widowed, and single. Kaplan‐Meier analysis and multivariate Cox proportional hazards regression analysis were conducted to establish the impact of marital status on the overall survival (OS) and cancer‐specific survival (CSS). Subgroup analyses were conducted based on age, SEER historic stage and surgery condition. Propensity score matching (PSM) was used to perform a 1:1 matched‐pair analysis to minimize the group differences caused by covariates.

Results

Married patients enjoyed better 5‐year overall survival (OS) and 5‐year cancer‐specific survival (CSS), compared with patients who were divorced, widowed, and single, respectively. Multivariate Cox proportional hazards regression analysis revealed that marital status was an independent prognostic and protective factor for survival among STS patients, and unmarried status was associated with higher mortality hazards for both OS and CSS. Additionally, widowed individuals had the highest risks of overall and cancer‐specific mortality compared to other unmarried groups. In the subgroup analyses, similar associations were also found. Furthermore, marital status still remained an independent prognostic and protective factor for both OS and CSS even in 1:1 matched‐pair analysis.

Conclusions

Marital status was an independent prognostic and protective factor for survival for STS patients. Widowed patients suffered the highest death risks among the unmarried groups.

Adjuvant chemotherapy and postoperative radiotherapy in high-risk soft tissue sarcoma patients defined by biological risk factors-A Scandinavian Sarcoma Group study (SSG XX)

PURPOSE

To investigate the outcome following adjuvant doxorubicin and ifosfamide in a prospective non-randomised study based on a soft tissue sarcoma (STS) patient subgroup defined by specific morphological characteristics previously shown to be at a high-risk of metastatic relapse. The expected 5-year cumulative incidence of metastases in patients with this risk profile has previously been reported to be about 50% without adjuvant chemotherapy.

METHODS

High-risk STS was defined as high-grade morphology (according to the Fédération Nationale des Centres de Lutte Contre le Cancer [FNCLCC] grade II-III) and either vascular invasion or at least two of the following criteria: tumour size ≥8.0 cm, infiltrative growth and necrosis. Six cycles of doxorubicin (60 mg/m²) and ifosfamide (6 g/m²) were given. Postoperative accelerated radiotherapy was applied and scheduled between cycles 3 and 4.

RESULTS

For the 150 eligible patients, median follow-up time for metastases-free survival was 3.9 years (range 0.2-8.7). Five-year metastases-free survival (MFS) was 70.4% (95% confidence interval [CI]: 63.1-78.4) with a local recurrence rate of 14.0% (95% CI: 7.8-20.2). For overall survival (OS), the median follow-up time was 4.4 years (range: 0.2-8.7). The five-year OS was 76.1% (95% CI: 68.8-84.2). Tumour size, deep location and reduced dose intensity (<80%) had a negative impact on survival. Toxicity was moderate with no treatment-related death.

CONCLUSIONS

A benefit of adjuvant chemotherapy, compared to similar historical control groups, was demonstrated in STS patients with defined poor prognostic factors. Vascular invasion, tumour size, growth pattern and necrosis may identify patients in need of adjuvant chemotherapy.

Four different treatment strategies in aggressive fibromatosis: A systematic review

•

Relative good overall local control rate of all four different treatment groups of  >75%.

•

Multivariate analysis shows deep seated tumors, age (<30 years) and extracompartmentally situated tumors as negative predicting markers of local outcome.

•

The radiotherapy alone group did not have better local control rates than the observation group (p = 0.355).

•

In case of recurrent disease, adjuvant radiotherapy has a definite advantage over surgery alone (p = 0.001).

•

Radiotherapy alone gives in 50% of cases partial or complete regression, and in 14% complete regression. Eventually 23% develop local progression.

•

Observation could be considered as first line treatment in patients with tumors not in close adherence to important structures and no symptoms.

•

Stabilization of the tumor arose after a median time of  >1 year after observation, and a local recurrence or progression occurred after a median time of <3 years.

Background

The treatment approach for aggressive fibromatosis is changing. Although surgery is the mainstay in common practice, recent literature is reporting a more conservative approach. We compared the local control rate for surgery, surgery with radiotherapy, radiotherapy alone and a wait and see policy in a systematic review.

Methods

A comprehensive search of the databases PubMed/Medline, Embase and Cochrane, of the medical literature published in 1999 till March 2017 was performed by two reviewers, including articles about extra abdominal aggressive fibromatosis without the genetical variants. A total of 671 studies were assessed for eligibility, and 37 studies were included for analysis, representing 2780 patients.

Results

The local control rates for surgery alone, surgery and radiotherapy, radiotherapy alone and observation were 75%, 78%, 85% and 78%, respectively. For patients with recurrent disease observation had a better local control rate than surgery alone (p = 0.001). In the observation group, stabilization of the tumor was seen in median 14 (range 12–35) months. The time to local recurrence in the treatment group was median 17 (range, 11–52) months.

Conclusion

A watchful conservative first line approach with just observation and closely monitoring, by means of physical examination and MRI, appears to be justified in a subgroup of patients without clinical symptoms and no possible health hazards if the tumor would progress.

Prognostic Significance of Apoptosis-related Markers in Patients With Soft-Tissue Sarcomas of Extremities

Bcl-2 and Bax proteins are key regulators of apoptosis, a process that is deregulated in many human diseases, particularly cancer. Overexpression of antiapoptotic Bcl-2 protein is associated with drug resistance and poor clinical outcome in cancer patients, whereas the expression of proapoptotic Bax protein, commonly detected in soft-tissue sarcoma (STS), is often associated with chemiosensitivity in different tumors. Studies on the clinical implications of apoptosis-related markers Bcl-2 and Bax in STS are limited. In this study, immunohistochemistry for Bcl-2 and Bax was performed on tissue microarrays of 86 multiple types of adult STS of the extremities. Bcl-2 and Bax positive expression was detected in 25.9% and 66.7% of the sarcomas, respectively. Overexpression of both, Bcl-2 and Bax, was directly associated with histologic grade and clinical stage. A significant association between Bax and Bcl-2 expression was also observed (P=0.007). The 5-year overall survival for the group was 57%, and it was lower for cases that overexpressed Bcl-2 (47.6% vs. 58.3%) and Bax (50% vs. 66.7%), although not statistically significant. After multivariate analysis, only the high histologic grade appeared as an independent prognostic factor for the patients (P=0.043; HR=8.0; 95% CI, 1.1-60.1). In our study, Bcl-2 and Bax expression was significantly associated with histologic grade and clinical stage, which are classic factors of poor prognosis. We suggest the use of these proteins as potential prognostic markers in STS of extremities.

Prognostic Value of Vascular Invasion in Pediatric Osteosarcomas

Metastatic status, histologic response, and quality of surgical resection are prognostic factors for osteosarcomas. Pathology reports sometimes describe peritumoral vascular invasion on surgical specimens after neoadjuvant chemotherapy but their prognostic significance as an independent parameter has never been reported. The aim of this study was to evaluate how the presence of this peritumoral vascular invasion could influence survival. We retrospectively analyzed histology, demographics, and outcomes of pediatric patients treated for osteosarcoma in our institutions between January 2007 and December 2012. A single pathologist analyzed the resection specimens after neoadjuvant chemotherapy. Fifty-one osteosarcomas were diagnosed over a 6-year period; nine had metastatic disease at diagnosis. Surgery was performed after neoadjuvant chemotherapy in all cases. We identified peritumoral vascular invasion in the surgical specimens in 15 cases. Two-year event-free survival (EFS) was 78 % (CI95%[64;93]) for patients without vascular invasion versus 48 % (CI95% [21;75]) in patients with vascular invasion, and 2-year overall survival (OS) was 94 % (CI95%[86;100]) for those without vascular invasion versus 79 % (CI95%[57;100]) for others. Multivariate analysis demonstrated correlation of metastatic status and presence of vascular invasion with survival. The histopathological description of peritumoral vascular invasion in surgical specimens of osteosarcoma after neoadjuvant chemotherapy can be considered a prognostic factor and could indicate modification of the postoperative therapeutic strategy.

Prognostic significance of histological invasion in high grade soft tissue sarcomas

High grade soft tissue sarcomas often show histological invasion to adjacent compartment including bone and vessel. This study aimed to evaluate histological invasion in high grade soft tissue sarcomas, clarify its impact on prognosis and devise treatment strategies. We retrospectively reviewed 133 patients with non-small round cell high grade soft tissue sarcomas surgically treated between 2001 and 2011. Clinical and histological factors examined for prognostic value included age, gender, size, depth, location, adjuvant therapy and invasion to adjacent compartment. Study endpoints included overall survival rate, event free survival rate and local recurrence free survival rate, estimated by the Kaplan-Meier method. Univariate and multivariate analyses were performed using the log-rank test and Cox proportional hazards model. Local recurrence was recognized in 14 cases (11%). The 5-year overall survival rate and 5-year event free survival rate were 82.2% and 63.6% respectively. The metastasis-free survival rate at 5 years and local recurrence-free survival rate at 5 years were 69.8% and 86.8% respectively. Histological invasion to adjacent compartment was noted in 52 cases (39%), and was significantly correlated with histological type (p = 0.01), tumor size (p = 0.009), and depth (p < 0.05). In multivariate analyses, we showed that tumor size and histological invasion were significant independent predictors of OS (hazard ratio 8.1/2.5) and EFS (hazard ratio 5.5/2.2), while only tumor size was a significant independent predictor of LRFS (hazard ratio 4.0). We evaluated the relation between histological invasion and the oncological outcomes of high grade soft tissue sarcomas. In multivariate analyses, histological invasion was found to be an independent adverse prognostic factor with hazard ratios of 2.2-2.5, suggesting that a detailed assessment of these factors is essential. Histological invasion showed a correlation with tumor size and histological type, and the surgical margin should be decided based on these factors.

Sarcoma excision and pattern of complicating sensory neuropathy

A potential complication of sarcoma excision surgery is a sensory neurological dysfunction around the surgical scar. This study utilised both objective and subjective sensation assessment modalities, to evaluate 22 patients after sarcoma surgery, for a sensory deficit. 93% had an objective sensory deficit. Light touch is less likely to be damaged than pinprick sensation, and two-point discrimination is significantly reduced around the scar. Results also show that an increased scar size leads to an increased light touch and pinprick deficit and that two-point discriminatory ability around the scar improves as time after surgery elapses. 91% had a subjective deficit, most likely tingling or pain, and numbness was most probable with lower limb sarcomas. Results also demonstrated that there were no significant relationships between any specific subjective and objective deficits. In conclusion, sensory disturbance after sarcoma surgery is common and debilitating. Efforts to minimize scar length are paramount in the prevention of sensory deficit. Sensation may also recover to an extent; thus, sensory reeducation techniques must become an integral aspect of management plans. Finally to obtain a comprehensive assessment of sensory function, both objective and subjective assessment techniques must be utilised.

Small soft tissue sarcomas do metastasize: identification of high-risk tumors

BACKGROUND

Small (≤ 5 cm) soft tissue sarcomas (STS) of the extremities and the trunk wall generally have a favorable prognosis. However, 1 of 10 patients do develop metastases, and we therefore aimed to determine predictors of metastasis in a population-based cohort of patients with small STSs.

PATIENTS AND METHODS

In the southern Sweden health care region, 848 adult patients with STS of the extremities or the trunk wall were diagnosed between 1986 and 2010. Of these, 243 STS (29 %) were ≤5 cm. Prognostic evaluation was performed in 229 patients with localized disease at diagnosis, 181 of whom had histologic high-grade tumors.

RESULTS

None of the 48 patients with low-grade tumors developed metastases, whereas 24 of 181 patients with high-grade tumors (13 %) tumors did. Presence of either tumor necrosis or vascular invasion predicted development of metastases with a hazard ratio of 2.9 (95 % CI, 1.0-7.9), and tumors with both factors had a hazard ratio of 12 (95 % CI, 4.1-37) for metastasis (adjusted for size).

CONCLUSIONS

Our population-based series of STSs ≤5 cm demonstrate an overall good prognosis with metastases developing in 13 % of the patients with high-grade tumors. Tumor necrosis and vascular invasion were the major predictors of metastatic disease in this subset. Tumors with both these risk factors metastasized in 8 of 18 patients, which corresponds to a 12-fold increased risk of metastasis. These findings suggest that although small STS generally are linked to a good prognosis, necrosis and vascular invasion are features indicating biologically aggressive tumors for which treatment and surveillance should equal that for larger tumors.

Prognostic value of 18F-FDG PET/CT in patients with soft tissue sarcoma: comparisons between metabolic parameters

OBJECTIVES

To investigate the relationship between volume-based PET parameters and prognosis in patients with soft tissue sarcoma (STS).

METHODS

We retrospectively reviewed 55 patients with pathologically proven STS who underwent pretreatment with (18) F-Fluorodeoxyglucose ((18)F-FDG) PET/CT. The maximum standardized uptake value (SUVmax), average SUV (SUVavg), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) of primary tumors were measured using a threshold SUV as liver activity for determining the boundary of tumors. Univariate and multivariate survival analyses for overall survival were performed according to the metabolic parameters and other clinical variables.

RESULTS

Cancer-related death occurred in 19 of 55 patients (35 %) during the follow-up period (29 ± 23 months). On univariate analysis, AJCC stage (stage IV vs. I-III, hazard ratio (HR) = 2.837, p = 0.028), necrosis (G2 vs. G0-G1, HR = 3.890, p = 0.004), SUVmax (1 unit - increase, HR = 1.146, p = 0.008), SUVavg (1 unit - increase, HR = 1.469, p = 0.032) and treatment modality (non-surgical therapy vs. surgery, HR = 4.467, p = 0.002) were significant predictors for overall survival. On multivariate analyses, SUVmax (HR = 1.274, p = 0.015), treatment modality (HR = 3.353, p = 0.019) and necrosis (HR = 5.985, p = 0.006) were identified as significant independent prognostic factors associated with decreased overall survival.

CONCLUSIONS

The SUVmax of the primary tumor is a significant independent metabolic prognostic factor for overall survival in patients with STS. Volume-based PET parameters may not add prognostic information outside of the SUVmax.

Tumor necrosis is a prognostic factor in thick cutaneous melanoma

The significance of tumor necrosis in cutaneous melanoma has not been well elucidated. The purpose of this study was to explore the prognostic impact of necrosis in comparison with other known clinicopathologic factors in these tumors. Initially, 457 consecutive cases of nodular cutaneous melanoma (1981 to 2008) were included in this series. Tumor necrosis was assessed on hematoxylin and eosin-stained sections and was recorded as significant when an area of at least a quarter of a high-power field (×400; 0.07 mm) was occupied by necrotic cells and as sparse when clusters of at least 5 necrotic cells were observed. Tumor necrosis (26% of the cases) was associated with increased tumor thickness, high mitotic count, presence of tumor ulceration, and decreased survival. Stratified analyses (univariate and multivariate) with standard microscopic variables indicated the strongest prognostic influence of necrosis in tumors thicker than 4 mm. Notably, in the stratum of pT4 tumors, presence of necrosis was a stronger prognostic predictor than was ulceration. Tumor necrosis was a significant prognostic indicator providing additional information to established predictors of patient outcome in this series of nodular cutaneous melanoma, predominantly among thick tumors (>4 mm). Presence of necrosis was a stronger indicator for worse outcome compared with ulceration in pT4 tumors.

A web-based prognostic tool for extremity and trunk wall soft tissue sarcomas and its external validation

BACKGROUND

We developed a web-based, prognostic tool for extremity and trunk wall soft tissue sarcoma to predict 10-year sarcoma-specific survival. External validation was performed.

METHODS

Patients referred during 1987-2002 to Helsinki University Central Hospital are included. External validation was obtained from the Lund University Hospital register. Cox proportional hazards models were fitted with the Helsinki data. The previously described model (SIN) includes size, necrosis, and vascular invasion. The extended model (SAM) includes the SIN factors and in addition depth, location, grade, and size on a continuous scale. Models were statistically compared according to accuracy (area under the ROC curve=AUC) of 10-year sarcoma-specific survival prediction.

RESULTS

The AUC of the SAM model in 10-year survival prediction in the Helsinki patient series was 0.81 as compared with 0.74 for the SIN model (P=0.0007). The corresponding AUCs in the external validation series were 0.77 for the SAM model and 0.73 for the SIN model (P=0.03). A web-based calculator for the SAM model is available at http://www.prognomics.org/sam.

CONCLUSION

Addition of grade, depth, and location as well as tumour size on a continuous scale significantly improved the accuracy of the prognostic model when compared with a model that includes only size, necrosis, and vascular invasion.

A phase II study evaluating neo-/adjuvant EIA chemotherapy, surgical resection and radiotherapy in high-risk soft tissue sarcoma

BACKGROUND

The role of chemotherapy in high-risk soft tissue sarcoma is controversial. Though many patients undergo initial curative resection, distant metastasis is a frequent event, resulting in 5-year overall survival rates of only 50-60%. Neo-adjuvant and adjuvant chemotherapy (CTX) has been applied to achieve pre-operative cytoreduction, assess chemosensitivity, and to eliminate occult metastasis. Here we report on the results of our non-randomized phase II study on neo-adjuvant treatment for high-risk STS.

METHOD

Patients with potentially curative high-risk STS (size ≥ 5 cm, deep/extracompartimental localization, tumor grades II-III [FNCLCC]) were included. The protocol comprised 4 cycles of neo-adjuvant chemotherapy (EIA, etoposide 125 mg/m(2) iv days 1 and 4, ifosfamide 1500 mg/m2 iv days 1 - 4, doxorubicin 50 mg/m(2) day 1, pegfilgrastim 6 mg sc day 5), definitive surgery with intra-operative radiotherapy, adjuvant radiotherapy and 4 adjuvant cycles of EIA.

RESULT

Between 06/2005 and 03/2010 a total of 50 subjects (male = 33, female = 17, median age 50.1 years) were enrolled. Median follow-up was 30.5 months. The majority of primary tumors were located in the extremities or trunk (92%), 6% originated in the abdomen/retroperitoneum. Response by RECIST criteria to neo-adjuvant CTX was 6% CR (n = 3), 24% PR (n = 12), 62% SD (n = 31) and 8% PD (n = 4). Local recurrence occurred in 3 subjects (6%). Distant metastasis was observed in 12 patients (24%). Overall survival (OS) and disease-free survival (DFS) at 2 years was 83% and 68%, respectively. Multivariate analysis failed to prove influence of resection status or grade of histological necrosis on OS or DFS. Severe toxicities included neutropenic fever (4/50), cardiac toxicity (2/50), and CNS toxicity (4/50) leading to CTX dose reductions in 4 subjects. No cases of secondary leukemias were observed so far.

CONCLUSION

The current protocol is feasible for achieving local control rates, as well as OS and DFS comparable to previously published data on neo-/adjuvant chemotherapy in this setting. However, the definitive role of chemotherapy remains unclear in the absence of large, randomized trials. Therefore, the current regimen can only be recommended within a clinical study, and a possibly increased risk of secondary leukemias has to be taken into account.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01382030, EudraCT 2004-002501-72.

The prognostic value of histological tumor necrosis in solid organ malignant disease: a systematic review

Background: Tumor necrosis has been proposed as a marker of poor prognosis in a variety of solid organ malignant tumor types. Despite this, its assessment has yet to be adopted into routine clinical practice and the mechanisms underpinning the relationships with cancer outcome are undetermined. Aims: To examine the prognostic value of tumor necrosis in solid organ malignant disease and to summarize the known clinical, pathological and inflammatory associations. Methods: A systematic review of data published from 1966–2011 was undertaken by two reviewers according to a predefined protocol. A total of 57 independent studies relating to renal (n = 23), breast (n = 13), lung (n = 7), colorectal (n = 5) and other solid tumors (n = 9) were included in the final review. Conclusion: There is now a substantial body of evidence confirming the prognostic value of tumor necrosis in solid organ malignant disease. There are consistent associations between necrosis and the presence of other high-risk tumor characteristics but the survival impact appears to be independent of pathological stage. We propose that relationships with the host inflammatory response, both local and systemic, may explain the influence of tumor necrosis on cancer outcome.