Prognostic factors in soft tissue leiomyosarcoma of the extremities: a retrospective analysis of 42 cases

Targeting the Molecular and Immunologic Features of Leiomyosarcoma

Leiomyosarcoma (LMS) is a rare, aggressive mesenchymal tumor with smooth muscle differentiation. LMS is one of the most common histologic subtypes of soft tissue sarcoma; it most frequently occurs in the extremities, retroperitoneum, or uterus. LMS often demonstrates aggressive tumor biology, with a higher risk of developing distant metastatic disease than most sarcoma histologic types. The prognosis is poor, particularly in patients with uterine disease, and there is a need for the development of more effective therapies. Genetically, LMS is karyotypically complex and characterized by a low tumor mutational burden, with frequent alterations in TP53, RB1, PTEN, and DNA damage response pathways that may contribute to resistance against immune-checkpoint blockade monotherapy. The LMS immune microenvironment is highly infiltrated with tumor-associated macrophages and tumor-infiltrating lymphocytes, which may represent promising biomarkers. This review provides an overview of the clinical and pathologic behavior of both soft tissue and uterine LMS and summarizes the genomic and immune characteristics of these tumors and how they may provide opportunities for the development of biomarker-based immune therapies.

"Malignant Mesenchymoma" Revisited: A Clinicopathologic Study of Leiomyosarcomas With Osteosarcomatous Differentiation

Leiomyosarcoma (LMS) is the most common sarcoma in adults. Rarely, LMS dedifferentiates into an undifferentiated sarcoma. Very few cases of LMS with heterologous osteosarcomatous differentiation (OS) have been reported. The purpose of this study was to evaluate the clinicopathologic features of LMS with OS. Of 5570 LMS cases diagnosed from 2006 to 2022, 15 cases (0.2%) of LMS with OS were identified, affecting 13 females and 2 males; ages ranged from 32 to 66 years (median: 53 y). Ten tumors arose in the uterus, 2 in the retroperitoneum, and 1 each in the mesentery, mediastinum, and rectum. Primary tumors ranged from 7 to 20 cm (mean: 16 cm). The LMS components showed conventional spindle cell morphology in most cases; 3 cases showed marked pleomorphism; 3 cases contained an epithelioid component; and 1 case showed myxoid features. In 5 cases OS was identified in the primary tumor, whereas in 10 cases OS was first detected in metastases. One metastatic and 2 primary LMS showed both OS and chondrosarcomatous differentiation. Prominent osteoclastic giant cells were seen in the OS components in 11 cases. Mitotic activity ranged from 17 to 61/10 HPF with tumor necrosis in 10 cases. Twelve patients developed metastases; sites included lungs, diaphragm, kidney, adrenal glands, colon, small intestine, liver, bone, and pancreas. At last follow-up, 8 patients had died of disease, and 4 patients were alive with metastases. The interval between OS and death ranged from 3 weeks to 18 months (median: 6.5 mo). Development of OS in LMS is exceptionally rare. This form of heterologous differentiation may occur in both primary tumors and metastases. LMS with OS is highly aggressive with poor outcomes. Awareness of this phenomenon is important to avoid misdiagnosis as osteosarcoma.

Leiomyosarcoma in the extremities and trunk wall: systematic review and meta-analysis of the oncological outcomes

Background

Leiomyosarcomas are aggressive malignancies which can occur on the trunk and extremities whose pathogenesis is poorly understood. We aim to quantify the prognostic impact of various clinical and pathological markers on survival and recurrence of leiomyosarcomas.

Methods

We conducted a systematic review as per PRISMA protocol. Survival, local recurrence, and metastasis were the outcome measures. Data were extracted from the studies for the outcome variables; the resultant odds ratios (OR) and 95% confidence interval (CI) were used for the synthesis of a forest plot.

Results

Our search revealed thirteen studies comprising 1380 patients. Seven of these 13 publications were since 2012. Our analysis showed that tumor size larger than 5 cm adversely affected the outcome with an OR 3.39 (2.26–5.10, p < 0.01). Other factors which reduced the overall survival were positive margins of excision OR 2.12 (1.36–3.32, p < 0.01). A reduced risk of metastasis has strongly associated the use of radiotherapy with OR 10.84 (4.41–26.61, p < 0.01). Only a few studies analyzed the impact of factors on local recurrence.

Conclusions

Size larger than 5 cm and positive margins of excision are associated with poor overall survival. In comparison, the use of adjuvant radiotherapy was associated with a lower metastatic rate. There is a need for methodically high-quality studies with more uniform study design and reporting to evaluate the impact of various risk factors on local recurrence and metastases.

Level of evidence

Level 1 Prognostic

Analysis of Extended Resection of Limb Soft Tissue Leiomyosarcoma

Leiomyosarcoma is an uncommon soft tissue sarcoma that composed of malignant mesenchymal cells with distinct features of the smooth muscle lineage. Typically affects the uterus and gastrointestinal tract, it can rarely be seen in large blood vessels, lymphatic and glandular duts, the mesentery, the omentum, retroperitoneum, and limbs. Occurrence is particularly rare in the limb region. Retrospective study based on patient records and postoperative pathological histological features. Four patients with limb leiomyosarcoma that were operated between 2016 and 2020 were included, three of them arising in the subcutis of the thigh region and one in cubitus. Extend resection with satisfactory outcomes is reported. Pathological examination showed that masses were composed of a fascicular arrangement of hyperchromatic spindle-shaped cells, characterized by the proliferation of epithelioid cells with eosinophilic cytoplasm for epithelioid leiomyosarcoma. Leiomyosarcomas that arise in the soft tissue, although rare, should be differentiated from other lesions, such as neurilemoma, neurofibroma, liomyoma,lipomyoma, synoviosarcoma, rhabdomyosarcoma, malignant fibrous histiotoma, and malignant neurinoma.

Cutaneous soft tissue sarcomas: survival-related factors

Cutaneous sarcomas are a heterogeneous group of rare mesenchymal neoplasms representing less than 1% of malignant tumors. Histology report remains the cornerstone for the diagnosis of these tumors. The most important clinicopathologic parameters related to prognosis include larger tumor size, high mitotic index, head and neck location, p53 mutations, depth of infiltration and histological grade, vascular and perineural invasion as well as the surgical margins status. Applying advanced biopsy techniques might offer more precise assessment of surgical margins, which constitutes a significant precondition for the management of these tumors. The management of cutaneous soft tissue sarcomas requires a multidisciplinary approach. Surgery remains the standard treatment, nonetheless adjuvant therapy may be required, consisting of radiotherapy, chemotherapy, and molecular targeted therapies to improve treatment outcomes. The role of molecular profiling in the treatment of uncontrolled disease is promising, but it may be offered to a relatively small proportion of patients and its use is still considered experimental in this setting. Due to the rarity of the disease, there is a need for knowledge and experience to be shared, pooled, organized and rationalized so that recent developments in medical science can have a major impact on the disease course. Multicenter clinical trials are needed to improve the care of patients with cutaneous sarcomas.

Construction, validation and, visualization of a web-based nomogram for predicting the overall survival and cancer-specific survival of leiomyosarcoma patients with lung metastasis

Background

This study sought to assess the prognostic factors for leiomyosarcoma (LMS) patients with lung metastasis and construct web-based nomograms to predict overall survival (OS) and cancer-specific survival (CSS).

Method

Patients diagnosed with LMS combined with lung metastasis between 2010 and 2016 were identified in the Surveillance, Epidemiology, and End Results (SEER) database. The patients were randomly divided into a training set and a testing set. The X-tile analysis provides the best age and tumor size cut-off point, and changes continuous variables into categorical variables. The independent prognostic factors were determined by Cox regression analysis, and 2 nomograms were established. Receiver operating characteristic curves and calibration curves were used to evaluate the nomograms. Based on the nomograms, 2 web-based nomograms were established.

Results

Two hundred and twenty-eight cases were included in the OS nomogram construction, and were randomly divided into a training set (n=160) and a validation set (n=68). Age, T stage, bone metastasis, surgery, chemotherapy, marital status, tumor size, and tumor site were found to be correlated with OS. One hundred and eighty-three cases were enrolled in the CSS nomogram construction, and randomly divided into a training set (n=129) and a validation set (n=54). Age, bone metastasis, surgery, chemotherapy, tumor size, and tumor site were found to be correlated with CSS. Two nomograms were established to predict OS and CSS. In the training set, the areas under the curve of the nomogram for predicting 1-, 2-, and 3-year OS were 0.783, 0.830, and 0.832, respectively, and those for predicting 1-, 2-, and 3-year CSS were 0.889, 0.777, and 0.884, respectively. Two web-based nomograms were established to predict OS (https://wenn23.shinyapps.io/lmslmosapp/), and CSS (https://wenn23.shinyapps.io/lmslmcssapp/).

Conclusion

The developed web-based nomogram is a useful tool for accurately analyzing the prognosis of LMS patients with lung metastasis, and could help clinical doctors to make personalized clinical decisions.

Comparison of clinicopathological features and outcomes in patients with primary leiomyosarcoma of bone and soft tissue

BACKGROUNDS AND OBJECTIVES

This investigation sought to describe the outcomes of primary leiomyosarcoma of bone (PLB) compared to soft tissue leiomyosarcoma (SLMS).

METHODS

This was a review of the Surveillance, Epidemiology, and End Results database from 1975 to 2016. Kaplan-Meier methods were used to estimate disease-specific survival (DSS), and a Cox regression model was used to identify prognostic factors.

RESULTS

Of the 7502 identifiable cases, 1% (n = 74) were PLB and 99% (n = 7428) were SLMS. Survival was the same between PLB and SLMS (p = .209). On multivariable analysis for high-grade SLMS, radiation (neoadjuvant: hazard ratio [HR], 0.56; 95% confidence interval [CI], 0.4-0.8; p = .003; adjuvant: HR, 0.75; 95% CI, 0.6-0.9; p = .008) and surgery (procedure specific) improved DSS. For PLB, wide resection/limb salvage (HR, 0.40; 95% CI, 0.3-0.5; p = .018) and amputation (HR, 0.69; 95% CI, 0.5-0.9; p < .001) were positive prognostic factors. Neither radiation nor chemotherapy were prognostic factors for survival in PLB.

CONCLUSIONS

For SLMS, radiation portends a survival advantage. For PLB, however, neither chemotherapy nor radiation were significant prognostic factors, which suggests the optimal treatment for PLB, similar to other primary soft tissue sarcomas originating in bone, remains an unmet medical need.

Soft-tissue sarcoma in adults: An update on the current state of histiotype-specific management in an era of personalized medicine

Soft-tissue sarcomas (STS) are rare tumors that account for 1% of all adult malignancies, with over 100 different histologic subtypes occurring predominately in the trunk, extremity, and retroperitoneum. This low incidence is further complicated by their variable presentation, behavior, and long-term outcomes, which emphasize the importance of centralized care in specialized centers with a multidisciplinary team approach. In the last decade, there has been an effort to improve the quality of care for patients with STS based on anatomic site and histology, and multiple ongoing clinical trials are focusing on tailoring therapy to histologic subtype. This report summarizes the latest evidence guiding the histiotype-specific management of extremity/truncal and retroperitoneal STS with regard to surgery, radiation, and chemotherapy.

Dedifferentiated soft tissue leiomyosarcoma with heterologous osteosarcoma component: case report and review of the literature

Background

Soft tissue dedifferentiated leiomyosarcoma with heterologous osteosarcomatous component is an extremely rare entity described in only few cases in the literature.

Case presentation

We report the case of a 65-year-old male patient who, after initial inadequate surgery of a tumor of the left forearm, developed local recurrence that was treated with neoadjuvant chemotherapy, surgery and postoperative radiation therapy. Histologically the tumor showed an abrupt separation of two different patterns. One component consisted of interlacing fascicles of spindle cells with cigar-shaped nuclei strongly positive for smooth muscle actin, desmin and H-caldesmon. The other component consisted of a high-grade pleomorphic sarcoma with osteoid and chondroid matrix production, which positive for SATB2. Thus, a final diagnosis of dedifferentiated leiomyosarcoma was rendered. Fifteen months after treatment, the patient presented further local and distant relapse with pulmonary metastases and died 23 months after the first presentation.

Discussion and conclusions

Dedifferentiated leiomyosarcoma is a highly malignant neoplasm with a poor outcome. Extensive sampling of soft tissue leiomyosarcomas is recommended to detect possible dedifferentiated areas as they represent a crucial prognostic parameter.

Nomograms Predict Cancer-Specific and Overall Survival of Patients With Primary Limb Leiomyosarcoma

To date, there have been no data to predict the survival of patients with leiomyosarcoma from soft limb tissue because of the rarity of this disease. Nomograms have been widely applied in clinical oncology to precisely predict the survival of individual patients. This was a retrospective study to construct and validate nomograms to predict the cancer-specific survival (CSS) and overall survival (OS) of patients with primary limb leiomyosarcoma (PL-LMS). A total of 1,208 patients with LMS from limb soft tissue were collected from the Surveillance, Epidemiology, and End Results database from 1975 to 2015. We identified independent prognostic factors using univariate and multivariate Cox analyses. These prognostic factors were then included in the nomograms to predict 3- and 5-year CSS and OS rates. Finally, we validated the nomograms internally and externally. A total of 1208 patients were collected and divided into validation (N = 604) and training (N = 604) groups. Age, race, grade, tumor size, stage, and surgical types were demonstrated as independent prognostic factors for CSS and OS (all p < 0.05) and further used to construct the nomograms. The concordance index (C-index) for CSS was 0.857 for internal validation and 0.727 for external validation. The C-index for OS and CSS both demonstrated that the nomogram prediction agreed perfectly with actual survival. We developed nomograms to predict CSS and OS in PL-LMS patients and can benefit from using them to identify patients' mortality risk and make more precise assessments regarding survival. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1649-1657, 2019.

Leiomyosarcoma: Clinicopathological study and retrospective analysis of prognostic factors in a series of 100 patients

The Authors reported a retrospective study of 100 Leiomyosarcoma (LMS), evaluating factors that may influence Overall Survival (OS), Local Recurrence Free Survival (LRFS), Metastasis Free Survival (MFS). Tumor Size (P = 0,0009), Local Recurrence (P = 0,0487), Distant relapse (P < 0,0001), Type of Presentation (P = 0,0213) were significant risk factors affecting overall survival (OS). Tumor Size (P = 0.024), age at diagnosis (P = 0,0086), type of presentation (P < 0,0001) and Local Recurrence (P = 0.0152) affected metastasis free survival (MFS). Type of presentation (P = 0,001) was an independent prognostic factor of local recurrence-free survival (LRFS).

Surgery plus chemotherapy improves survival of patients with extremity soft tissue leiomyosarcoma and metastasis at presentation

Purpose: Extremity soft tissue leiomyosarcoma (LMS) with metastasis is a rare disease with a poor prognosis. The purpose of our study was to define clinical features of extremity soft tissue LMS with metastasis as well as to identify multivariable predictors of survival. Methods: During 1973-2015, 239 patients with metastatic extremity soft tissue LMS were identified from the Surveillance, Epidemiology, and End Results (SEER) program database. The prognostic analysis was performed using the Kaplan-Meier method and a Cox proportional hazards regression model. Results: This group comprised 126 females (52.7%) and 113 males (47.3%), whose ages ranged from 8 to 95 years (median 67 years). The overall survival (OS) and cancer-specific survival (CSS) rates of the entire group at 3 years were 22.6% and 23.4%, respectively. The median OS and CSS were 14.0±1.5 and 15.0±2.3 months, respectively. Multivariate analysis revealed that tumor size >10 cm, no surgery and no chemotherapy were independent risk factors of decreased OS and CSS. Radiotherapy was not significantly associated with OS or CSS. Conclusion: Extremity soft tissue LMS patients who present with metastasis at diagnosis had a poor prognosis. Patients who performed surgery for primary tumors and chemotherapy had a better chance for prolonged survival.

Development and Validation of a Prognostic Nomogram for Extremity Soft Tissue Leiomyosarcoma

Background: Extremity soft tissue leiomyosarcoma (LMS) is a rare disease with a poor prognosis. The aim of this study is to develop nomograms to predict the overall survival (OS) and cancer-specific survival (CSS) of patients with extremity soft tissue LMS.

Methods: Based on the Surveillance, Epidemiology, and End Results (SEER) database, 1,528 cases of extremity soft tissue LMS diagnosed between 1983 and 2015 were included. Cox proportional hazards regression modeling was used to analyze prognosis and obtain independent predictors. The independent predictors were integrated to develop nomograms predicting 5- and 10-year OS and CSS. Nomogram performance was evaluated by a concordance index (C-index) and calibration plots using R software version 3.5.0.

Results: Multivariate analysis revealed that age ≥60 years, high tumor grade, distant metastasis, tumor size ≥5 cm, and lack of surgery were significantly associated with decreased OS and CSS. These five predictors were used to construct nomograms for predicting 5- and 10-year OS and CSS. Internal and external calibration plots for the probability of 5- and 10-year OS and CSS showed excellent agreement between nomogram prediction and observed outcomes. The C-index values for internal validation of OS and CSS prediction were 0.776 (95% CI 0.752–0.801) and 0.835 (95% CI 0.810–0.860), respectively, whereas those for external validation were 0.748 (95% CI 0.721–0.775) and 0.814 (95% CI 0.785–0.843), respectively.

Conclusions: The proposed nomogram is a reliable and robust tool for accurate prognostic prediction in patients with extremity soft tissue LMS.

Primary parapharyngeal leiomyosarcoma: A case report

Leiomyosarcoma is a rare malignant soft-tissue tumor whose cells resemble smooth-muscle tissue. It has been reported to arise in different areas of the head and neck region. Primary leiomyosarcoma of the parapharyngeal space, however, is extremely rare, as only 4 cases have been previously reported to date. We describe the somewhat urgent case of a primary leiomyosarcoma of the right parapharyngeal space in a 30-year-old man. We also review the diagnostic and therapeutic challenges that clinicians face in managing this rare tumor.

Soft tissue leiomyosarcoma-diagnostics, management, and prognosis: Data of the registry cancer of the center of Tunisia

Background:

Soft tissue leiomyosarcomas are rare, accounting for almost 5%–10% of all soft tissue sarcomas; they account for almost 1% of all sarcomas. They are aggressive tumors where location, size, and management require a multidisciplinary approach. Since there are few series published, we here analyze epidemiological pattern, clinical and pathologic features of soft tissue leiomyosarcomas.

Methods:

We conducted a retrospective study of 29 consecutive cases of histologically proven soft tissue leiomyosarcoma extracted from the database of the Cancer Registry of the Center of Tunisia and the Department of Pathology of Farhat Hached University Hospital of Sousse of Tunisia, during a 10-year period (from January 1996 to December 2005). Epidemiologic details, clinico-pathological features, and treatment modalities were assessed with focus on patients’ 5-year overall survival, tumor relapse, and metastases.

Results:

Soft tissue leiomyosarcoma accounted for 17.5% of all soft tissue sarcomas diagnosed at our pathology department. Most of patients were of advanced age (median: 52 years), with extremes ranging from 12 and 87 years. There was a slight male predominance (sex-ratio = 1.07). Tumors were located mostly in the lower limbs (45%). Deep sites as retroperitoneum was found only in two cases. Tumor size was more than 5 cm in 83% of cases (average size = 9.4 cm). Five cases had metastasis on initial staging. For 24 patients, the disease was locally limited at the moment of diagnosis. Palliative chemotherapy was indicated for four patients and surgery was performed for 20 patients. Local recurrence occurred in 11 patients (55% of operated patients) and metastasis in 6 patients. Overall, 5-year survival was about 24%.

Conclusion:

Our study results highlight the scarcity of soft tissue leiomyosarcoma. Unfortunately, unusual tumor sites, disease’s advanced stages, and intralesional resection made the prognosis poorer than in other series. Clinical course of soft tissue leiomyosarcoma was highly marked by local recurrence and metastasis.

A Case of "en bloc" Excision of a Chest Wall Leiomyosarcoma and Closure of the Defect with Non-Cross-Linked Collagen Matrix (Egis®)

Sarcomas arising from the chest wall account for less than 20% of all soft tissue sarcomas, and at this site, primitive tumors are the most frequent to occur. Leiomyosarcoma is a malignant smooth muscle tumor and the best outcomes are achieved with wide surgical excision. Although advancements have been made in treatment protocols, leiomyosarcoma remains one of the more difficult soft tissue sarcoma to treat. Currently, general local control is obtained with surgical treatment with wide negative margins. We describe the case of a 50-year-old man who underwent a chest wall resection involving a wide portion of the pectoralis major and minor muscle, the serratus and part of the second, third and fourth ribs of the left side. The full-thickness chest wall defect of 10 × 8 cm was closed using a non-cross-linked acellular dermal matrix (Egis^®) placed in two layers, beneath the rib plane and over it. A successful repair was achieved with no incisional herniation and with complete tissue regeneration, allowing natural respiratory movements. No complications were observed in the postoperative course. Biological non-cross-linked matrix, derived from porcine dermis, behaves like a scaffold supporting tissue regeneration; it can be successfully used as an alternative to synthetic mesh for chest wall reconstruction.

High-Grade Leiomyosarcoma Arising in a Previously Replanted Limb

Sarcoma development has been associated with genetics, irradiation, viral infections, and immunodeficiency. Reports of sarcomas arising in the setting of prior trauma, as in burn scars or fracture sites, are rare. We report a case of a leiomyosarcoma arising in an arm that had previously been replanted at the level of the elbow joint following traumatic amputation when the patient was eight years old. He presented twenty-four years later with a 10.8 cm mass in the replanted arm located on the volar forearm. The tumor was completely resected and pathology examination showed a high-grade, subfascial spindle cell sarcoma diagnosed as a grade 3 leiomyosarcoma with stage pT2bNxMx. The patient underwent treatment with brachytherapy, reconstruction with a free flap, and subsequently chemotherapy. To the best of our knowledge, this is the first case report of leiomyosarcoma developing in a replanted extremity. Development of leiomyosarcoma in this case could be related to revascularization, scar formation, or chronic injury after replantation. The patient remains healthy without signs of recurrence at three-year follow-up.

Recent advances in understanding and managing leiomyosarcomas

Leiomyosarcomas are malignant mesenchymal tumours that derive from the smooth muscle lineage. They are studied and frequently treated as if they are the same as other soft tissue sarcomas. Recent developments suggest that a different approach may be more appropriate. Their underlying genetic mechanisms remain unclear, and complex. Unbalanced karyotypic defects are the only shared features observed across different leiomyosarcoma subtypes. Unlike other soft tissue sarcomas, leiomyosarcomas are particularly sensitive to the combination of gemcitabine and docetaxel. Furthermore, treatment with trabectedin has shown a good efficacy in leiomyosarcomas, mainly in the form of chronic disease stabilisation.

MRI, MDCT features, and clinical outcome of extremity leiomyosarcomas: experience in 47 patients

OBJECTIVE

To describe MRI, MDCT features, and clinical outcome of extremity leiomyosarcomas (LMS).

MATERIALS AND METHODS

In this IRB-approved, HIPAA-compliant retrospective study, we included 47 patients (23 women, 24 men; mean age: 55.3 years, range: 17-85 years) with pathologically confirmed extremity LMS seen at our adult tertiary cancer center between 2000 and 2012. MRI/MDCT of primary tumors in 23 patients and follow-up in all patients were reviewed by two radiologists in consensus. Clinical data were extracted from electronic medical records.

RESULTS

Primary tumors were distributed in bones (6 out of 47), deep soft tissues (24 out of 47), and superficial soft tissues (17 out of 47). On imaging (bone = 4, deep soft tissue = 11, superficial soft tissue = 8), compared with skeletal muscle, they were T1 iso-hypointense and T2 hyperintense. Bone LMS were metaphyseal tumors with cortical destruction (3 out of 4). Deep soft-tissue LMS were large with hemorrhage (7 out of 11) and necrosis (10 out of 11). Superficial soft-tissue LMS were relatively smaller, homogeneously enhancing (6 out of 8) tumors. Distant metastases developed in 32 out of 47 patients (bone LMS [6 out of 6], deep soft-tissue LMS [18 out of 24], superficial soft-tissue LMS [8 out of 17]), commonly to lung (29 out of 47) and bone (14 out of 47). At the time of writing, 22 out of 36 patients (bone LMS [4 out of 6], deep soft-tissue LMS [15 out of 24], superficial soft-tissue LMS [4 out of 17]) have died. There was no statistically significant correlation between metastatic disease and tumor size or grade.

CONCLUSION

Extremity LMS arise in bones and in the deep and superficial soft tissues, frequently metastasize to the lungs, and have a poor prognosis. Superficial LMS tend to have a better prognosis than bone or deep soft-tissue LMS.

Recurrent subcutaneous trunk leiomyosarcoma: Management and review of the literature

Superficial leiomyosarcomas are rare malignant smooth-muscle tumors accounting for 4-6.5% of all soft-tissue sarcomas, less than 2-3% of cutaneous soft-tissue neoplasms and 0.04% of all cancers. They are divided into cutaneous or dermal and subcutaneous leiomyosarcomas. Subcutaneous tumors have been reported to be associated with an increased risk of local recurrences and distant metastases, compared to their cutaneous counterparts. In this study, we describe a rare case of a recurrent subcutaneous trunk leiomyosarcoma in a 68-year-old male patient. Local recurrence developed two years after the complete surgical resection with wide margins and adjuvant postoperative radiotherapy. The management of the patient is discussed along with a review of the literature. We conclude that subcutaneous leiomyosarcoma is a rare clinical entity which may be associated with an atypical clinical presentation. Physicians should be aware of the misleading features of this tumor in order to avoid delay in diagnosis and treatment. Early complete surgical resection with wide margins of at least 2 cm is the cornerstone of treatment and has been reported to mostly influence the prognosis. However, the tumor has a high tendency to recur locally and metastasize. Recurrence may develop despite wide resection and radiotherapy. Long-term follow-up is mandatory.

Adult soft tissue sarcoma local recurrence after adjuvant treatment without resection of core needle biopsy tract

BACKGROUND

Core needle biopsies of sarcomas allow a diagnosis in a high percentage of patients with few complications. However, it is unclear whether the tract needs to be excised to prevent recurrences.

QUESTIONS/PURPOSES

We therefore determined the rates of recurrence and metastases in patients with Stage III extremity sarcomas, who underwent wide local resection without excision of the needle tract and also received adjuvant treatment.

METHODS

We retrospectively reviewed 59 adult patients with deep, larger than 5 cm, high-grade soft tissue sarcomas of the upper or lower extremity treated between January 1999 and April 2009. All the patients underwent a core needle biopsy. Resection was performed with wide margins. The biopsy tract was not resected during the definitive surgery. Fifty-seven patients (97%) received preoperative and/or postoperative radiation, whereas 49 patients (83%) received chemotherapy. Local recurrence and distant recurrence rates were determined. The minimum followup was 24 months (median, 56 months; range, 24-122 months).

RESULTS

The local recurrence rate was 9%. Fifteen patients (25%) developed metastasis after diagnosis. Seven of the 59 patients (12%) had microscopic positive margins at resection.

CONCLUSIONS

Our data demonstrate no increase in local recurrence rates or rates of metastatic disease compared with previously published studies when resection of the core biopsy tract was not performed.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Advances in the systemic treatment of cutaneous sarcomas

Cutaneous sarcomas are a rare subset of soft tissue sarcomas. These tumors are primarily managed with definitive surgical resection; however, upon unresectable recurrence or metastatic spread, systemic therapy is warranted. As with other sarcomas, these treatments have classically included cytotoxic chemotherapy programs that were associated with variable response rates and poor overall survival. Recently, major advances have been made in the understanding of the molecular biology of these tumors, and treatment paradigms are changing. Multiple pathways have been documented to be important in the growth of cutaneous sarcomas, including receptor tyrosine kinases such as platelet-derived growth factor receptor, insulin-like growth factor receptor and KIT. Dysregulated angiogenesis, through vascular endothelial growth factor (VEGF) and other pathways, is also associated with the growth of these tumors. In this review, we discuss the current standard therapies of cutaneous sarcoma and the recent advances and ongoing investigations into cutaneous sarcoma biology.

Classification, molecular characterization, and the significance of pten alteration in leiomyosarcoma

Leiomyosarcoma is a malignant smooth muscle neoplasm with a complicated histopathologic classification scheme and marked differences in clinical behavior depending on the anatomic site of origin. Overlapping morphologic features of benign and borderline malignant smooth muscle neoplasms further complicate the diagnostic process. Likewise, deciphering the complex and heterogeneous patterns of genetic changes which occur in this cancer has been challenging. Preliminary studies suggest that reproducible molecular classification may be possible in the near future and new prognostic markers are emerging. Robust recapitulation of leiomyosarcoma in mice with conditional deletion of Pten in smooth muscle and the simultaneous discovery of a novel role for Pten in genomic stability provide a fresh perspective on the mechanism of leiomyosarcomagenesis and promise for therapeutic intervention.

The enigma of myxofibrosarcoma of the extremity

BACKGROUND

The reported high rate of local recurrence (LR) in myxofibrosarcoma raises the question of whether this sarcoma histology should be considered radioresistant. In this study, the authors compared rates and patterns of LR of high-grade (HG) myxofibrosarcoma with rates and patterns of HG leiomyosarcoma, which was chosen because of the similarity in incidence and general treatment approach.

METHODS

Two hundred two patients with primary, nonmetastatic extremity myxofibrosarcoma (n = 114) and leiomyosarcoma (n = 88) underwent limb-sparing surgery and were followed prospectively. All 202 patients had HG tumors, and 138 patients (68%) received adjuvant radiation therapy.

RESULTS

The groups were comparable in terms of age, sex, and receipt of chemotherapy. Compared with leiomyosarcoma, myxofibrosarcoma presented more frequently with tumors >5 cm (P < .001), deep location (P = .036), and upper extremity site (P = .015). In addition, rates of positive/close margins (P < .001) and the receipt of radiation therapy (P < .001) were significantly higher in the myxofibrosarcoma group. The 5-year overall LR rate was not significantly different according to histology (14.6% for myxofibrosarcoma, 13.2% for leiomyosarcoma; P = .594). The only predictor of LR for the whole cohort of patients was positive/close margins (P = .01). Of 17 myxofibrosarcoma LRs, 8 (47%) occurred out of field, versus 1 of 12 (8%) leiomyosarcoma LRs (P = .04). Leiomyosarcoma more commonly recurred distantly (54.1% vs 24.3% at 5 years; P = .014).

CONCLUSIONS

Despite more adverse clinical features, myxofibrosarcoma recurred distantly less often than leiomyosarcoma, whereas the LR rates were comparable between the 2 groups, suggesting that adjuvant radiation therapy is effective in myxofibrosarcoma. Myxofibrosarcoma LRs more commonly occurred out of field. Reduction in radiation field margins may not be advisable in patients with myxofibrosarcoma.

Exophytic growth of a neglected giant subcutaneous Leiomyosarcoma of the lower extremity. A case report

Background

Superficial leiomyosarcoma is an exceedingly uncommon malignant tumor which could be located either to cutaneous or subcutaneous tissues. Increased mass size and depth, advanced tumor staging and inadequate surgical excision are the main prognostic factors for poor result.

Case presentation

We report a rare case of a 71-year-old man with an extensive exophytic lesion (12 × 10 cm) in the anterior-medial side of the proximal right tibia. The lesion was painless and consistently neglected by the patient until a skin trauma caused ulceration of the affected area. Magnetic Resonance Imaging revealed a soft-tissue mass which was well defined from the surrounding bone and muscles. As initial biopsy in another hospital hadn't clarified the true nature of the lesion, new samples were taken and the diagnosis of leiomyosarcoma was established. Laboratory examination showed no distant metastasis and wide excision of the neoplasm was decided. After tumor resection, the remaining soft tissue and skin defect was covered with a gastrocnemius myocutaneous flap. The postoperative period was uneventful and wound healing was followed by local radiotherapy and systemic chemotherapy. At 3 years follow up, no recurrence or metastasis was identified and the patient was able to walk and stand without impairment of his ambulatory status.

Conclusion

Proper surgical management of soft tissue leiomyosarcoma continues to remain the cornerstone of treatment efficacy and the most important prognostic factor for patients' survival. Reconstruction of the remaining soft tissue defect should be always performed at the same operative time when removal of giant size tumors leaves an uncovered cavity with an inadequate sleeve of muscular and skin tissues.

Leiomyosarcoma of the Cephalic Vein: Case Report and Review of the Literature

Vascular leiomyosarcoma is extremely rare and represents < 2% of all leiomyosarcomas. The frequency of occurrence of leiomyosarcomas in veins is five times more than in arteries, with approximately half of them occurring in the inferior vena cava. Although leiomyosarcomas originating from large arteries or veins have been widely reported, similar tumors of peripheral vessels of upper extremities are extremely rare. To our knowledge, leiomyosarcomas of the cephalic vein over the wrist area have not been previously documented. We report a case of leiomyosarcoma of the cephalic vein in a 63-year-old man who presented with right hand and forearm swelling and tenderness for more than 1 year. Grossly, a solitary, elongated, white, and firm intraluminal growth tumor was infiltrative along the vessel wall with focal nodular formation and filled the lumen of cephalic vein, measuring 11 cm in length. Histological study revealed an intermediate-grade leiomyosarcoma of vascular origin.

Clinical course of nonvisceral soft tissue leiomyosarcoma in 225 patients from the Scandinavian Sarcoma Group

BACKGROUND

Leiomyosarcoma of nonvisceral soft tissues is an uncommon malignant tumor; thus, only small numbers of cases have been reported. This study was based on a large series of patients from the Scandinavian Sarcoma Group Register acquired during a 15-year period (from 1986 to 2001). Follow-up information was available for all patients.

METHODS

The authors analyzed the clinical features of 225 patients with cutaneous, subcutaneous, or deep-seated leiomyosarcoma of the extremities, trunk wall, and superficial parts of the head and neck region to determine the natural course of the disease. Only patients who received their treatment at a specialist sarcoma center were included. Re-evaluation of histopathology was performed.

RESULTS

The age of the patients (121 women and 104 men) ranged from 20 years to 98 years (median, 70 years), and the tumors ranged in size from 0.6 cm to 35 cm (median, 4.0 cm). Eighty-two percent of the tumors were classified as high grade. The median follow-up for survivors was 5.5 years. The local treatment was adequate in 154 of 206 patients (75%) who were without metastasis at presentation. At 10 years, 84% of the 206 patients with localized disease at presentation were free from local recurrence, 66% remained metastasis free, and 49% were alive. Multivariate analysis showed that higher malignancy grade (P = .006), larger tumor size (P = .003), and deeper tumor location (P = .002) were correlated significantly with decreased metastasis-free survival, inadequate local treatment was correlated with local recurrence (P = .007), and high malignancy grade was correlated with decreased overall survival (P = .007).

CONCLUSIONS

The long-term prognosis for patients with subcutaneous and deep-seated soft tissue leiomyosarcoma remains poor despite the ability to achieve adequate local control through nonmutilating surgery with or without radiotherapy.

Tumor necrosis has no prognostic value in neoadjuvant chemotherapy for soft tissue sarcoma

Neoadjuvant chemotherapy for treatment of soft tissue sarcomas is controversial, and the correlation between local recurrence and survival is unclear. Histologic necrosis is a well-documented predictor of survival in patients with malignant bone tumors; however, the association is unknown in patients with soft tissue sarcomas. We assessed the prognostic significance of tumor necrosis for treatment of soft tissue sarcomas. We retrospectively collected data from 82 patients who received neoadjuvant chemotherapy for treatment of soft tissue sarcomas of the extremities. Patients had wide resections if tumors were high-grade, deep to the investing fascia, and had clear margins. We quantified the amount of necrosis and analyzed the relationship with local recurrence and overall survival. At an average followup of 65 months (range, 24-154 months), the 5-year local recurrence rates for patients with less than 95% and 95% or greater necrosis were 20% and 33%, respectively. The overall 5-year survivorship rates for patients with less than 95% necrosis and 95% or greater necrosis were 82% and 78%, respectively. There was no difference in recurrence-free survival or overall patient survival based on the amount of histologic necrosis. Tissue necrosis from neoadjuvant chemotherapy does not seem to predict outcome in soft tissue sarcomas.

Inflammatory leiomyosarcoma of the ankle: a case report and review of the literature

Inflammatory leiomyosarcoma is a rare morphologic expression of smooth muscle tumor, which is more often found in the trunk, extremities, and retroperitoneoum. We present a case of inflammatory leiomyosarcoma arising near the ankle joint, superior to the medial malleolus, in a 55-year-old man. Immunohistochemistry, electron microscopy, and cytogenetics were used in the differentiation of this rare morphologic expression of leiomyosarcoma. As in all soft tissue leiomyosarcomas, the accurate prediction of the clinical behavior of this morphologic expression often proves to be difficult. Age, vascular invasion, depth, grade, tumor disruption, size, and stage have prognostic value. Nevertheless, prognosis of inflammatory leiomyosarcoma seems to be favorable when treated early with wide excision of the tumor as in the case presented. Sixteen months after excision of the tumor the patient is doing well with no signs of recurrence.

[Varying characteristics of subcutaneous and dermal leiomyosarcomas. Two case reports and literature review]

Cutaneous leiomyosarcomas (LMS) originating from smooth muscle of the skin are rare malignant neoplasms. Preferential sites are hair-bearing areas, especially the legs. We report two patients in their 5th and 7th decade, in whom leiomyosarcomas were encountered in the lower leg and the capillitium, respectively. Histologically, the former was found to be a dermal leiomyosarcoma with subcutaneous infiltration, the latter an exclusively dermal tumor. The LMS of the lower leg had been excised three years previously in a different institution and had been diagnosed as a leiomyoma. Both lesions were excised with adequate safety margins in our institution and within a two-year postoperative observation period no recurrences were encountered. Dermal leiomyosarcomas have a 33% recurrence rate while that of subcutaneous leiomyosarcomas show is 50%. In contrast to exclusively dermal tumors, subcutaneous LMS show a tendency for hematogenic and lymphogenic metastases. Therapy of choice is excision with wide safety margins.