Head and neck soft-tissue sarcoma in adults

A Retrospective Study of 291 Patients With Head and Neck Sarcomas: Treatment, Outcomes, and Prognostic Factors

AIMS

Sarcomas constitute a group of rare malignant neoplasms, commonly subcategorized into soft tissue sarcomas (STS) and bone sarcomas. This study aims to describe the treatment modalities and outcome of head and neck sarcoma (HNS) patients in western Denmark and to identify prognostic factors for overall survival and recurrence in HNS patients.

MATERIALS AND METHODS

The Aarhus sarcoma registry, The National Danish Sarcoma Database, and the Danish National Pathology Registry were used to identify HNS adult patients diagnosed between 1979 and 2022.

RESULTS

Altogether, 291 patients were included in this study. The prevalent histological subtypes were undifferentiated pleomorphic sarcoma (16%; 48/291) and leiomyosarcoma (15%; 44/291) for STS patients (n = 230) and chondrosarcoma (10%; 28/291) and osteosarcoma (7%; 19/291) for bone sarcoma patients (n = 61). Surgery with curative intent was performed in 71% (164/230) and 70% (43/61) of STS and bone sarcoma patients, respectively. Clear resection was achieved in 59% (97/164) of STS patients and 44% (19/43) of bone sarcoma patients. Eighty-nine patients relapsed (STS n = 66, bone sarcoma n = 23) after a median time of 2.7/5.5 years for STS/bone sarcoma patients. The five-year overall survival rates were 45% for STS patients and 66% for bone sarcoma patients. The following factors were significantly, negatively associated with overall survival in STS patients: Age (hazard ratio (HR)) = 1.02, p < 0.001), tumour size ≥5 cm (HR = 1.75, p = 0.003), metastatic disease (HR = 3.17, p < 0.001), high grade tumour (HR = 2.24, p = 0.004), previous cancer (HR = 2.84, p < 0.001), and high Aarhus composite biomarker score (ACBS) (HR = 4.56, p = 0.001). For relapse in STS patients, higher tumour grade (HR = 3.19, p = 0.014), intralesional margins (HR = 2.84, p < 0.001), ≥2 previous cancers (HR = 3.00, p = 0.004), and high ACBS (HR = 3.29, p = 0.047), were negatively associated. For bone sarcomas only higher age (HR = 1.02, p = 0.049) and intralesional margins (HR = 2.91, p = 0.042) were significant negative factors for overall survival.

CONCLUSION

Multiple prognostic factors for overall survival and relapse were identified, especially for STS patients.

The inflammatory-nutritional score and nomogram for R0 resected head and neck soft tissue sarcoma

OBJECTIVES

To explore the predictive value of inflammatory-nutritional score (INS) and a nomogram for survivals in head and neck soft tissue sarcoma (HNSTS) patients with negative resection margins (R0).

METHODS

Clinical characteristics and hematological features of 315 HNSTS patients underwent R0 surgery were analyzed.

RESULTS

The 5-year overall survival (OS) rate, 3-year recurrence-free survival rate and disease-free survival (DFS) rate were 77.3%, 61.0% and 55.4%, respectively. High INS was associated with a deep tumor location (p < 0.001), high tumor grade (p < 0.001), and advanced AJCC stage (p < 0.001). The low-risk group (INS 0) exhibited a higher 5-year OS rate and 3-year DFS rate than others (87.6% vs. 81.3% vs. 53.3%, p < 0.001; 62.2% vs. 56.9% vs. 37.9%, p = 0.007). The INS (p = 0.023), tumor depth (p < 0.001), pT classification (p = 0.022), pN classification (p < 0.001) and tumor grade (p < 0.001) were independent survival predictors. Moreover, a novel nomogram for predicting OS was generated and assessed by the concordance index, exhibiting a better performance than the p7TNMG classification alone (p < 0.001).

CONCLUSIONS

For R0 resected HNSTS patients, the oncological outcomes can be predicted using the INS system and a specific nomogram.

Management of head & neck sarcomas in adults: A retrospective study

The research purpose is to review the surgical approach and evaluate the results in adult patients with head and neck sarcomas. The histopathology varied, including two leiomyosarcomas, six malignant fibrous histiocytomas, two malignant peripheral nerve sheath tumors, four dermatofibrosarcomas protuberans, three osteosarcomas, two angiosarcomas, one liposarcoma, one Ewing sarcoma, one synovial sarcoma, two unclassified/non-differentiated sarcomas and one solitary fibrous tumor. Surgical resection included maxillectomy, mandibulectomy, craniectomy, parotidectomy, scalp resection, face skin resection and laminectomy. The reconstruction was performed with one rectus abdominis flap, four radial forearm flaps, two latissimus dorsi flaps, two vascularized fibula flaps, two pectoralis major myocutaneous flaps, two trapezius flaps, two temporalis flaps, seven scalp flaps and two nasolabial flaps. The total patient number was 24. The hospitalization was uncomplicated, followed by postoperative radiotherapy in the majority of cases. In a mean 15-year follow-up period, 11 patients are still alive and disease-free. There were four recurrences treated with palliative radiotherapy. The surgical approach for head and neck sarcomas, including the achievement of a functionally acceptable result by organ sparing techniques, remains challenging. Wide resection combined with the appropriate reconstruction, particularly with microsurgical techniques, and followed by adjuvant radiotherapy or chemotherapy offer improved prognosis and quality of life.

Biphenotypic Sinonasal Sarcoma with Orbital and Skull Base Involvement Report of 3 Cases and Systematic Review of the Literature

Biphenotypic sinonasal sarcoma (BSNS) is a rare malignant tumour of the upper nasal cavity and ethmoid sinuses that presents predominantly in middle aged female patients and show a characteristic infiltrative and hypercellular proliferation of spindle cells that demonstrate a specific immunoreactivity. We present three cases with BSNS that had different presenting complaints, either sinonasal or orbital problems, underwent endoscopic surgical treatment and/or radiotherapy and have been disease free on long follow up. A systematic review of all published cases was performed to identify all BSNS cases known at present. BSNS requires prompt and correct diagnosis with accurate surgical resection as well as consideration of radiotherapy. Our three cases confirm the findings of the literature and support that BSNS is an aggressive but treatable malignant disease of the sinonasal tract.

Time to Local Recurrence as a Predictor of Survival in Adult Head and Neck Soft Tissue Sarcoma

OBJECTIVES

We sought to evaluate the impact of the time interval from surgical resection to local recurrence (TTLR) on clinical outcomes in head and neck soft tissue sarcoma (HNSTS).

METHODS

A total of 401 patients who underwent R0 resection for primary HNSTS were included in this study. Patients with local recurrence as the first event after their initial resection were divided into early local recurrence (ELR) or late local recurrence (LLR) groups according to TTLR. Multiple survival analyses were performed to identify the independent prognostic predictors of overall survival (OS) and survival after local recurrence (SAR).

RESULTS

Two hundred and nine of the 401 patients (52.1%) developed local recurrence during a median follow-up period of 134.6 months. Patients in the ELR group had a shorter median OS time (35.0 vs. 120.6, p < 0.001) and lower 5-year OS rate (47.7% vs. 80.9%, p < 0.001) than those in the LLR group. Moreover, the ELR group exhibited worse SAR (p = 0.001) than the LLR group, and multivariate analyses demonstrated TTLR as an independent prognostic factor for SAR (p = 0.048) and OS (p = 0.004). Additionally, re-resection significantly prolonged SAR than other salvage interventions or no treatment (p < 0.001).

CONCLUSION

In patients with HNSTS, ELR after R0 resection presents adverse effects on OS and SAR than those with LLR, and TTLR could serve as a promising predictor for survival. Salvage therapies, especially the re-resection could improve SAR and should be recommended when there are surgical indications after recurrence.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:2174-2182, 2023.

[Rare cancers of the head and neck on behalf of the REFCOR, part 2]

Among the 16,000 new cases of malignant tumors of the head and neck diagnosed in France each year, 10% are not conventional squamous cell carcinomas. These so-called rare cancers are distinguished by their presentation and patterns of failure, which is important to recognize in order to offer specific adapted management and maximize the chances of tumor control. These cancers can be rare by their histology as well as their anatomical location when arising from the paranasal sinuses, salivary glands and ear. The management of these heterogeneous rare diseases of complex treatment has considerably been structured over the last 15 years, in particular via the French ENT Cancer Expertise Network (REFCOR) and international networks and registries (EURACAN, etc.). Structuration also favors research with identification of new entities and setting up of specific therapeutic trials. A first article (part 1) discusses the diagnostic and therapeutic specificities of these rare cancers, and develops the recommendations of the REFCOR concerning rare epithelial tumors, i.e., salivary tumors, sinonasal tumors, variants of conventional squamous cell carcinomas, neuroendocrine carcinomas, malignant odontogenic tumors, and ear tumors. This second article (part 2) is focused on non-epithelial tumors (sarcomas, mucosal melanomas, lymphomas, tumors of uncertain or undetermined malignancy) and describes the organization and missions of the REFCOR.

Comparison of Definitive Radiotherapy-Based Treatment and Surgical-Based Treatment for Locally Advanced Head and Neck Soft Tissue Sarcoma

Background: Head and neck soft-tissue sarcomas are rare but aggressive malignancies. Definitive radiotherapy might be an alternative treatment choice in patients unfit for surgery with preservation of organ function and facial morphology. Whether definitive radiotherapy is comparable with surgery has not been fully demonstrated. In this study, we compared the prognosis of patients with radiotherapy-based treatment and with surgery-based treatment. Methods: From May 2014 to February 2021, patients with locally advanced head and neck soft-tissue sarcoma treated with either definitive radiotherapy-based treatment or radical surgery-based treatment were retrospectively enrolled. Clinical outcomes including tumor response, patients' survival and acute treatment-related toxicities were evaluated. Kaplan-Meier curves with log-rank test were used to compare survival data. Cox regression analysis was used to explore prognostic factors. Results: A total of 24 patients (12 males and 12 females, 3 to 61 years old) were eligible for analysis. The median follow-up time was 49 (range: 6-96) months. In 16 patients receiving definitive radiotherapy-based treatment, 6 reached complete response. The survival curve showed that there was no statistically significant difference in overall survival (OS), distant metastasis-free survival (DMFS), loco-regional relapse-free survival (LRRFS) and progression-free survival (PFS) between the two groups of patients (p = 0.35, p = 0.24, p = 0.48, p = 0.1, respectively). COX regression analysis showed that older age was associated with poor DMFS. There was no significant difference in grade 3-4 toxicities between the two groups. Conclusions: In cases of contradictions to surgery, refusal to surgery or failure to complete resection, chemoradiotherapy might be an alternative treatment option.

Clinical course and features of soft tissue sarcomas in geriatric patients: a single-center experience

OBJECTIVE

This study was performed to examine the disease course in geriatric patients with soft tissue sarcoma and determine the risk factors for mortality.

METHODS

We retrospectively analyzed patients who were treated at Istanbul University Oncology Institute from January 2000 to August 2021.

RESULTS

Eighty patients were included in the study. The patients' median age was 69 years (range, 65-88 years). The median overall survival of patients diagnosed between the ages of 65 and 74 years was 70 months, and that of patients diagnosed at the age of ≤75 years was significantly lower at 46 months. The median survival of patients who did and did not undergo surgical resection was 66 and 11 months, respectively, with a significant difference. The median overall survival of patients with positive and negative surgical margins was 58 and 96 months, respectively, also with a significant difference. Age at diagnosis and recurrence/metastasis significantly affected mortality. A 1-year increase in the age at diagnosis increased mortality by 1.147 times.

CONCLUSION

Age of >75 years, inability to undergo surgery, positive surgical margins, and head and neck location may be associated with a poor prognosis in geriatric patients with soft tissue sarcoma.

Prognostic Utility of Nutritional Risk Index in Patients with Head and Neck Soft Tissue Sarcoma

BACKGROUND

The nutritional risk index (NRI) is an excellent indicator of nutritional status and a significant prognostic factor in several malignancies, but the relationship between NRI and the prognosis of head and neck soft tissue sarcoma (HNSTS) patients remains unclear. The aim of this study was to investigate the role of NRI in patients with HNSTS.

METHODS

We retrospectively reviewed patients with HNSTS between 1990 and 2021. In order to determine the optimal cut-off value of NRI, the Maximally selected log-rank statistic was performed. We evaluated the effect of NRI on overall survival (OS) and progression-free survival (PFS) by using the Kaplan-Meier method and Cox regression analysis. Then, OS and PFS nomograms based on NRI were constructed.

RESULTS

In total, 436 HNSTS patients were included in this study. The optimal cut-off value of NRI was 99.34. Patients with low-NRI showed significantly worse OS and PFS than patients with high-NRI, respectively (5-year OS rate of 43.0 vs. 70.8%, 5-year PFS rate of 29.0 vs. 45.0%, all p < 0.05). In the multivariate analysis, distant metastasis, deep tumor depth, tumor grade, and NRI were prognostic factors for both PFS and OS, and treatment modality was associated with OS but not PFS. The concordance indexes (C-indexes) of OS and PFS nomograms were 0.794 (95% CI, 0.759-0.829) and 0.663 (95% CI, 0.626-0.700), respectively, which also performed well in the validation set.

CONCLUSIONS

NRI is an independent predictor of OS and PFS in HNSTS patients. The validated nomograms based on NRI provide useful predictions of OS and PFS for patients with HNSTS.

Radiotherapy of sinonasal cancers

We present the update of the recommendations of the French society of radiotherapy and oncology on the indications and the technical methods of carrying out radiotherapy of sinonasal cancers. Sinonasal cancers (nasal fossae and sinus) account for 3 to 5% of all cancers of the head and neck. They include carcinomas, mucosal melanomas, sarcomas and lymphomas. The management of sinonasal cancers is multidisciplinary but less standardized than that of squamous cell carcinomas of the upper aerodigestive tract. As such, patients with sinonasal tumors can benefit from the expertise of the French expertise network for rare ENT cancers (Refcor). Knowledge of sinonasal tumour characteristics (histology, grade, risk of lymph node involvement, molecular characterization, type of surgery) is critical to the determination of target volumes. An update of multidisciplinary indications and recommendations for radiotherapy in terms of techniques, target volumes and radiotherapy fractionation of the French society of radiotherapy and oncology (SFRO) was reported in this manuscript.

Update on MR Imaging of Soft Tissue Tumors of Head and Neck

This article reviews soft tissue tumors of the head and neck following the 2020 revision of WHO Classification of Soft Tissue and Bone Tumours. Common soft tissue tumors in the head and neck and tumors are discussed, along with newly added entities to the classification system. Salient clinical and imaging features that may allow for improved diagnostic accuracy or to narrow the imaging differential diagnosis are covered. Advanced imaging techniques are discussed, with a focus on diffusion-weighted and dynamic contrast imaging and their potential to help characterize soft tissue tumors and aid in distinguishing malignant from benign tumors.

Pretreatment tumor sampling and prognostic factors in patients with soft-tissue sarcoma of the head and neck

BACKGROUND

Insufficient preoperative work-up and consequent intralesional or marginal resection of soft-tissue sarcomas of the head and neck (STSHNs) is common.

METHODS

This retrospective cohort study comprised 63 patients with STSHN treated at the Helsinki University Hospital between 2005 and 2017. We assessed the effect of pretreatment tumor sampling on surgical margin status and need for supplemental surgery, as well as prognostic factors and survival.

RESULTS

The lack of representative pretreatment biopsy specimen was associated with unfavorable margin status. Primary surgery at a non-academic center was associated with need for supplemental surgery. The 3-year overall survival (OS) was 68%, disease-specific survival (DSS) 71%, and recurrence-free survival (RFS) 61%. Higher tumor grade and primary tumor size over 5 cm were associated with reduced DSS.

CONCLUSIONS

Diagnosis and management of STSHNs should be centralized to experienced academic centers. Decision-making between needle biopsy, open biopsy, or upfront radical surgery depends on tumor location and size.

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.

Understanding giant cell sarcoma of the head and neck: A population-based study

BACKGROUND

Giant cell sarcomas (GCS) are rare head and neck neoplasms.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was analyzed for all patients who have been diagnosed with GCS from 1973 to 2014.

RESULTS

Four hundred and forty cases of GCS of the head and neck were identified. The average age at diagnosis was 74.4 years, 86.8% were white, 82.5% were male, 70.7% were insured, and 88.2% lived in an urban metropolitan region. Connective tissue was the most frequent primary site (42.5%). The 5Y-DSS rate was 91.1%, while the 5Y-OS was 54.6% for all cases. Patients treated with surgery alone had the highest 5Y-DSS rate of 94.5. T-classification odds ratio was a significant predictor of survival accounting for confounding variables on multivariate analysis.

CONCLUSIONS

GCS presents most frequently in connective tissue of the head and neck with overall high probability of survival. The treatment of choice is surgery alone.

Nomogram based on pre-treatment inflammatory biomarkers predicting survival in patients with head and neck soft tissue sarcoma

BACKGROUND

Systemic inflammatory biomarkers reflect level of inflammatory response, which have been suggested as prognostic factors in cancer patients.

OBJECTIVE

To estimate the prognostic value of inflammatory biomarkers in 149 patients with head and neck soft tissue sarcoma (HNSTS).

METHODS

Pre-treatment neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR), systemic immune-inflammation index (SII), neutrophil-platelet score (NPS) and Aarhus Composite Biomarker Score (ACBS) were analyzed for association with overall survival (OS) and progression-free survival (PFS). Nomograms were consisted of independent predictors for OS and PFS, and evaluated by calibration curve and concordance index (C-index).

RESULTS

In multivariate analysis, LMR (HR = 0.42, 95% CI: 0.19-0.94, P= 0.035), ACBS (HR = 2.05, 95% CI: 1.02-4.12, P= 0.045) and AJCC stage were independent prognostic markers of OS. Moreover, high NLR (HR = 1.78, 95% CI: 1.07-2.94, P= 0.024) and advanced AJCC stage were independently related with worse PFS. Calibration curves reflected good discriminative ability of prognosis. The nomograms showed better accuracy of predicting OS (C-index: 0.748 vs. 0.690, P= 0.009) and PFS (C-index: 0.644 vs. 0.612, P= 0.028) than stage.

CONCLUSIONS

Pre-treatment LMR, ACBS and AJCC stage were effective predictor of OS. The NLR and AJCC stage could independently predict PFS. The nomogram might act as a promising prognostic model for OS and PFS in HNSTS.

RREB1-MKL2 fusion in a spindle cell sinonasal sarcoma: biphenotypic sinonasal sarcoma or ectomesenchymal chondromyxoid tumor in an unusual site?

Biphenotypic sinonasal sarcoma (BSNS) is a rare, low grade spindle cell sarcoma, recently recognized in the WHO classification of head and neck tumors, which is characterized by a dual myogenic and neural differentiation and recurrent gene fusions, often involving PAX3-MAML3, and less commonly PAX3 fusions with other partners such as NCOA1, NCOA2, or WWTR1. Yet, in about 4% of tumors no gene rearrangements are identified. Herein, we describe a RREB1-MKL2 fusion in a BSNS lesion occurring in a 73-year-old female patient with a right maxillo-ethmoidal angle lesion. The polypoid, moderately cellular tumor with infiltrative submucosal growth was composed of fascicles of relatively bland spindle cells embedded in a loose collagenous matrix. The tumor cells showed moderate amounts of eosinophilic cytoplasm with indistinct borders and uniform, pale, ovoid to slender nuclei. The slowly proliferating neoplastic cells co-expressed smooth muscle actin and S100, and showed focal nuclear positivity for ß-catenin, while lacking staining for cytokeratins, desmin, myogenin, caldesmon, glial fibrillary acid protein, and SOX-10. Molecular analysis by targeted RNA-based next-generation sequencing identified an in-frame fusion between exon 8 of RREB1 and exon 11 of MKL2, a genetic event that was reported to be a molecular hallmark of ectomesenchymal chondromyxoid tumor. Gene rearrangements in both genes were independently verified by fluorescence in situ hybridization (FISH). To evaluate its recurrent potential an additional group of 15 fusion negative BSNS were tested for abnormalities in RREB1 and MKL2 genes by FISH, but no additional positive cases were identified.

Sarcomas of the Larynx: One Institution's Experience and Treatment Protocol Analyses

Soft tissue sarcomas in the head and neck are rare malignancies. They occur in this area in less than 1% of all malignant tumors. Some authors have described the development of sarcoma from the mesenchymal tissue in the larynx. The histological diagnosis of a sarcoma depends on the immunohistochemical investigation. In particularly difficult diagnoses, electron microscopy has to be used. The treatment recommendation depends on the histological type of sarcoma. We analysed and summarized data on the diagnostic criteria and therapy for sarcoma of the larynx presented in the literature. We present three new cases of laryngeal sarcoma and describe the analyses of the published diagnostic and treatment schedules of laryngeal sarcomas. We developed a treatment protocol recommendation for laryngeal sarcoma based on an analysis of literature data and case reports. This recommendation is based on histological type, staging, grading, size, and survival data.

Epithelioid Sarcoma of the External Auditory Canal: An Uncommon Tumor at an Unusual Site and a Brief Overview of the Literature

We present a case (41 years old pregnant female) with epithelioid sarcoma arising in the left external auditory canal. On immunohistochemistry, the tumor cell diffusely expressed cytokeratins and showed patchy expression of ERG and CD34. The neoplastic cells demonstrated uniform loss of INI1-expression. Epithelioid sarcoma arising in the external auditory canal is rare. Awareness that ES may rarely arise at unusual sites is of critical importance in order to apply a broad enough panel in the immunohistochemical study, so a misdiagnosis of carcinoma can be avoided.

From head and neck lipoma to liposarcoma: a wide spectrum of differential diagnoses and their therapeutic implications

PURPOSE OF REVIEW

To overview the array of differential diagnoses among lipomatous tumours of the head and neck with special focus on their evaluation, three-dimensional assessment, and their available treatments.

RECENT FINDINGS

The head and neck is an infrequent localization for lipomatous tumours, even though they represent the most common mesenchymal lesions. Lipoma, spindle cell/pleomorphic lipoma (SC/PL), atypical lipomatous tumour/well differentiated liposarcoma (ALT/WDLPS), de-differentiated liposarcoma (DDLPS), myxoid liposarcoma (MLPS), and pleomorphic liposarcoma (PLPS) are the most distinctive histotypes. Lipoma and SC/PL present alterations of chromosomes 12 and 13, ALT/WDLPS and DDLPS both show the Mouse Double Minute 2 amplification, whereas MLPS presents a CHOP gene fusion. Diagnosis of PLPS is purely morphological as there is no pathognomonic genetic alteration identified to date. Radiological assessment can be challenging for the presence of nonadipose components within the lesion. Surgery is the mainstay of treatment, even though achieving true radicality in terms of a large cuff of healthy tissue surrounding the tumour is not always realistic in the head and neck. Adjuvant radiation, eventually in combination with systemic chemotherapy, has been shown to improve overall survival in patients with positive margins, high-grade, deep, and more than 5 cm lesions. Further studies should be aimed at the evaluation of the role of hadron therapy, as well as targeted drugs against overexpressed proteins.

SUMMARY

Adequate differential diagnosis of the histotypes collected under the umbrella term of head and neck lipomatous tumours plays a fundamental role in treatment and follow-up of these lesions and requires specific expertise with referral to high-volume centres.

Head and neck adult-type soft tissues sarcomas: survival analysis and comparison between the last two editions of the TNM staging system

PURPOSE

Head and neck soft tissues sarcomas (HNSTS) are a heterogeneous group of rare tumours. The 8th edition of the TNM staging system (8TNM) considered these lesions separately for the first time. The aim of this study is to assess its effectiveness and identify the most significant prognostic factors for HNSTS.

METHODS

A retrospective survival analysis on 101 HNSTS operated between 1995 and 2015 at the National Cancer Institute of Milan was carried out. The variables considered were pathological stage (according to both the 7TNM and 8TNM), site, histotype, depth, grading, surgical radicality, (neo)adjuvant radiotherapy and/or chemotherapy.

RESULTS

According to the 7TNM, the T category distribution was 35 T1a, 23 T1b, 11 T2a, and 32 T2b. Applying the 8TNM, the distribution changed to 19 T1, 18 T2, 35 T3, and 29 T4. Five-year overall and disease-specific survivals were 74.3 and 76.2%, respectively. Univariate analysis demonstrated an increased hazard ratio (HR) for deep lesions invading adjacent structures, high-grade, surgery with close/microscopically positive margins, and chemotherapy. Multivariate analysis confirmed an increased HR for deep location and size > 5 cm, G2-G3 tumours, and marginal surgery. No significant difference was found among T categories of the 8TNM.

CONCLUSION

The present study underlines the negative prognostic impact of depth, size > 5 cm, high grade, and marginal treatment for HNSTS. Our results did not allow to validate the 8TNM staging system since, apparently, it was not associated with meaningful prognostic stratification. Further studies with wider multicentric cohorts should, however, be performed to obtain more powerful statistical data.

Radiation Therapy in Adult Soft Tissue Sarcoma-Current Knowledge and Future Directions: A Review and Expert Opinion

Simple Summary

Radiation therapy (RT) is an integral part of the treatment of adult soft-tissue sarcomas (STS). Although mainly used as perioperative therapy to increase local control in resectable STS with high risk features, it also plays an increasing role in the treatment of non-resectable primary tumors, oligometastatic situations, or for palliation. This review summarizes the current evidence for RT in adult STS including typical indications, outcomes, side effects, dose and fractionation regimens, and target volume definitions based on tumor localization and risk factors. It covers the different overall treatment approaches including RT either as part of a multimodal treatment strategy or as a sole treatment and is accompanied by a summary on ongoing clinical research pointing at future directions of RT in STS.

Abstract

Radiation therapy (RT) is an integral part of the treatment of adult soft-tissue sarcomas (STS). Although mainly used as perioperative therapy to increase local control in resectable STS with high risk features, it also plays an increasing role in the treatment of non-resectable primary tumors, oligometastatic situations, or for palliation. Modern radiation techniques, like intensity-modulated, image-guided, or stereotactic body RT, as well as special applications like intraoperative RT, brachytherapy, or particle therapy, have widened the therapeutic window allowing either dose escalation with improved efficacy or reduction of side effects with improved functional outcome. This review summarizes the current evidence for RT in adult STS including typical indications, outcomes, side effects, dose and fractionation regimens, and target volume definitions based on tumor localization and risk factors. It covers the different overall treatment approaches including RT either as part of a multimodal treatment strategy or as a sole treatment, namely its use as an adjunct to surgery in resectable STS (perioperative RT), as a primary treatment in non-resectable tumors (definitive RT), as a local treatment modality in oligometastatic disease or as palliative therapy. Due to the known differences in clinical course, general treatment options and, consequently, outcome depending on lesion localization, the main part of perioperative RT is divided into three sections according to body site (extremity/trunk wall, retroperitoneal, and head and neck STS) including the discussion of special applications of radiation techniques specifically amenable to this region. The review of the current evidence is accompanied by a summary on ongoing clinical research pointing at future directions of RT in STS.

Efficacy and safety of CT-guided 125I seed implantation as a salvage treatment for locally recurrent head and neck soft tissue sarcoma after surgery and external beam radiotherapy: A 12-year study at a single institution

OBJECTIVES

The objective of this study was to evaluate the efficacy and safety of CT-guided radioactive ¹²⁵I seed implantation as a salvage treatment for locally recurrent head and neck soft tissue sarcoma (HNSTS) after surgery and external beam radiotherapy.

METHODS AND MATERIALS

From December 2006 to February 2018, 25 patients with locally recurrent HNSTS after surgery and external beam radiotherapy were enrolled. All the patients successfully underwent CT-guided ¹²⁵I seed implantation. The primary end points included the objective response rate (ORR) and local progression-free survival (LPFS). The secondary end points were survival (OS) and safety profiles.

RESULTS

After ¹²⁵I seed implantation, the ORR was 76.0%. The 1-, 3-, and 5-year LPFS rates were 65.6%, 34.4%, and 22.9%, respectively, with the median LPFS of 16.0 months. The 1-, 3-, and 5-year OS rates were 70.8%, 46.6%, and 34.0%, respectively, with the median OS of 28.0 months. Furthermore, univariate analyses showed that the recurrent T stage and histological grade were prognostic factors of LPFS, whereas only the histological grade was a predictor of OS. The major adverse events were skin/mucosal toxicities, which were generally of lower grade (≤Grade 2) and were well tolerated.

CONCLUSIONS

Radioactive ¹²⁵I seed implantation could be an effective and safe alternative treatment for locally recurrent HNSTS after failure of surgery and radiotherapy. Recurrent T stage and histological grade were the main factors influencing the efficacy.

Comparison of prognostic implications between the 7th and 8th edition of AJCC TNM staging system for head and neck soft-tissue sarcoma in adult patients

PURPOSE

This study aimed to investigate the prognostic factors for head and neck soft-tissue sarcoma (HNSTS) in adults, with the comparisons between the 7th and 8th edition of AJCC TNM staging system.

METHODS

From a cancer registry of a single, tertiary referral medical center, the medical records of 67 patients treated from February 2005 to December 2017 were reviewed.

RESULTS

T1b stage by AJCC 7th edition showed most diverse stage migration by AJCC 8th edition, and T1a or T2b stage by 7th edition remained in T1-3 or T3-4 by 8th edition. T2 stage by 7th edition showed a significantly higher death rate than the T1 stage, with fair discrimination in overall survival. Higher histologic grade and angiosarcoma were significant prognostic factors for recurrence as well as overall survival. Also, nodal and distant metastasis worsen overall survival.

CONCLUSIONS

In our series of patients with HNSTS, higher histologic grade, angiosarcoma, N1, and M1 stage significantly increased the risk of recurrence and worse overall survival, which was not evident in revised T stage by AJCC 8th edition.

Local Relapse and Survival Outcomes in Patients with Scalp Sarcoma: A Retrospective Study of 95 Patients Treated in a Provincial Cancer Care Institution Over 25 Years

Objectives

There is limited literature on the optimal treatment of sarcoma arising in the scalp. This study evaluates local relapse (LR) and survival outcomes of patients with scalp sarcoma treated at a provincial cancer care institution.

Methods

A retrospective review of 95 patients with a primary diagnosis of scalp sarcoma referred from 1990-2015 was completed. Kaplan-Meier statistics were used to estimate LR-free survival (LRFS) and overall survival (OS). Survival curves were compared using log-rank tests. Regression analyses were performed using Cox proportional hazards model.

Results

The median age at diagnosis was 77 years. The most common histologies were angiosarcoma (27%), undifferentiated pleomorphic sarcoma (24%), and pleomorphic dermal sarcoma (21%). Final margins were 36% positive, 28% close, 31% negative, and 5% unknown. Of 73 patients treated with curative-intent, 32 (44%) experienced LR. Five-year LRFS was 56.0% and overall survival was 48.3%. Patients with close or positive margins who received pre- or post-operative radiotherapy (n=19) had similar LR risk compared to patients who did not (n=34) (five-year LRFS 41.8% vs 69.1%; p=0.145). On multivariate analysis, angiosarcoma was associated with a higher LR risk (Hazard ratio (HR) 12.06, p<0.001). The use of radiotherapy showed a trend towards reduced LR risk but did not reach statistical significance (HR 0.37, p=0.066).

Conclusions

Patients with scalp sarcoma have high risk of LR, particularly in cases with positive margins. Adjuvant radiation was not associated with improved local control for close or positive margins. Complete surgical excision to establish negative margins remains the primary standard treatment for patients with this rare disease.

Intensity-Modulated Proton and Carbon-Ion Radiation Therapy in the Management of Head and Neck Sarcomas

PURPOSE

We report our experience of intensity-modulated proton and carbon-ion radiotherapy (IMPT/IMCT) for head and neck sarcomas (HNS).

METHODS AND MATERIALS

An analysis of the ongoing prospective data registry from the Shanghai Proton and Heavy Ion Center (SPHIC) for patients with HNS was conducted. The 12- and 24-month rates of local recurrence-free, overall, distant metastasis-free, progression-free survival (LRFS, OS, DMFS, and PFS), and acute/late toxicities were calculated. The prognostic factors for the effectiveness of the treatment were also analyzed.

RESULTS

Between 7/2014 and 5/2018, 51 consecutive patients with HNS received definitive doses of IMCT (41 cases), IMPT (two cases), or their combination (eight cases). One patient had R0 resection and another treated on the Chinese Food and Drug Administration registration trial received IMPT only. Twenty-seven patients were treated according to various dose escalation trials or institutional protocols using IMCT or IMPT + IMCT boost. Twenty-two patients with locoregional recurrence (10 and four patients failed surgery or surgery followed by radiotherapy, respectively) or radiation-induced second primary sarcomas (eight patients) received salvage particle radiotherapy. With a median follow-up time of 15.7 months, four patients with second primary sarcoma died. The 1- and 2-year OS, PFS, LRFS, and DMFS rates for the entire cohort were 92.9% vs 90%, 73.6% vs 57.4%, 88.4% vs 78.9%, and 84.6% vs 76.5%, respectively. Those rates for patients without prior radiotherapy were 100% vs 100%, 82.1% vs 65.8%, 93.6% vs 85.3%, and 88.4% vs 79.5%, respectively. Multivariate analyses revealed that re-irradiation was an independent prognostic factor for both LRFS and PFS (P = 0.015 and 0.037, respectively). In addition, gross tumor volume (GTV) was an independent prognostic factor for PFS (P = 0.048). One patient experienced Grade 3 acute toxicity (oral mucositis); another experienced Grade 4 acute event (hemorrhage) which required embolization. He lately died from hemorrhage (Grade 5) at 3.4 months after the completion of treatment. No patient experienced radiation-induced acute/late toxicity of ≥ Grade 2 otherwise.

CONCLUSION

With few observed acute/late toxicities, IMPT/IMCT provided effective short-term tumor control in our patients with HNS. Further investigations, preferably in a prospective fashion, will be required to confirm the efficacy and toxicities of IMPT/IMCT in this group of patients.

Multimodality treatment of head-and-neck soft-tissue sarcomas and short-term outcomes: Analysis from sarcoma medical oncology clinic

Background

Head-and-neck soft-tissue sarcomas (HNSTS) are extremely rare and lack definite guidelines.

Methods:

We retrospectively analyzed consecutive adult patients with HNSTS who presented to our sarcoma medical oncology clinic from January 2016 to October 2017.

Results:

There were a total of 30 patients. Unresectable localized disease was seen in 13 (43%) patients, metastatic disease 10 (34%) patients, while resectable disease in 7 (23%) patients only. Among unresectable localized disease, 3 (25%) patients could be converted to resectable disease after neoadjuvant therapy. Median follow period was 11 months. Progression-free survival was 19 months in patients with resectable disease and 6 months in patients with the unresectable/metastatic disease. Median OS was not reached.

Conclusion:

Unresectable HNSTS has a poor outcome. Neoadjuvant therapy can be tried in selected cases for achieving respectability or for vital organ preservation until robust data are available. A multidisciplinary approach for local control is crucial in managing unresectable HNSTS.

Head and Neck Sarcomas: A Review of Clinical and Imaging Findings Based on the 2013 World Health Organization Classification

OBJECTIVE

Head and neck sarcomas are a complex, heterogeneous group of tumors that present a diagnostic challenge to radiologists because they have many overlapping imaging features. The purpose of this article is to review the imaging and clinical features and highlight distinguishing features of head and neck sarcomas.

CONCLUSION

An understanding of characteristic imaging and clinical features of head and neck sarcomas is important for the radiologist to narrow the differential diagnosis and help guide management.

Clinical Utility of In Situ Hybridization Assays in Head and Neck Neoplasms

Head and neck pathology present a unique set of challenges including the morphological diversity of the neoplasms and presentation of metastases of unknown primary origin. The detection of human papillomavirus and Epstein-Barr virus associated with squamous cell carcinoma and newer entities like HPV-related carcinoma with adenoid cystic like features have critical prognostic and management implications. In salivary gland neoplasms, differential diagnoses can be broad and include non-neoplastic conditions as well as benign and malignant neoplasms. The detection of specific gene rearrangements can be immensely helpful in reaching the diagnosis in pleomorphic adenoma, mucoepidermoid carcinoma, secretory carcinoma, hyalinizing clear cell carcinoma and adenoid cystic carcinoma. Furthermore, molecular techniques are essential in diagnosis of small round blue cell neoplasms and spindle cell neoplasms including Ewing sarcoma, rhabdomyosarcoma, synovial sarcoma, biphenotypic sinonasal sarcoma, dermatofibrosarcoma protuberans, nodular fasciitis and inflammatory myofibroblastic tumor. The detection of genetic rearrangements is also important in lymphomas particularly in identifying 'double-hit' and 'triple-hit' lymphomas in diffuse large B cell lymphoma. This article reviews the use of in situ hybridization in the diagnosis of these neoplasms.

Primary clear cell sarcoma of the tongue and surgical reconstruction: About a rare case report

Clear cell sarcomas (SCC), also called "soft-tissue melanoma", are rare and aggressive tumors that preferentially affect the lower limbs (tendons and fasciae) and which have also been described in head and neck localizations. Their clinical and immunohistochemical mimicry with melanoma makes it difficult to diagnose sarcomas. SCC treatment is mainly focused on large-scale resection surgery with adjuvant radiotherapy because of their low chemo-sensitivity and extreme lymphophilia. In case of head and neck localization, these treatments may lead to function and aesthetic sequelae thus requiring the use of modern techniques of reconstructive surgery. The authors describe the diagnosis, treatment and follow-up of large lingual SCC case using a DIEP free flap reconstruction according to an original technique developed in the department. Given the characteristics of patients with SCC (a high proportion of women between 20 and 40 years old) and its inherent qualities (low morbidity of the donor site, volume delivered and excellent plasticity), the fascio-cutaneous free flap type "DIEP" "taken according to the design of the" Cathedral triptych seems to be a viable choice among the range of reconstruction solutions.

Current update on the diagnosis and management of head and neck soft tissue sarcomas

Head and neck soft tissue sarcomas are a group of rare heterogeneous tumours arising from embryonic mesoderm. They comprise <1% of all head and neck malignancies and 5-15% of all sarcomas with most head and neck sarcomas arising from soft tissues. Although rare, they are associated with both high recurrence and mortality rates. We review the current management of head and neck soft tissue sarcomas.