Clinical outcome of deep-seated atypical lipomatous tumor of the extremities with median-term follow-up study

Histology-Tailored Approach to Soft Tissue Sarcoma

Soft tissue sarcomas are a diverse and heterogeneous group of cancers of mesenchymal origin. Each histological type of soft tissue sarcoma has unique clinical particularities, which makes them challenging to diagnose and treat. Multidisciplinary management of these rare diseases is thus key for improved survival. The role of surgery has been well established, and it represents the cornerstone curative treatment for soft tissue sarcomas. To date, local recurrence is the leading cause of death in low-grade sarcomas located at critical sites, and distant metastasis in high-grade sarcomas, regardless of the site of origin. Management must be tailored to each individual histologic type. We describe the most common types of extremity, trunk, abdominal, and retroperitoneal soft tissue sarcoma along with characteristics to consider for optimized management.

Atypical Spindle Cell/Pleomorphic Lipomatous Tumor: A Review and Update

Atypical spindle cell/pleomorphic lipomatous tumor (ASCPLT) is a rare and recently described adipocytic neoplasm that primarily occurs in the subcutis of the limbs and limb girdles, particularly of middle-aged adults. It has locally recurrent potential if incompletely excised but no risk for distant metastasis. ASCPLT is histologically similar to spindle cell/pleomorphic lipoma and atypical lipomatous tumor and shows a mixture of atypical spindle cells, adipocytes, lipoblasts, floret-like multinucleated giant cells, and/or pleomorphic cells. It has been recently recognized that ASCPLT can undergo sarcomatous transformation. However, the biological significance of morphological sarcomatous transformation in ASCPLT remains uncertain. Immunohistochemically, the tumor cells show variable expression of CD34, S-100 protein, and desmin. Loss of nuclear Rb expression is observed in the majority of cases. ASCPLT lacks MDM2 gene amplification but can show RB1 gene deletion in a significant subset of cases. Complete surgical excision is the treatment of choice. This review provides an overview of the current knowledge on the clinicoradiological features, pathogenesis, histopathology, and treatment of ASCPLT. In addition, we will discuss the differential diagnosis of this new entity.

UK guidelines for the management of soft tissue sarcomas

Soft tissue sarcomas (STS) are rare tumours arising in mesenchymal tissues and can occur almost anywhere in the body. Their rarity, and the heterogeneity of subtype and location, means that developing evidence-based guidelines is complicated by the limitations of the data available. This makes it more important that STS are managed by expert multidisciplinary teams, to ensure consistent and optimal treatment, recruitment to clinical trials, and the ongoing accumulation of further data and knowledge. The development of appropriate guidance, by an experienced panel referring to the evidence available, is therefore a useful foundation on which to build progress in the field. These guidelines are an update of the previous versions published in 2010 and 2016 [1, 2]. The original guidelines were drawn up by a panel of UK sarcoma specialists convened under the auspices of the British Sarcoma Group (BSG) and were intended to provide a framework for the multidisciplinary care of patients with soft tissue sarcomas. This iteration of the guidance, as well as updating the general multidisciplinary management of soft tissue sarcoma, includes specific sections relating to the management of sarcomas at defined anatomical sites: gynaecological sarcomas, retroperitoneal sarcomas, breast sarcomas, and skin sarcomas. These are generally managed collaboratively by site specific multidisciplinary teams linked to the regional sarcoma specialist team, as stipulated in the recently published sarcoma service specification [3]. In the UK, any patient with a suspected soft tissue sarcoma should be referred to a specialist regional soft tissues sarcoma service, to be managed by a specialist sarcoma multidisciplinary team. Once the diagnosis has been confirmed using appropriate imaging and a tissue biopsy, the main modality of management is usually surgical excision performed by a specialist surgeon, combined with pre- or post-operative radiotherapy for tumours at higher risk for local recurrence. Systemic anti-cancer therapy (SACT) may be utilised in cases where the histological subtype is considered more sensitive to systemic treatment. Regular follow-up is recommended to assess local control, development of metastatic disease, and any late effects of treatment.

Low local recurrence rates following marginal surgical resection of non-coelomic Atypical Lipomatous Tumours/Well-differentiated Liposarcomas

INTRODUCTION

High rates of local recurrence (LR) have been reported following resection of extremity Atypical lipomatous tumours/Well-differentiated liposarcomas (ALTs). This retrospective study of patients who underwent resection of primary deep extremity and trunk ALTs at a specialist sarcoma centre aims to assess morbidity and factors associated with low local recurrence rates (LRR).

METHODS

To review a homogeneous cohort of patients with low-grade disease, tumours with known high-risk histological features were excluded. Prognostic variables potentially influencing local recurrence (LR) (age, size, site, margin status, and histological findings) were analysed. Endpoints were LR, distant recurrence (DR) and local disease-free survival (LDFS).

RESULTS

127 patients were identified, with median follow-up of 54 months (0-235). Median tumour size was 17.5 cm (5-36). 85 % occurred in the lower limb. 93.7 % underwent marginal resection. No patients received radiotherapy. Median hospital stay was 3 days (0-16). 7.9 % returned to theatre for evacuation of haematoma or infected seroma and 18.1 % had outpatient seroma aspiration. Surgical margins were R0/R1 in 93.7 % of patients and R2 in 6.3 % with a LR rate of 8.4 % and 75 % respectively at median time of 54 months. One- and 5-year LDFS was 100 % and 88.4 %, respectively. DR rate was 0.8 % (1/127) this patient had pleomorphic liposarcomatous transformation on recurrence and subsequently developed distant metastases. No patients died of disease.

CONCLUSION

Function-preserving marginal resection of non-coelomic ALTs has low morbidity, low LR and extremely low rates of distant relapse. Patients with lower limb ALT were found to have significantly lower LR, which may impact follow-up protocols.

Bone and soft tissue tumors at the borderlands of malignancy

This review examines findings of musculoskeletal neoplasms whose equivocal imaging and/or histopathologic features make it difficult to determine if they will show aggressive behavior. We include both intermediate tumors as defined by the World Health Organization (WHO), and a single low-grade malignancy, low-grade central osteosarcoma, which mimics a benign lesion on imaging and histology. Intermediate tumors are a broad category and are subdivided into tumors that have risk of local recurrence only, and ones that have a risk of distant limb and pulmonary metastases. Difficult intermediate musculoskeletal lesions include atypical cartilaginous tumor/grade 1 chondrosarcoma, atypical lipomatous tumor/grade 1 liposarcoma, and solitary fibrous tumor. We review diagnostic criteria, differential diagnosis, and recommendations for surveillance.

The Immune Contexture of Liposarcoma and Its Clinical Implications

Liposarcomas (LPS) are the most frequent malignancies in the soft tissue sarcoma family and consist of five distinctive histological subtypes, termed well-differentiated LPS, dedifferentiated LPS (DDLPS), myxoid LPS (MLPS), pleomorphic LPS, and myxoid pleomorphic LPS. They display variations in genetic alterations, clinical behavior, and prognostic course. While accumulating evidence implicates a crucial role of the tumor immune contexture in shaping the response to anticancer treatments, the immunological landscape of LPS is highly variable across different subtypes. Thus, DDLPS is characterized by a higher abundance of infiltrating T cells, yet the opposite was reported for MLPS. Interestingly, a recent study indicated that the frequency of pre-existing T cells in soft tissue sarcomas has a predictive value for immune checkpoint inhibitor (CPI) therapy. Additionally, B cells and tertiary lymphoid structures were identified as potential biomarkers for the clinical outcome of LPS patients and response to CPI therapy. Furthermore, it was demonstrated that macrophages, predominantly of M2 polarization, are frequently associated with poor prognosis. An improved understanding of the complex LPS immune contexture enables the design and refinement of novel immunotherapeutic approaches. Here, we summarize recent studies focusing on the clinicopathological, genetic, and immunological determinants of LPS.

Adjuvant Radiation after Primary Resection of Atypical Lipomatous Tumors of the Extremity Reduces Local Recurrence but Increases Complications: A Multicenter Evaluation

Background

Radiation after resection of an atypical lipomatous tumor (ALT) is controversial. This study evaluates local control and complications after the first resection of ALTs of the extremity with or without adjuvant radiation.

Methods

A dual institution, retrospective review of patients treated from 1995 to 2020 with first-time resection of an ALT in the extremity was performed. In total, 102 patients underwent adjuvant radiation (XRT group) and 68 patients were treated with surgery alone (no-XRT group). The median follow-up time was 4.6 years (interquartile range (IQR) 2.0–7.3 years). The median radiation dose was 60 Gy (IQR 55–66 Gy). Univariable and multivariable analyses evaluated the association of patient, tumor, and treatment variables with recurrence and complications. Kaplan–Meier analysis evaluated local recurrence-free survival (LRFS) and time to complication.

Results

The overall incidence of local recurrence was 1% (1/102) in the XRT group and 24% (16/68) in the no-XRT group (p < 0.001). The median time-to-recurrence was 8.2 years (IQR 6.5–10.5 years). In the XRT and the no-XRT groups, 5-yr LRFS was 98% and 92% (p=0.21) and 10-yr LRFS was 98% and 41% (p < 0.001), respectively. The absence of radiation (HR = 23.63, 95% CI (3.09–180.48); p < 0.001) and R2 surgical resection margins (HR = 11.04, 95% CI (2.07–59.03); p < 0.001) incurred a 23-fold and 11-fold increased risk of local recurrence, respectively, while tumor size, depth, location, and neurovascular involvement were not found to be independent predictors of recurrence. The complication rate was 37% (38/102) in the XRT group and 10% (7/68) in the no-XRT group (p < 0.001). Eight patients (8/102, 8%) required surgical management for complication in the XRT group compared with two patients (2/68, 3%) in the no-XRT group (p=0.10). Higher radiation dose had a modest correlation with increased severity of complication (ρ=0.24; p=0.02).

Conclusions

Adjuvant radiation after first-time resection of an ALT of the extremity was associated with a significantly reduced risk of local recurrence but a three-fold increase in complication rate. These data support a 10-year follow-up for these patients and inform a notable clinical trade-off if considering adjuvant radiation for this tumor with recurrent potential.

Lipoma and Its Doppelganger: The Atypical Lipomatous Tumor/Well-Differentiated Liposarcoma

Lipomatous tumors are among the most common soft tissue lesions encountered by the general surgeon. Shared history and clinical presentation make differentiation between benign lipomas and low-grade liposarcomas a diagnostic dilemma. This article reviews the epidemiology, clinical history, diagnostic workup, management, natural history, and surveillance of benign lipomas and atypical lipomatous tumors/well-differentiated liposarcomas. Although it is important that aggressive, potentially malignant atypical lipomatous tumors and liposarcomas be managed in a multidisciplinary, preferably high-volume setting, it is equally as important for the nonspecialist general surgeon to be familiar with lipoma and its doppelganger-the well-differentiated liposarcoma.

Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of soft tissue tumors 2020 - Secondary publication

BACKGROUND

These clinical practice guidelines are intended to provide recommendations based on the best evidence obtained to date on key issues in clinical practice to improve the prognosis, diagnostic and therapeutic processes for patients with soft tissue tumors.

METHODS

The Guidelines Development Committee and Systematic Review Committee were composed of a multidisciplinary team of specialists who play an important role in soft tissue tumor care. Clinical questions (CQs) were determined by choosing key decision-making points based on Algorithms for the diagnosis and treatment of soft tissue tumors. The guidelines were developed according to the "Medical Information Network Distribution Service (Minds) Handbook for Clinical Practice Guideline Development 2014" and "Minds Manual for Clinical Practice Guideline Development 2017." Recommendation strength was rated on two levels and the strength of evidence was rated on four levels. The recommendations were decided based on agreement by 70% or more voters.

RESULTS

Twenty-two CQs were chosen by the Guidelines Development Committee. The Systematic Review Committee reviewed the evidence concerning each CQ, a clinical value judgment was added by experts, and the text of each recommendation was determined.

CONCLUSION

We established 22 CQs and recommendations for key decision-making points in the diagnosis and treatment of soft tissue tumors according to the Minds Clinical Practice Guideline development methods. We hope that these guidelines will assist the decision-making of all medical staff engaged in the treatment and diagnosis of soft tissue tumors, and eventually lead to improved soft tissue tumor care in the country.

Marginal resection for patients with atypical lipomatous tumours of the extremities and trunk wall: a systematic review and meta-analysis

BACKGROUND

This systematic review assessed and compared the efficacy of marginal resection to wide resection in patients with atypical lipomatous tumours (ALT) by evaluating the local recurrence rates, overall survival and adverse event rates.

METHODS

We evaluated studies published between 1 January 1990 and 31 January 2019. The risks of bias in the selected studies were analyzed using the Cochrane Collaboration Risk of Bias Tool. The quality of the evidence was evaluated using the Grading of Recommendations, Assessment, Development and Evaluation approach.

RESULTS

Three case-control studies and three case series studies were identified. A meta-analysis was performed of six studies to evaluate the local recurrence rate after resection. Comparison of marginal and wide resections showed that the local recurrence rate was not significantly higher in the marginal resection group (14.2 and 1.4%, odds ratio: 2.88, 95% confidence interval 0.99-8.33, P = 0.05). We observed no difference in overall survival. In one study, the rates of adverse events were 14.7% in the marginal resection group and 45.4% in the wide treatment group (odds ratio, 0.32; 95% confidence interval 0.11-80.91, P < 0.05).

CONCLUSIONS

In our analyses, five of six studies reported no recurrence for wide resection, compared to three to seven recurrences in the marginal resection group. One study reported only one case of recurrence for wide resection. Because ALT has a relatively good prognosis, the use of marginal resection is acceptable to preserve musculoskeletal function.

Resection Status Does Not Impact Recurrence in Well-Differentiated Liposarcoma of the Extremity

BACKGROUND

Well-differentiated liposarcoma (WDLPS) is a low-grade soft tissue sarcoma with a propensity for local recurrence. The necessity of obtaining microscopically free surgical margins (R0) to minimize local recurrence is not clear. This study evaluates recurrence-free survival (RFS) of extremity WDLPS in relation to resection margin status.

METHODS

A retrospective review of adult patients with primary extremity WDLPS at seven US institutions from 2000 to 2016 was performed. Patients with recurrent tumors or incomplete resection (R2) were excluded. Clinicopathologic factors were analyzed to assess impact on local RFS.

RESULTS

97 patients with primary extremity WDLPS were identified. The majority of patients had deep, lower extremity tumors. Mean tumor size was 18.2±8.9cm. Patients were treated with either radical (76.3%) or excisional (23.7%) resections; 64% had R0 and 36% had microscopically positive (R1) resection margins. Ten patients received radiation therapy with no difference in receipt of radiation between R0 vs R1 groups. Thirteen patients (13%) developed a local recurrence with no difference in RFS between R0 vs R1 resection. Five-year RFS was 59.5% for R0 vs 85.2% for R1. Only one patient died of disease after developing dedifferentiation and distant metastasis despite originally having an R0 resection.

DISCUSSION

In this large multi-institutional study of surgical resection of extremity WDLPS, microscopically positive margins were not associated with an increased risk of recurrence. Positive microscopic margin resection for extremity WDLPS may yield similar rates of local control while avoiding a radical approach to obtain microscopically negative margins.

Quantitative signal intensity ratios to distinguish between subfascial lipoma and atypical lipomatous tumor/well-differentiated liposarcoma using short-tau inversion recovery (STIR) MRI

PURPOSE

To establish simple quantitative variables at short-tau inversion recovery (STIR) magnetic resonance imaging (MRI) to identify lipomas with high specificity in patients with indeterminate subfascial lipomatous tumors.

MATERIALS AND METHODS

The MRI examinations of 26 patients (14 men, 12 women; mean age 63±12.5 [SD] years; range: 40-84years) with histopathologically proven subfascial atypical lipomatous tumors/well-differentiated liposarcomas (ALT/WDLs) and those of 68 patients (32 men, 36 women; mean age, 56±13.5 [SD] years; range: 21-83years) with lipomas were retrospectively reviewed. Ratios derived from region of interest based signal intensity (SI) measurements of tumors and adjacent fat on STIR images were calculated and maximum tumor diameters were noted. Diagnostic parameter capabilities were assessed using ROC curve analysis. Interreader agreement was evaluated by calculation of intraclass correlation coefficients (ICC).

RESULTS

Using a cut-off value of 1.18, STIR-SI ratios allowed discriminating between lipoma and ALT/WDL (AUC=0.88; P<0.001) yielding 93% specificity (95% CI: 77-99%) and 74% sensitivity (95% CI: 61-84%) for the diagnosis of lipoma. Interreader agreement was excellent (ICC=0.93). A significant difference in maximum tumor diameter was found between ALT/WDLs (mean: 18.1±6.0 [SD] cm; range: 5.6-33.1cm) and lipomas (mean: 9.7±5.0 [SD] cm; range: 2.9-29.1cm) (P<0.001). Using a cut-off of 11cm, maximum tumor diameter allowed discriminating between lipoma and ALT/WDLs with 92% specificity (95% CI: 75-99%) and 69% sensitivity (95% CI: 57-80%). The combination of a STIR-SI ratio<1.4 and maximum tumor diameter<11cm yielded 100% specificity (95% CI: 87-100%) and 65% sensitivity (95% CI: 54-77%) for the diagnosis of lipoma.

CONCLUSION

The combination of STIR-SI ratio and maximum diameter allows discriminating between lipoma and ALT/WDL in initially indeterminate lipomatous tumors.

Atypical Lipomatous Tumors: Does Our Inconsistent Terminology Have Patient Repercussions? Results of a Meta-Analysis

OBJECTIVES

Misnaming low-grade lipomatous tumors poses a clinical and medicolegal challenge, potentially subjecting patients to expensive and unnecessary surgeries. The terms atypical lipomatous tumor (ALT) and "well-differentiated" liposarcoma (WDL) have been used interchangeably in pathology reports, scholarly works and consensus recommendations, creating vagaries between low-virulence extremity tumors and retroperitoneal disease with metastatic potential.

METHODS

A systematic review was performed on all studies that reported on the local recurrence rate and metastasis of ALTs and WDLs in living human subjects. Local recurrence and metastases were compared using Fisher's Exact Test.

RESULTS

In total, 20 studies evaluated ALTs (n=936), whereas 13 studied WDLs (n=626). Mean follow-up was 6.6±2.0 years (median, 7.0 y). No metastatic disease was observed among ALTs, whereas 15 patients with WDLs (2.7%, P<0.0001) had metastases. The local recurrence rate of ALTs was significantly lower than WDLs after both marginal (15.1%, 141/936 vs. 46.0%, 288/626, P<0.0001) and wide excisions (3.3%, 2/59 in ALT vs. 17.4%, 19/109, P=0.007).

CONCLUSIONS

ALT should be reserved for extremity lesions meeting appropriate histopathologic criteria that represent nonmetastatic disease, reducing over-diagnosis, over-treatment, and patient risk.

Surgical management of truncal and extremities atypical lipomatous tumors/well-differentiated liposarcoma: A systematic review of the literature

INTRODUCTION

Atypical lipomatous tumors or well-differentiated liposarcomas (ALT/WDLS) are low-grade soft tissue tumors that are commonly located on the trunk and extremities. There is no consensus on the best surgical approach for ALT/WDLS.

METHODS

A systematic literature review of PubMed, Medline, Embase, Scopus, and google scholar was performed. All published studies on trunk or extremities ALT/WDLS with reported outcome data were considered and independently screened for inclusion by at least two of the authors.

RESULTS

A total of eighteen studies comprising 793 patients with ALT/WDLS were included. 580 patients underwent marginal excision, with local recurrence observed in 69 (11.9%). 213 patients underwent wide excision with local recurrence in 7(3.3%). Recurrent tumors were successfully re-resected with marginal or wide excision. Dedifferentiation was confirmed in 9 patients (1.1%), and a distant pulmonary metastasis in 1 patient (0.1%).

DISCUSSION

Marginal excision of truncal or extremities ALT/WDLS results in a slightly higher local recurrence rate. However, recurrences are almost always amenable to re-resection. The findings support the use of marginal excision for truncal or extremities ALT/WDLS.

Low Recurrence Rate and Risk of Distant Metastases following Marginal Surgery of Intramuscular Lipoma and Atypical Lipomatous Tumors of the Extremities and Trunk Wall

OBJECTIVE

The purpose of the present study was to determine the local recurrence rate, risk of dedifferentiation, and distant metastasis after surgical excision of intramuscular lipomas (IML) and atypical lipomatous tumors (ALT).

SUBJECTS AND METHODS

We retrospectively assessed all IML and ALT surgically removed from the extremities or trunk wall in our clinic between 1997 and 2006. Data from 141 patients with IML and 35 patients with ALT were extracted from the National Pathology Registry and patient files.

RESULTS

IML and ALT recurred in 10 and 6 tumors, respectively. No metastases were observed in either group. The 5- and 10-year local recurrence-free survival rates were 97.1% (94.3-99.9) and 94.8% (CI: 91.1-98.6) for IML and 84.6% (CI: 72.1-97.1) and 81.1% (CI: 67.6-94.8) for ALT, respectively. ALT were found to dedifferentiate in 2/35 cases.

CONCLUSION

Both IML and ALT showed a low recurrence rate when removed surgically from the extremities or trunk wall with intended marginal resection. No distant metastases were observed in any of the groups. It, therefore, seems safe to treat these tumors with marginal resection.

Natural history of well-differentiated liposarcoma of the extremity compared to patients treated with surgery

BACKGROUND

Patients with well-differentiated liposarcoma (WDLPS) of the extremity are mostly treated surgically, thereby possibly inducing severe morbidities. Despite the excellent prognosis, the natural history is barely studied. The aim of this study was to evaluate the natural history of extremity WDLPS by evaluating the outcome of patients treated with active surveillance (AS), who thereby exhibited the natural history of extremity WDLPS, and of patients treated surgically.

METHODS

A large retrospective database of patients with extremity WDLPS was assessed to evaluate treatment, dedifferentiation and disease-specific survival. Lastly, our experience with patients treated with AS was explored.

RESULTS

Distant metastases (5/191 patients, 2.6%) were mainly seen after a dedifferentiated local recurrence. Death of disease occurred in 4/191 patients (2.1%); two patients died from metastatic disease (although not pathologically proven), two patients died of treatment-related complications. In our center, 24 patients are treated with AS. Time of AS varied from 0.1 to 8.9 years (median 1.8). Four patients eventually underwent surgery after a period of AS (range 14-52 months) because of symptoms and/or tumor growth. No areas of dedifferentiation were found in these resection specimens. The other patients are still under active surveillance.

CONCLUSION

Since surgical treatment might induce morbidity and even mortality, there might be overtreatment of these patients. Evaluation of the natural history of extremity WDLPS showed that AS could be a reasonable option for selected patients. Prospective studies in patients with extremity WDLPS are needed to assess the safety of AS as a treatment option.

The role of surgical margins in atypical Lipomatous Tumours of the extremities

Background

Atypical lipomatous tumours (ALT) are common adipocytic tumours. Due to their large size and deep-seated location, wide resection might result in severe functional deficits. The question which margins should be aimed is hence discussed controversially.

Methods

Forty consecutive patients underwent limb-sparing resections. Margins were defined as R0 (wide resection), R1 (marginal resection) or R2 if tumour was left. All patients were followed for evidence of local recurrence or remote metastases. Overall and recurrence-free survival was calculated.

Results

The mean age at the time of surgery was 61.9 years. The mean tumour diameter was 17 cm with no patient having metastatic disease. In 8 cases a wide (R0) resection, in 31 cases a marginal (R1) and in one patient a R2-resection was performed. The median follow-up time was 40 months. Four patients died due to causes that were not tumour-related. 3 (7.5%) patients (all R1) developed local recurrences. Two of our 3 recurrences in this series occurred in 6 already recurring cases. We observed no dedifferentiation of tumours and no metastatic disease.

Conclusions

ALT represents a comparatively common diagnosis in large deep-seated lesions of the extremities, especially in patients over 60 years. Marginal resection shows an acceptable rate of local recurrence. The risk of dedifferentiation as proven also in a metaanalysis of the English literature of the last 30 years is close to 1%, metastatic disease is exceedingly rare.

Reliability and Validity of the Musculoskeletal Tumor Society Scoring System for the Upper Extremity in Japanese Patients

BACKGROUND

The Musculoskeletal Tumor Society (MSTS) scoring system developed in 1993 is a widely used disease-specific evaluation tool for assessment of physical function in patients with musculoskeletal tumors; however, only a few studies have confirmed its reliability and validity.

QUESTIONS/PURPOSES

The aim of this study was to validate the MSTS scoring system for the upper extremity (MSTS-UE) in Japanese patients with musculoskeletal tumors for use by others in research. Does the MSTS-UE have: (1) sufficient reliability and internal consistency; (2) adequate construct validity; and (3) reasonable criterion validity in comparison to the Toronto Extremity Salvage Score (TESS) or SF-36?

METHODS

Reliability was performed using test-retest analysis, and internal consistency was evaluated with Cronbach's alpha coefficient. Construct validity was evaluated using a scree plot to confirm the construct number and the Akaike information criterion network. Criterion validity was evaluated by comparing the MSTS-UE with the TESS and SF-36.

RESULTS

The test-retest reliability with intraclass correlation coefficient (0.95; 95% CI, 0.91-0.97) was excellent, and internal consistency with Cronbach's α (0.7; 95% CI, 0.53-0.81) was acceptable. There were no ceiling and floor effects. The Akaike Information Criterion network showed that lifting ability, pain, and dexterity played central roles among the components. The MSTS-UE showed substantial correlation with the TESS scoring scale (r = 0.75; p < 0.001) and fair correlation with the SF-36 physical component summary (r = 0.37; p = 0.007). Although the MSTS-UE showed slight correlation with the SF-36 mental component summary, the emotional acceptance component of the MSTS-UE showed fair correlation (r = 0.29; p = 0.039).

CONCLUSIONS

We can conclude that the MSTS is not an adequate measure of general health-related quality of life; however, this system was designed mainly to be a simple measure of function in a single extremity. To evaluate the mental state of patients with musculoskeletal tumors in the upper extremity, further study is needed.

UK guidelines for the management of soft tissue sarcomas

Soft tissue sarcomas (STS) are rare tumours arising in mesenchymal tissues, and can occur almost anywhere in the body. Their rarity, and the heterogeneity of subtype and location means that developing evidence-based guidelines is complicated by the limitations of the data available. However, this makes it more important that STS are managed by teams, expert in such cases, to ensure consistent and optimal treatment, as well as recruitment to clinical trials, and the ongoing accumulation of further data and knowledge. The development of appropriate guidance, by an experienced panel referring to the evidence available, is therefore a useful foundation on which to build progress in the field. These guidelines are an update of the previous version published in 2010 (Grimer et al. in Sarcoma 2010:506182, 2010). The original guidelines were drawn up following a consensus meeting of UK sarcoma specialists convened under the auspices of the British Sarcoma Group (BSG) and were intended to provide a framework for the multidisciplinary care of patients with soft tissue sarcomas. This current version has been updated and amended with reference to other European and US guidance. There are specific recommendations for the management of selected subtypes of disease including retroperitoneal and uterine sarcomas, as well as aggressive fibromatosis (desmoid tumours) and other borderline tumours commonly managed by sarcoma services. An important aim in sarcoma management is early diagnosis and prompt referral. In the UK, any patient with a suspected soft tissue sarcoma should be referred to one of the specialist regional soft tissues sarcoma services, to be managed by a specialist sarcoma multidisciplinary team. Once the diagnosis has been confirmed using appropriate imaging, plus a biopsy, the main modality of management is usually surgical excision performed by a specialist surgeon. In tumours at higher risk of recurrence or metastasis pre- or post-operative radiotherapy should be considered. Systemic anti-cancer therapy (SACT) may be utilized in some cases where the histological subtype is considered more sensitive to systemic treatment. Regular follow-up is recommended to assess local control, development of metastatic disease, and any late-effects of treatment. For local recurrence, and more rarely in selected cases of metastatic disease, surgical resection would be considered. Treatment for metastases may include radiotherapy, or systemic therapy guided by the sarcoma subtype. In some cases, symptom control and palliative care support alone will be appropriate.

Hibernoma: diagnostic and surgical considerations of a rare benign tumour

Hibernoma is a rare, benign tumour of brown fat origin. Less than 250 cases have been reported in the literature. We present a case of a 19-year-old man referred to surgical oncology for evaluation of a large soft tissue mass near the apex of his right scapula. Complete surgical excision was performed, sparing the overlying latissimus dorsi musculature. Surgical pathology revealed findings were consistent with hibernoma, grossly showing a well-encapsulated fluctuant mass measuring 21.4×14.4×5.3 cm, and histologically composed of brown fat adipocytes. The mainstay of treatment is surgical excision of the mass. Primary goals of the operation include complete removal of the mass to prevent recurrence and sparing of adjacent structures as it is a benign, non-invasive tumour. We present a case of a large chest wall hibernoma in a young adult, diagnosed on final pathology after complete surgical excision.

Atypical Lipomatous Tumors of the Extremities and Trunk Wall-The First Case Series of Chinese Population With 45 Cases

BACKGROUND

Atypical lipomatous tumor (ALT) is a low-grade, slow-growing, locally aggressive malignant mesenchymal neoplasm. ALT of the extremities and trunk wall is associated with a relatively favorable outcome. However, these tumors can still recur locally and secondary dedifferentiation after recurrence has been reported. There is currently no consensus about the optimal surgical treatment of ALT. Therefore, we aimed to clarify the clinical behavior, appropriate treatment, and outcomes of ALT of the extremities and trunk wall.

METHODS

We retrospectively reviewed the files of 45 patients treated between 2000 and 2014 with the diagnosis of atypical lipomatous tumors of the extremities and trunk wall at our institution. The median follow-up period was 84.5 months (range, 24-183 months). The patient demographics, clinical presentation, surgical methods, margin status, and administration of radiation therapy were recorded. Patients were evaluated for their local recurrence, dedifferentiation, and postoperative complications.

RESULTS

Wide resection was performed on 11 patients, and marginal resection was performed on 34 patients. Seven patients underwent adjuvant radiotherapy. The overall recurrence rate was 17.8% (8/45), and dedifferentiation rates was 0% (0/8). The mean time to local recurrence was 5.25 years (range, 2.6-10.6 years). No ALT-related deaths occurred during the follow-up period. There were no differences in recurrence-free survival for the different surgical methods (P = 0.337) and radiotherapy (P = 0.228), whereas the R0 resection had better recurrence-free survival (P = 0.031). The postoperative complication rates were higher in wide resection group than in marginal resection group. (45.5% vs 14.7%, P = 0.048).

CONCLUSIONS

Atypical lipomatous tumors of the extremities and trunk wall are associated with a favorable overall survival and do not metastasis. Although they have a tendency to recur, the risk of secondary dedifferentiation is small. Wide resection had similar recurrence rates to marginal resection, but it might lead to more complications. Therefore, marginal resection is considered appropriate for the treatment of ALTs.

The histological variants of liposarcoma: predictive MRI findings with prognostic implications, management, follow-up, and differential diagnosis

Liposarcoma is the single most common soft tissue sarcoma accounting for up to 35 % of sarcomas. It represents a histologically diverse group of soft tissue tumors that demonstrate a wide range of imaging appearances with varied behavior patterns. Correspondingly, more aggressive histological subtypes often require management that includes a combination of surgery, chemotherapy, and radiation therapy. Distinguishing among liposarcoma subtypes has important therapeutic and prognostic implications. In this manuscript, we review the liposarcoma subtypes and their histologic and MRI findings, prognostic implications, and differential diagnostic considerations.

Clinical outcome of dedifferentiated liposarcoma in the extremities: A retrospective case series of 7 patients

BACKGROUND

Wide resection is the generally recommended surgical treatment for dedifferentiated liposarcoma (DDLPS) in the extremities. However, it may be appropriate to distinguish the surgical margin of low-grade atypical lipomatous tumor (ALT)/well-differentiated liposarcoma (WDLPS) area from the high-grade dedifferentiated area, because the low- and high-grade areas can be clearly separated, both radiologically and histologically. This study re-evaluated the details of surgical margin of DDLPS in the extremities, and aimed to investigate the optimal surgical margin and the usefulness of adjuvant therapy for DDLPS in the extremities.

METHODS

Seven patients diagnosed with DDLPS in the extremities and treated between 1995 and 2013 were analyzed. The use of adjuvant therapy before and after surgery was assessed, and the surgical margins for the ALT/WDLPS and dedifferentiated areas were re-evaluated by using the specimens resected at surgery. Subsequently, the recurrence rates, metastatic rates, and oncological outcomes were examined.

RESULTS

Four and three patients had wide (adequate wide margin, n = 3; inadequate wide margin, n = 1) and marginal margins for the dedifferentiated area, respectively, while three and four patients had wide (adequate wide margin, n = 2; inadequate wide margin, n = 1) and marginal margins for the ALT/WDLPS area, respectively. Postoperative radiotherapy was performed in three patients with an inadequate wide margin or a marginal margin for the dedifferentiated area. No patient had local recurrence. Distant metastases occurred in two patients. These patients died of their disease. The other five patients were disease-free.

CONCLUSION

The ALT/WDLPS and dedifferentiated areas in the tumor margin may be better to be considered separately in determining the appropriate resection extent for DDLPS in the extremities. Postoperative radiotherapy may provide good local control for cases with a narrow surgical margin.