Soft-tissue sarcomas of the head and neck

Non-squamous Cancers of the Larynx

PURPOSE OF REVIEW

Although non-squamous tumors of the larynx are really rare, they may not always be viewed from the same perspective in the multidisciplinary treatment approach once the diagnosis is made. In this review, non-squamous tumors of the larynx and current approaches in treatment will be discussed.

RECENT FINDINGS

When the studies and meta-analyses presented in the last 5 years are evaluated, it is seen that these tumors usually show non-specific symptoms. Due to their submucosal location, the stage of the disease at the time of diagnosis is often advanced. In the literature, treatment may vary in these particular cases. The majority of non-squamous tumors of the larynx includes minor salivary gland tumors, neuroendocrine carcinomas, sarcomas, cartilage tumors, and malignant melanomas. Once treating a patient with these diagnoses, it should be kept in mind that the histopathological subtype is almost as important as the stage of the tumor.

Biphenotypic sinonasal sarcoma: Report of 3 cases with a review of literature

Biphenotypic sinonasal sarcoma (BSNS) is a rare recently described distinct spindle cell sarcoma which arises exclusively in the sinonasal region and is characterized by concomitant neural and myogenic differentiation. Before this neoplasm was characterized, most were classified as other entities including adult fibrosarcoma, monophasic synovial sarcoma and malignant peripheral nerve sheath tumor. By immunohistochemistry, these tumors characteristically express S100 and smooth muscle actin (SMA) and/or muscle specific actin (MSA). Most cases harbor rearrangements of PAX3 (paired box gene 3), and the most frequent translocation partner is MAML3 (mastermind like transcriptional coactivator 3). Herein, we described three cases of BSNS involving the nasal cavity with or without paranasal sinus involvement. We also did a literature review of the clinical features, histologic and immunophenotypic findings, cytogenetics, pathogenesis and behavior of this rare entity.

A rare case of a laryngeal leiomyosarcoma with a lymph node metastasis

INTRODUCTION

Leiomyosarcoma is a rare mesenchymal tumor that originates from smooth muscle cells. Head and neck LMSs represent only 3% of all leiomyosarcomas with less than 50 cases of laryngeal LMS reported in the literature till now.

CASE PRESENTATION

We report a case of 50-year-old male presented at our ENT department for a chronic hoarseness. Clinical examination investigations found small submucosal lesion in the right vocal cord. Treatment consisted of CO2 Laser excision of the lesion. The evolution was marked by the appearance of a tumefaction in the left submandibular region and a severe dyspnea requiring an emergency tracheotomy. Paraclinical examination investigations found a supraglottis-glottis-subglottis tumor. A total laryngectomy with bilateral functional neck dissection was performed and the histopathological examination found a laryngeal leiomyosarcoma.

CONCLUSION

LMS of the larynx a very rare malignancy. The accurate diagnosis is histological. Surgery is the mainstay of treatment. Its prognosis is correlated to local recurrence and distant metastases.

Head and neck sarcomas: treatment outcomes in a tertiary referral center in Argentina

PURPOSE

To analyze the clinical findings, management, and results of oncological treatments and to identify prognostic factors in patients diagnosed with head and neck sarcoma.

METHODS

We performed a retrospective analysis including 48 adult patients with primary head and neck sarcomas, treated between 2006 and 2018 in a referral center of Argentina.

RESULTS

The median follow-up time was 44 months (range: 4-146 months). Five-year overall survival was 68%. On univariate analysis, radiation-induced sarcomas (p=0.038) had worse survival. Five-year disease-free survival was 58% and local recurrence at 2 years was 22.7%. On multivariate analysis, positive/close resection margins (p=0.031), radiation-induced sarcomas (p=0.037), and mandibular and oral cavity location (p=0.002) were independent prognostic factors associated to local recurrence and shorter disease-free survival.

CONCLUSION

Head and neck sarcomas are a rare entity. Surgery is feasible in more than 80% of patients, with an acceptable overall and disease-free survival. Radiation-induced sarcomas, location in the mandible and oral cavity, and close margins were significant prognostic factors in our population.

Assessment of Prognostic Factors and Adjuvant Treatment Modalities in Adult Head and Neck Soft Tissue Sarcoma Patients Treated With Upfront Surgery

Objectives

Head and neck soft tissue sarcomas (HNSTSs) are a heterogeneous group of rare tumors. Surgical resection with negative margins remains the standard primary treatment for patients with HNSTS. The role of chemotherapy (CT) and radiotherapy (RT) remains controversial. In this multicenter study, we aimed to demonstrate the real-world assessing prognostic factors and the effect of adjuvant treatment modalities in adult patients with HNSTS treated with upfront surgery.

Methods

We included a total of 47 patients who underwent curative-intent resection of a primary HNSTS between 2000 and 2019.

Results

The median follow-up was 29 months. The median age of patients was 51 years, and 66% of patients were male. The median relapse-free survival (RFS) of the study population was 31 months (range: 1.0-61.1 months), and the median overall survival (OS) was 115 months (range: 60.8-169.2 months). The univariable analysis revealed that treatment modalities showed a significant impact on RFS (p = 0.021); however, no difference was found in its impact on OS (p = 0.137). R0 resection did not showed impact on RFS (p = 0.130), but a significant association was found with OS (p = 0.004). In multivariable analysis, T stage of the tumor (hazard ratio [HR]: 3.834; 95% CI: 1.631-9.008; p = 0.002) and treatment with surgery and sequential RT and CT (HR: 0.115; 95% CI: 0.035-0.371; p < 0.001) were independent factors associated with RFS. R0 resection was independently associated with OS (HR: 4.902; 95% CI: 1.301-18.465; p = 0.019).

Conclusion

Our study revealed that R0 resection improved OS, and T3-4 stage of tumor was a negative independent factor for RFS in surgically resected HNSTS patients. The use of sequential CT and RT after resection was associated with a better RFS, which emphasizes the importance of multidisciplinary evaluation of the treatment of HNSTS. Randomized prospective studies are needed

Sarcomas of the paranasal sinuses: An analysis of the SEER database

Objective

To determine the demographics, treatment modalities, and overall survival of patients with sinonasal sarcoma.

Methods

All cases of primary sinonasal sarcomas diagnosed between the years of 2009 and 2014 were extracted from the National Cancer Institute's Surveillance, Epidemiology, and End Results database. Additional variables collected included age, gender, ethnicity, tumor histological subtype, tumor size, treatment modality, vitality status, and follow-up time. Kaplan-Meier survival curves were generated and overall survival was calculated.

Results

One hundred and four cases of sinonasal sarcoma were identified. The majority of patients were female (55%), white (76%), and non-Hispanic (84%), and the mean age was 47 ± 22 years. The most common tumor sites were the maxillary sinus, followed by the ethmoid, sphenoid, and frontal sinus. Forty six percent of tumors were rhabdomyosarcoma type. Most patients (66%) had some type of surgery, 64% received radiation, and 58% received chemotherapy as part of their treatment. Overall 1- and 5-year survival was 79% and 31%, respectively. There was no significant difference in survival based on patient gender, age, ethnicity, radiation, or chemotherapy treatment.

Conclusions

This study adds to the current literature of sinonasal sarcomas and is the first to report in detail the surgical interventions performed as well as characteristics about lymph node spread, tumor histology, and treatment outcomes since the advent of radiation and chemotherapy. As these tumors are so rare, continued study of the demographics, tumor characteristics, and long-term outcomes of this population is necessary to guide treatment modalities and strategies for otolaryngologists.

Level of Evidence

2b.

Primary dedifferentiated liposarcoma of the orbit, a rare entity: Case report and review of literature

Head and neck liposarcomas are rare entities accounting for less than 5% of all liposarcomas. The primary orbital location is even rarer, with about 40 cases described in the English literature. According with the widely accepted classification of Enzinger and Weis there are 5 histologic variants of liposarcomas: well differentiated, myxoid, dedifferentiated, round cell and pleomorphic. The first two are considered low-grade and display a favourable prognosis (>90% 5-year DSS and OS), whereas the dedifferentiated, round cell, and pleomorphic are defined high-grade and burdened with poorer prognosis (5-year DSS ranging 45-73%). Dedifferentiated liposarcomas (DDL) of the head and neck region are exceedingly rare, therefore there are scattered and contrasting data regarding their clinical history, treatment modality, and prognosis. We presented a case of DDL arising in the the left orbit (fourth case of primary orbital DDL described), free from disease after 5-year follow-up. Clinical history, treatment, and characteristics of the presented case were described and discussed in the light of how reported in the literature, in the attempt to bring further insight in the nature and management of this rare pathological entity.

The importance of surgery in scalp angiosarcomas

BACKGROUND

Scalp angiosarcomas (SA) are rare, representing <1% of soft tissue sarcomas. The optimal management of these tumors is unknown, with management based on small case series. We sought to assess the impact of different therapies on overall survival (OS), the practice patterns nationally, and identify factors associated with OS for non-metastatic scalp angiosarcomas.

METHODS

A prospectively maintained database was used to identify non-metastatic scalp angiosarcomas who received some form of definitive therapy. Logistics regression, Kaplan-Meier, and Cox proportional-hazard models were utilized.

RESULTS

A total of 589 patients met study entry criteria with a median follow-up of 4.2 years. The majority (482 patients, 81.8%) had upfront definitive resection and an additional 317 patients (65.8%) received postoperative radiation. Of the 107 patients who didn't have surgery, the majority (65 patients, 60.7%) received definitive radiation and 42 patients (39.3%) received radiation and chemotherapy. One-year and five-year survival estimates for patients not receiving definitive surgery were 68.0% (95%CI: 57.5-76.4) and 18.0% (95%CI: 10.2-27.5) respectively compared to 78.2% (95%CI: 74.0-81.9) and 34.1% (95%CI: 28.9-39.3) for patients receiving definitive surgery (p < 0.01). On multivariable analysis, age ≥65 years, tumor size ≥5 cm, and not receiving definitive surgery was associated with worse OS.

CONCLUSIONS

The majority of patients with non-metastatic scalp angiosarcomas had upfront definitive surgery, with a subsequent improvement in OS, including when accounting for other patient and tumor factors. Postoperative radiation was frequently given. Our large series confirmed age and tumor size as prognostic factors for this rare disease.

Ending 40 years of silence: Rationale for a new staging system for soft tissue sarcoma of the head and neck

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For 40 years, all soft tissue sarcoma (STS) used the same TNM where T1 was <=5 cm.

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This staging is unsuited for STS of the head and neck (STSHN) since only a minority are >5 cm.

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Despite smaller size, local recurrence is higher in STSHN compared to other STS.

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A new T classification with 2 and 4 cm cut-offs for STSHN was introduced in TNM-8.

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Future requirements for STSHN Stage Group development are mentioned.

The tumor, node, metastases (TNM) anatomic staging system plays a pivotal role in cancer care, research, and cancer control activities. Since the first edition of the American Joint Committee on Cancer TNM staging classification published in 1977, soft tissue sarcomas have been staged in an anatomic site agnostic fashion whereby the primary tumor size (T) was categorized as T1 if <=5 cm and T2 if >5 cm; this remained unchanged through the 7th edition of the TNM. However, soft tissue sarcomas of the head and neck (STSHN) usually present smaller than sarcomas of other sites, but carry a disproportionate risk of local recurrence. Up to 70% of tumors are less than 5 cm at presentation, and therefore classified together as T1. Given the rarity of STSHN, there is a paucity of data to guide progress in their classification. Moreover, the majority of publications only report tumor size as less than or greater than 5 cm, presumably based on conventions of the TNM system that remained unchanged for 40 years, thereby affecting progress of STSHN classification. This formed the impetus for change in the 8th edition in 2 key ways: 1) several soft tissue sarcoma site based changes occurred including STSHN now having its own system, and 2) primary tumor size cut-offs of 2 cm and 4 cm used in STSHN now reflect sizes that head and neck specialists commonly encounter in their practice. This update was pragmatic in modifying the TNM from a system with a T category not serving STSHN and which was originally based on sarcoma data from non-head and neck anatomic sites. The background to this change is outlined which provides a framework in which data can be reported to generate evidence for future staging modifications.

Low-Grade Fibrosarcoma of the Anterior Skull Base: Endoscopic Resection and Repair

Background

Fibrosarcomas of the paranasal sinuses and skull base are uncommon tumors. Traditionally, “open approach” surgery remains the mainstay for treatment of choice for these tumors.

Methods

A 49-year-old man underwent resection of a right anterior skull base fibrosarcoma using the endoscopic approach.

Results

Close follow-up using both endoscopic and imaging methods over a period of four years has revealed a well-healed skull base with no evidence of recurrence.

Conclusion

Significant resistance exists at present for such a technique to deal with malignant diseases of the head and neck, but results from advanced centers continue to prove that this may be a technique worth mastering and improving on.

Relapse in dermatofibrosarcoma protuberans: A histological and molecular analysis

BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) is a rare low grade tumor with a locally aggressive behavior and low metastatic potential.

OBJECTIVES

To evaluate the factors that are associated with relapse in DFSP. Methods Retrospective analysis of medical records from 61 patients with dermatofibrosarcoma. Fluorescence in situ hybridization was used to detect translocations.

RESULTS

Of 61 patients, 6 experienced a relapse. No patient with resection margins greater than 3 cm had a recurrence. One relapse was observed in a patient treated with at least 2 cm margins and 4 relapses occurred in 16 patients whose margins were below 2 cm (P = 0.018). The frequency of translocations was 77.8%. The recurrence rate was lower in patients with translocation, but this difference was not significant. Immunohistochemical markers did not correlate with recurrence rates, but greater FasL expression was associated with recurrence in patients with margins smaller than 3 cm.

CONCLUSIONS

Surgical margins smaller than than 2 cm are related to higher recurrences in dermatofibrosarcomas. In this analysis a 2 cm margin was acceptable for treatment. Between all the immunohistochemical markers analyzed, only FasL was associated with a higher recurrence rate in patients with margins smaller than 3 cm.

Sarcomas of the sinonasal tract

BACKGROUND

Sinonasal sarcomas are rare and heterogeneous in nature. Continuously collecting data influencing the prognosis is fundamental for optimizing therapeutic assessment of this highly destructive neoplasm.

METHODS

We conducted a single-institution retrospective cohort study considering 27 patients with sinonasal sarcoma.

RESULTS

The overall survival (OS) rates for 1 year and 5 years were calculated as 74% and 36%, respectively. Extent of the primary tumor (P = .010), nodal spread (P = .009), and age (P = .004) significantly reduced the OS. Disease-free survival (DFS) was significantly reduced by age (P = .003), extent of the primary (P = .006), nodal (P = .004), and hematogenous (P = .048) spread. Multimodal therapy including surgery improved the OS and DFS rates (P < .05).

CONCLUSION

Prognosis is poor due to late disease recognition. However, multimodal therapeutic regimens, including surgery, may improve the outcome.

Combined chemoradiation for head and neck region myxofibrosarcoma of the maxillary sinus

Aims and background

Adult sarcomas of the head and neck region (HNSs) are considered a rare clinicopathological entity. They account for only 2–15% of all adult sarcomas and for less than 1% of all head and neck malignancies. The preferred initial treatment option is wide surgical excision. Whenever surgery is considered infeasible, a frontline combined-modality approach including radiotherapy and chemotherapy might be proposed. We here report on a case of localized sarcoma of the maxillary sinus treated with induction chemotherapy and subsequent intensity-modulated radiation therapy (IMRT), achieving a persistent complete remission status.

Methods

A 66-year-old man was referred to our institution hospital for left-sided facial pain with swollen left cheek and ipsilateral facial palsy. Magnetic resonance imaging showed a mass within the left maxillary sinus extending to the orbital floor and adjacent alveolar bones. Histological examination of the biopsy specimen demonstrated a myxofibrosarcoma. The patient underwent induction chemotherapy with gemcitabine 900 mg/m2 (days 1–8) and taxotere 80 mg/m2 every 3 weeks for 3 cycles and sequential simultaneous integrated boost (SIB) IMRT up to a total dose of 70 Gy/35 fractions to the macroscopic disease with 59.5 Gy/35 fractions to the level IB-II lymph nodes in the left neck.

Results

Treatment was well tolerated with mild acute toxicity. Complete remission was achieved at restaging MRI 6 months after the end of the combined modality approach. The patient remains in complete, unmaintained clinical and instrumental complete remission 18 months after treatment, with no late side effects.

Conclusion

Combination therapy with induction chemotherapy and sequential SIB-IMRT could therefore be a promising modality for head and neck sarcomas, allowing for simultaneous tumor control and normal tissue sparing.

CO2 Laser in the Treatment of Laryngeal Synovial Sarcoma: A Clinical Case

Synovial sarcoma is a rare mesenchymal neoplasm that is usually located in the limbs. Its occurrence in the head and neck region, and particularly in the larynx, is exceptional, with only 16 cases reported to date. Two histological variants have been described, a biphasic and a monophasic variant. Immunohistochemistry is determinant in the differential diagnosis between synovial sarcoma and other spindle and biphasic neoplasms. The treatment of choice is conservative surgery with tumor-free margins, while radiotherapy is effective in local control of the disease after recurrence. Chemotherapy is indicated for the treatment of distant metastases. We present a case of monophasic synovial sarcoma of the laryngeal ventricle that was successfully treated with CO2 laser excision and we briefly review the literature on the subject.

Undifferentiated sarcoma of the sphenoid sinus

Paranasal sinuses sarcomas are rare and no treatments have been established. We report a young-adult case of sphenoid sinus sarcoma treated by carbon-ion radiotherapy. The patient presented with progressive left-sided visual impairment. A tumor was then identified and partial resection by transnasal approach was performed. The resected mass showed typical morphology of mesenchymal tumor, and morphological and molecular analyses ruled out a predominant-differentiation phenotype. The pathological diagnosis was undifferentiated sarcoma. The residual lesion was treated with carbon-ion radiotherapy, and tumor progression was absent for one year. The patient died of the tumor regrowth 20 months after initial diagnosis. Although this case had a poorer outcome compared with cases of the more-common sarcoma types, our experience suggested that carbon-ion radiotherapy is potentially beneficial in unresectable undifferentiated sarcomas cases of sphenoid sinus.

Metastatic Angiosarcoma Presenting as Ischemic Anterior Circulation Stroke

BACKGROUND

Angiosarcoma is a rare malignant neoplasm that can arise from vascular endothelium. We report a case of angiosarcoma that presented as thromboembolic stroke, review the current literature, and discuss the management challenges.

CASE REPORT

A 77-year-old man presented with a right anterior circulation stroke with a history of multiple, recent transient ischemic attacks. The diagnosis was confirmed on computed tomography and subsequent investigation revealed thrombus within the distal common carotid artery, with an atherosclerotic plaque causing a significant stenosis of the origin of the internal carotid artery above this. In the context of the presentation with recurrent events, carotid endarterectomy was recommended and subsequently performed. At the time of surgery, the common, internal, and external carotid arteries had macroscopic evidence of atherosclerotic disease but appeared otherwise normal. Intraoperatively friable thrombus adherent to the common carotid endothelium was retrieved and sent for histologic assessment. Subsequent immunohistochemistry evaluation revealed changes pathognomic with angiosarcoma.

RESULTS

It is unclear in this case whether the pathology originated in the carotid artery or was the result of embolization from a proximal source. There was no extraluminal carotid pathology identified at the time of surgery, and no abnormalities identified on cross-sectional imaging. Similarly, there was no evidence of a proximal source that may have resulted in tumor embolization. As such, it has proved impossible to define an optimal therapeutic pathway for this patient.

Analysis of Clinical Prognostic Factors for Adult Patients with Head and Neck Sarcomas

Objective

To evaluate the treatment, outcome, and prognostic factors in patients with head and neck sarcomas treated in an academic medical center.

Study Design

Case series.

Setting

Academic medical center.

Subjects and Methods

We performed a retrospective analysis of adult patients (n = 97) with primary head and neck sarcomas treated between 2000 and 2012. We analyzed the treatment, outcome, and potential factors predictive of disease-free survival and disease-specific survival. We also evaluated the outcome and prognostic factors in patients with bone and soft tissue sarcomas.

Results

The median overall survival was 6.8 years, with 2-year and 5-year overall survival rates of 78% (95% confidence interval [CI], 66%-86%) and 59% (95% CI, 44%-72%), respectively. Univariable analysis revealed that age at diagnosis (>60 years: hazard ratio [HR], 2.7; 95% CI, 1.2-6.2; P = .01), surgical intervention (HR, 8.3; 95% CI, 3.5-19.5; P < .001), and metastatic disease (HR, 4.3; 95% CI, 1.3-13.6; P = .01) were significantly associated with disease-specific survival.

Conclusion

In this study, patients over the age of 60 years at diagnosis and those with inoperable disease at initial presentation had significantly worse disease-specific survival. Surgical intervention remains the optimal treatment modality for those with resectable disease and was associated with significantly better survival in this heterogeneous series. Further multi-institutional studies are required to better define prognostic factors in individual histological subtypes.

Soft tissue sarcomas of the head and neck. Clinical and pathological evaluation of 108 cases in Mexico

BACKGROUND

Sarcomas constitute 1% of all malignancies, but 10% occur in the head and neck (HN), and they are poorly understood. We present a large series of Soft Tissue HN sarcomas in Mexican patients with survival analysis.

STUDY DESIGN

This is a retrospective study of cases in a cancer hospital.

METHODS

Review of files and pathology material. Literature review.

RESULTS

We analysed 108 patients (55 men / 53 women). The age at presentation was 37 years. The original diagnosis changed in nine cases (8.3%). The most common subtype was rhabdomyosarcoma. Ninety percent of tumours were deep, 91% were high grade, 44% had metastasis, 63% measured >5 cm, overall 5-year survival (5 y-OS) was 48%, and histological high grade was associated with poor survival (p = 0.026).

CONCLUSION

Sarcomas of the HN are rare. The most affected sites were paranasal sinuses. The majority of tumours were deep, > 5 cm and high grade, 50% had metastasis, the 5 y-OS was 48% and the only independent factor associated with 5 y-OS was histologic grade.

Combination therapy for scalp angiosarcoma using bevacizumab and chemotherapy: a case report and review of literature

Bevacizumab, an angiogenesis inhibitor, is a recombined humanized monoclonal antibody against vascular endothelial growth factor and a promising therapeutic option for angiosarcoma management. This is a case report and review of the literature using bevacizumab and combination chemotherapy for angiosarcoma. The understanding of the effectiveness of combined therapy of bevacizumab and chemotherapy agents is still limited. The benefits of bevacizumab treatment for angiosarcoma will need to be weighed against the risks of venous thromboembolism in this population.

Prognostic factors in sinonasal sarcomas: analysis of the surveillance, epidemiology and end result database

OBJECTIVES/HYPOTHESIS

Sinonasal sarcomas are rare and often aggressive malignant tumors. Although tumor histology and location are the only reported prognostic indicators for this disease, we sought to determine if additional clinical factors might influence patient survival.

STUDY DESIGN

Retrospective cohort study using a national cancer database.

METHODS

Cases of sinonasal sarcomas from 1973 to 2008 were extracted from the Surveillance, Epidemiology and End Result (SEER) database. The influence of patient age, gender, race, and prior irradiation, as well as tumor histology and subsite, was calculated using the Kaplan-Meier method.

RESULTS

A total of 352 patients with sinonasal sarcomas were identified. Histologic subtype, tumor location, gender, and patient age were found to influence patient survival. Specifically, increased age, male sex, frontal and maxillary sinus subsites, and rhabdomyosarcoma and Kaposi sarcoma histologies were associated with a significant increase in mortality rate (P < .05).

CONCLUSIONS

This study comprises the largest analysis of patients with sinonasal sarcoma in the literature and demonstrates the impact of patient age, tumor histology, and tumor location on the overall survival of individuals with these rare malignancies.

Radiation-induced leiomyosarcoma of the posterior neck region

INTRODUCTION

Leiomyosarcomas are mesenchymal malignant tumours that appear in smooth muscle cells. Their most frequent locations are the uterus and gastrointestinal tract. Their occurrence in head and neck is considered exceptional. We present a patient with a posterior neck region leiomyosarcoma who had received radiation for a nasopharyngeal carcinoma 20 years earlier. The incidence ratio of these tumours in radiated patients (therefore considered radiation-induced) ranges from 0,035 to 0,2%. Radiation-induced sarcomas are difficult to diagnose due to the induration and fibrosis in the radiated area and the non-specific symptoms that they present. Their prognosis is very poor.

Maxillary Sinus Sarcomas: Epidemiological and Clinicopathological Experience of 25 Years in a National Reference Cancer Center

The aim of this study was to report our experience with malignant soft tissue tumors of the maxillary sinus in the period between 1985 to 2010. This is a retrospective case study in a tertiary cancer center setting. Review of patient's records and new evaluation of pathological specimens were made for 20 patients (14 men and 6 women) still met present criteria. After review the most common histological diagnoses were malignant peripheral nerve sheath tumor and malignant fibrous histiocytoma. There are male sex predilection, the median age was 38.9 years; 95% of tumors were >5 cm, 80% were high grade, 0% have metastatic disease at the diagnosis and the tumors were initially treated by surgical resection had better survival (p = 0.02). We present the results of a one of the larger series published to date in maxillary sinus sarcomas where analyzed the clinicopathological characteristics of 20 cases.

Leiomyosarcoma of the head and neck: a population-based analysis

OBJECTIVES

To describe the characteristics of head and neck leiomyosarcoma and to identify factors associated with survival.

DESIGN

Retrospective population-based study.

PATIENTS

The 17-registry Surveillance, Epidemiology, and End Results database was used to identify 578 patients with leiomyosarcoma of the head and neck.

INTERVENTIONS

Surgery and primary and adjuvant radiotherapy.

MAIN OUTCOME MEASURES

Patient demographics and tumor characteristics were examined. Treatment modalities were compared, and survival was assessed using the log-rank test.

RESULTS

The mean age at diagnosis was 64 years. Most tumors were smaller than 5 cm in greatest dimension (87%) and high grade (44% were moderately differentiated and 39% were poorly differentiated). The primary tumor demonstrated deep extension in 39% of cases, and 2% had lymph node metastases. The most common primary site was the skin and soft tissue of the head and neck (83%). Surgical treatment was provided to 89% of patients, 14% received adjuvant radiotherapy, and 4% received radiotherapy alone. The median observed survival was 84.7 months. The 5-year disease-specific survival rate was 87.6% in patients with well-differentiated tumors, 85.7% in patients with moderately differentiated tumors, and 52.7% in patients with poorly differentiated tumors (P < .001). Survival was better for patients who received surgery alone (median survival, 100.1 months [n = 413]) than for those who received radiotherapy alone (median survival, 16 months [n = 16]) or adjuvant radiotherapy (median survival, 64.2 months [n = 80]) (P < .001). The latter group was more likely to have poorly differentiated, large, locally invasive tumors.

CONCLUSIONS

Leiomyosarcoma typically presents in older patients; it is often poorly differentiated; and improved survival is associated with surgical treatment.

Head and neck leiomyosarcoma

Soft tissue sarcomas of head and neck region, account for 4-15% of all soft tissue sarcomas and less than 1% of all neoplasms in this region. Leiomyosarcoma is malignant tumor of smooth muscle which accounts for only 4% of head and neck sarcomas. The tumor is commonly encountered as a slow growing, discrete firm, and non-ulcerated painless mass. The physical appearance of these tumors can be deceptively benign and can be mistaken for non-malignant conditions. An early diagnosis and aggressive initial treatment remains the mainstay of therapy for a good prognosis. We are presenting eight cases of primary leiomyosarcoma of head and neck region with review of literature and highlight the need for early prudent diagnosis and treatment.

Collet Sicard syndrome as atypical presentation of neck fibrosarcoma: a case report

We report a 57 years old female patient with neck fibrosarcoma. Her main complaints consisted of hoarseness, difficulty swallowing, pain in the left side of her neck and left shoulder region, which all indicated the Collet Sicard syndrome, so the working diagnosis was glomus tumor. Diagnostic MSCT was used, and the characteristics of the radiologic finding did not indicate any of the paraganglioma types, although the tumor was localized in the area of the carotid bifurcation, demonstrating the signs of extension into the jugular foramen. The patient has been treated surgically in general anesthesia and pathologic diagnosis was fibrosarcoma.

Scalp Angiosarcoma Remission with Bevacizumab and Radiotherapy without Surgery: A Case Report and Review of the Literature

Angiosarcoma (AS) is a rare and aggressive vascular neoplasm with very poor prognosis. Patients with extensive cutaneous AS who are not surgical candidates have very limited options since there is no standard treatment. Treatment options include radiation, chemotherapy, and angiogenesis inhibitor with varying success rates. Here, we report a case an 88 year old patient with extensive scalp angiosarcoma having biopsy proven remission with bevacizumab and radiotherapy without undergoing surgery.

Management of adult soft tissue sarcomas of the head and neck

Adult soft tissue sarcoma of the head and neck are rare and represent a heterogeneous group of tumours of different histological variants. Management of these neoplasms presents a great challenge. Malignant fibrous histiocytoma, fibrosarcoma, angiosarcoma and malignant peripheral nerve sheath tumour are the most frequently found sarcoma types in the head and neck. Although traditional morphological assessment is the foundation of clinical decision making, the role of immunohistochemistry and molecular biology are useful for diagnosis, prognosis and identification of possible targets for molecular therapy. The most frequently involved tumour sites are scalp/face, sinonasal tract/anterior skull base and parotid/neck. The management of soft tissue sarcomas in the head and neck is primarily surgical. Since it is difficult to obtain wide margins during surgical treatment in head and neck sarcomas, because of anatomic constraints, most patients undergo post-operative irradiation. Survival varies from 50 to 80%. Prognostic factors are tumour grade, margin status and tumour size. With further insight into the biology of soft tissue sarcoma, modern imaging techniques and new treatment options, we will most certainly be able to improve clinical outcome in patients with soft tissue sarcoma in the upcoming years.

The role of surgery and radiotherapy in treatment of soft tissue sarcomas of the head and neck region: review of 30 cases

BACKGROUND

Thirty adult patients with head and neck soft tissue sarcoma (HNSTS) treated between 1987 and 2000 were retrospectively analysed.

PATIENTS AND METHODS

The most frequent histopathological subtypes were chondrosarcomas (27%) and malignant fibrous histiocytoma (20%). The surgical resection was performed in 25 of the 30 patients (83%). Twenty-three patients in the surgical resection arm received postoperative radiotherapy.

RESULTS

Five-year local control rates for patients with negative surgical margins (n=9), microscopically positive disease (n=10), gross residual disease (n=6) and inoperable cases (n=5) were 64, 70, 20 and 0%, respectively. However, there was no significant difference in local control between patients with negative or microscopically positive disease who received postoperative radiotherapy (71 vs. 70%). The patients who received doses>or=60 Gy had significantly higher local control rates than the ones who received doses lower than 60 Gy (p=0.048). The local control rates were lower in patients with grade 2-3 tumours when compared with grade 1 tumours (44 vs. 83%). The median overall survival of whole group was 31 months. Median survivals of patients receiving both surgery and radiotherapy with negative and microscopically positive margins were significantly better than patients who were not treated with surgery (34.8 and 36 vs. 13.3 months).

CONCLUSION

Our results confirm that the optimal treatment of HNSTSs is complete surgical excision, and that postoperative adjuvant radiotherapy clearly improves local control.

Leiomyosarcoma of the Larynx: Case Report and Review of the Literature

Leiomyosarcoma of the larynx is an extremely rare entity. This tumor is aggressive and is associated with dismal treatment results. We present a case of leiomyosarcoma of the larynx treated with surgery and postoperative radiotherapy. In this article we also discuss laryngeal leiomyosarcoma's clinical manifestations, associated diagnostic dilemmas, and optimal management, as well as a review of the literature.

Report of a Radiation-Induced Leiomyosarcoma Arising From the Posterior Neck

Radiation-induced leiomyosarcoma of the head and neck region has been very seldom described. Herein, we report a 48-year-old male patient who developed leiomyosarcoma in his posterior neck region, which was previously radiated due to a cerebellar astrocytoma.

Analysis of prognostic factors in 146 patients with anterior skull base sarcoma: An international collaborative study

BACKGROUND

Single-institutional studies lack sufficient power to assess the role of surgery and radiotherapy in the management of sarcomas involving the anterior skull base. For this study, an international collaborative study group analyzed a large cohort of patients who underwent surgery for the treatment of skull base tumors.

METHODS

A subset of 146 patients who had a histologic diagnosis of skull base sarcoma (SBS) formed the basis of this report. Most patients were aged > or =21 years (77%) and had stage IV disease (56%). Adjuvant radiotherapy was received by 35% of patients, and chemotherapy was received by 10% of patients.

RESULTS

Orbital involvement was encountered in 53% of patients, involvement of the orbital wall was encountered in 46% of patients, and intracranial extension was encountered in 28% of patients. Positive microscopic margins were reported in 43% of patients (51 of 118 patients). Treatment-related complications were reported in 27% of patients, and postoperative mortality was reported in 1.4% of patients. With a median follow-up of 34 months, the 5-year overall, disease-specific, and recurrence-free survival rates were 62%, 64%, and 57%, respectively. Tumor grade and adjuvant radiotherapy were not significant predictors of survival. Prior radiotherapy, intraorbital extension, positive margins, and postoperative complications were significant predictors of reduced disease-specific survival on univariate analysis. The presence of positive/close margins, however, was the only independent predictor of poor overall, recurrence-free, and disease-specific survival on multivariate analysis (relative risk, 2.4; P = .006). The 5-year disease-specific survival rate was 77%, 43%, and 36% for patients with negative, close, and positive margins, respectively.

CONCLUSIONS

The current results indicated that wide craniofacial resection with negative margins is an independent prognostic predictor of better outcome. Patients with positive margins have a high risk for tumor recurrence independent of tumor grade.

Prognostic factors in adult soft tissue sarcomas of the head and neck: A single-centre experience

Adult soft tissue sarcomas of the head and neck are rare and consist of a variety of histopathological subtypes and sites. The purpose of this study was to review patients treated for adult soft tissue sarcomas of the head and neck at our institute. The medical records of 41 adult patients treated for head and neck soft tissue sarcomas between 1983 and 2004 were reviewed. Thirty-six tumours were histologically reviewed. Histopathological revision showed that 7% of the original sarcomas were found not to be sarcomas and 39% of the sarcoma subtypes changed. Multivariate analysis showed that surgical margin status and lymph node metastases are the most important prognostic factors. Review of histopathological examination of tumours showed a change in subtype in a substantial number of head and neck sarcomas. Negative surgical margins are an important prognostic factor, but are difficult to obtain in head and neck sarcomas.

Sarcoma of the larynx: treatment results and literature review

BACKGROUND

Sarcomas of the larynx are rare neoplasms that constitute less than 1% of laryngeal malignancies. A Medline search found no large series focusing on laryngeal sarcomas. We reviewed the cases of laryngeal sarcomas treated in our cancer center and compared our experiences and treatment results with those from other centers.

METHODS

A retrospective review of 10 patients with laryngeal sarcoma treated in our institute between 1980 and 2000 was done to identify tumor characteristics, therapeutic modalities, and treatment outcomes.

RESULTS

The patients showed a male predominance (9/10) and presented 8 types of pathology. Nine patients underwent surgery, including 2 total laryngectomy, 4 partial laryngectomy, and 3 endoscopic laser cordectomy. During a median follow-up of 92 months, the 5-year overall survival and disease-specific survival were 76% and 90%, respectively. Two patients developed recurrence, including 1 local recurrence and 1 distant metastasis.

CONCLUSION

Surgical intervention was the first choice in the treatment of laryngeal sarcomas. The prognosis is relatively good when compared with sarcoma originating from other anatomic sites.

Magnetic Resonance Imaging Findings of Angiosarcoma of the Scalp

OBJECTIVE

The purpose of this study was to investigate the magnetic resonance (MR) imaging findings of angiosarcoma of the scalp retrospectively.

METHODS

Eight patients with angiosarcoma of the scalp were included in this study. All patients were examined with 1.5-T MR imaging units and commercially available head coils.

RESULTS

In all 8 patients, MR images revealed thickened scalp or tumors with prolonged T1 and T2 relaxation times. They were well enhanced. T2-weighted MR imaging with fat saturation and contrast-enhanced T1-weighted MR imaging with fat saturation clearly showed tumors invading the subcutaneous fat tissue and muscles. In 4 patients, the tumors were larger on MR images than on inspection.

CONCLUSIONS

Magnetic resonance imaging was useful in determining the extent of angiosarcoma of the scalp because it visualized the tumor invasion into surrounding structures that could not be seen on physical inspection.

Leiomyosarcoma of the head and neck: Report of two cases and review of the literature

Leiomyosarcoma is a malignant smooth-muscle tumor that is exceedingly rare in the head and neck region. Two cases of this uncommon tumor localized in the larynx and the parapharyngeal region are presented in this report, which might be the second leiomyosarcoma in the parapharyngeal region reported so far to our knowledge. We also discuss the diagnosis and treatment of leiomyosarcoma in this aspect.

Soft tissue sarcomas of the head and neck: a single-centre experience

OBJECTIVE

The aim of this study was to report our experience with malignant and borderline soft tissue tumours (STS) of the head and neck region in the period 1977-2000.

DESIGN

Retrospective case study including new evaluation of histological specimens.

SETTING

Tertiary centre, single centre.

PARTICIPANTS

Review of patient's records and new evaluation of pathological specimens were made for 66 patients. After evaluation only 36 patients (26 men and 10 women) still met present criteria for a STS in head and neck in adults.

RESULTS

The original histological diagnosis was changed in 27 (41%) of the 66 patients with a primary diagnosis of sarcoma. After review the most common histological diagnoses were leiomyosarcoma (5) and rhabdomyosarcoma (5). Overall 5-year survival rate was 60%. Overall 5-year disease-free survival rate was 44%. The study showed that both tumour grade and surgical margin had a statistically significant impact on survival. No relation was found between survival and tumour size or age.

CONCLUSION

The grave prognosis especially for high-grade tumours emphasizes the need for improved treatment strategies. Furthermore, conclusions from older studies concerning prognosis may be obsolete as approximately 40% of tumours previously diagnosed as sarcomas may be invalid by present day standards.

Sarcomas of the head and neck. Results from the treatment of 25 patients

AIMS

Head and neck sarcomas comprise a heterogenous and biologically diverse group of rare neoplasms. In an effort to clarify some of the obscure clinical behavior of head and neck sarcomas, we present our experience and review the relevant literature.

METHODS

Retrospective analysis of patients with histologically proven head and neck sarcomas treated in a tertiary Hospital Department between 1992 and 2002.

RESULTS

During this period, 25 patients with head and neck sarcomas were registered. Follow-up ranged from 8 to 144 months. Twenty-three patients were treated with surgery as the primary modality; 14 were treated by surgery alone. Clear margins were obtained in all of them and local control was achieved in 12/13. The 2- and 5-year survival rates for the entire group were 80 and 40%, respectively. Mean overall survival time of our patients was 62 months (median 52 months).

CONCLUSIONS

Surgical treatment remains the cornerstone of therapeutic management of head and neck sarcomas.

Primary Columellar Angiosarcoma: A Case Report

Angiosarcoma of the head and neck, a rare malignancy, is associated with a high degree of invasiveness and poor survival. A high level of suspicion followed by histopathologic and immunohistochemical studies is warranted in order to arrive at a well-timed and accurate diagnosis. We report the case of a 56-year-old man who developed an unusually small neoplasm in the nasal columella. Rapid diagnosis allowed for simple treatment with surgical excision, a rare circumstance because most of these tumors require extensive surgery. Close long-term follow-up of patients with angiosarcoma of the head and neck is vitally important.

Management of sarcomas of the head and neck

Soft tissue and bone sarcomas in the head and neck are rare tumors. The 1000 to 1500 yearly cases in the United States are distributed among at least 10 main histologies and multiple head and neck subsites. Although this makes structured studies difficult to perform and high-level evidence-based treatment algorithms difficult to find, basic treatment recommendations can be made from the existing literature for most histologies and subsites. This paper discusses the epidemiology, natural history, and treatment approaches for several of the most common head and neck sarcomas, including the "adult soft tissue sarcomas," osteosarcoma, chondrosarcoma of the larynx, angiosarcoma, rhabdomyosarcoma, desmoid tumors, and dermatofibrosarcoma protuberans.

Sarcomas of the head and neck region

PURPOSE OF REVIEW

This review discusses the classification, etiology, diagnosis, evaluation, treatment, and prognosis of sarcoma of the head and neck region.

RECENT FINDINGS

Sarcomas account for less than 1% of all malignancies in the United States with only 5 to 15% of these sarcomas occurring in the head and neck region. However, about 1 in 3 pediatric sarcomas will occur in the head and neck region. Occasionally, these tumors are associated with genetic syndromes or previous radiation exposures, but, most commonly, no clear etiology exists. Pathologic classification is critical to the ultimate treatment and prognosis of sarcoma of the head and neck. Osteosarcoma, rhabdomyosarcoma, malignant fibrous histiocytoma, and angiosarcoma are the most common types of sarcoma to occur in the head and neck region; however, up to 20% of head and neck sarcomas will remain unclassified. Surgery has been central to the management of these malignancies with some exceptions in the pediatric population. Adjuvant chemotherapy is being utilized and/or studied for most high-grade sarcomas and adjuvant radiotherapy is important for disease control in high-grade soft-tissue sarcomas. Prognosis is clearly related to tumor grade and margin status.

SUMMARY

Sarcomas of the head and neck region are rare malignancies often without a clear etiology. Expert pathologic review and classification is critical, as are quality imaging and multidisciplinary management.

Sarcomas of the head and neck

With the exception of pediatric RMS, soft tissue sarcomas only rarely arise in the head and neck region. Soft tissue sarcomas include a diverse array of histologic types because of the variety of mesenchymal tissues from which they originate. The combination of infrequent occurrence, varied pathologic features, and the many potential sites of presentation makes these tumors a challenge for the head and neck oncologist and underscore the need for review by a pathologist experienced with soft tissue tumors. Classification schemes that group sarcomas according to grade have been helpful in providing prognostic information. Although local control of the primary tumor is critical to successful treatment of both high- and low-grade lesions, the high rate of distant metastases in high-grade tumors supports the role of combined modality therapy. Compared with other types of head and neck neoplasms, such as squamous cell carcinoma, soft tissue sarcomas have low rates of regional metastases. Surgery generally has been recommended as the primary method of treatment for achieving local control, except in those high-grade tumors arising in sites not amenable to resection. Exceptions to this principle include RMSs of the orbit, paranasal sinuses, and masticator space in children; these are usually treated with radiotherapy and combined multiagent chemotherapy, thereby avoiding the functional and cosmetic impact of surgery. Also, extensive angiosarcomas of the scalp should be treated with multimodality therapy combining surgery and wide-field radiation therapy in an attempt to achieve local control. Adjuvant radiotherapy is generally recommended for high-grade sarcomas, large tumors, close or positive surgical margins, and certain histologic variants. Systemic chemotherapy is recommended for those tumors with a significant risk of distant metastases. Increasingly, neoadjuvant chemotherapy is being used to determine responsiveness to chemotherapy, which can help physicians select patients who may benefit from systemic postoperative therapy. Traditional predictors of treatment failure for soft tissue sarcomas include larger tumor size, high-grade histology, and positive surgical margins. The advent of more advanced reconstructive techniques, including free tissue transfer, has made more aggressive surgical resection of these tumors possible. Nevertheless, a considerable number of ancillary support staff are critical to the patient's postoperative rehabilitation and eventual return to a satisfactory level of function and quality of life. In the future, the discovery of the molecular pathogenesis of specific tumor types, such as the cytogenetic findings in synovial sarcoma, will improve physicians' prognostic abilities and selection of patients who are most likely to benefit from emerging adjuvant therapies.

Superficial Leiomyosarcoma of the Head and Neck: Case Report and Review of the Literature

Superficial leiomyosarcomas are rare in the head and neck region. Because of the infrequent nature of soft tissue sarcomas in general, superficial leiomyosarcomas are often misdiagnosed on clinical grounds. Immunohistochemistry is essential for an accurate histologic diagnosis, and it should include a broad panel of antibody studies. With respect to differences in clinical appearance and biologic behavior, superficial leiomyosarcomas can be broadly classified as either cutaneous or subcutaneous; local control and overall survival are significantly more favorable in patients with the former. The primary treatment of a leiomyosarcoma is a wide surgical excision with an emphasis on negative margins. Treatment failures are usually attributable to a local recurrence. Systemic metastasis occurs in about one-third of patients with subcutaneous involvement. Although cutaneous leiomyosarcoma is considered a relatively more benign process with minimal metastatic potential, systemic metastasis is still possible. This was demonstrated in our case, as a recurrent cutaneous leiomyosarcoma metastasized to the lung. Proper management requires inclusion of this entity in the differential diagnosis, as well as familiarity with its clinical behavior. In this article, we review the literature on superficial leiomyosarcoma and discuss its epidemiology, presentation, clinical behavior, evaluation, tissue diagnosis, staging, and treatment.