Treatment results and prognostic factors in patients with malignant fibrous histiocytoma

Primary Undifferentiated Pleomorphic Sarcoma of the Biceps Femoris Muscle Complicated by Hemorrhage: An Underrecognized Entity

Malignant fibrous histiocytoma currently known as undifferentiated pleomorphic sarcoma is the commonest soft tissue sarcoma of mesenchymal origin. Undifferentiated pleomorphic sarcoma is commonly located in the extremities, trunk, head and neck in decreasing order of frequency. We report a case of primary undifferentiated pleomorphic sarcoma of the biceps femoris muscle in a 50-year-old male complicated by hemorrhage. Diagnostic workup included ultrasonography, magnetic resonance imaging (MRI), histopathology and positive results on immunohistochemistry especially CD-68. High-grade liposarcoma and rhabdomyosarcoma were regarded as differential diagnoses of undifferentiated pleomorphic sarcoma. Demonstration of spontaneous hemorrhage within the lesion on follow-up ultrasonography done at one month from the time of diagnosis deserves a special mention in this report. Radical excision with tumor-free margins of the biceps femoris and tendon reconstruction was undertaken. MRI at six months follow-up did not reveal tumor recurrence at the site of surgery and CT chest did not reveal metastases.

Novel Nomograms-Based Prediction Models for Patients with Primary Undifferentiated Pleomorphic Sarcomas Resections

Simple Summary

Undifferentiated pleomorphic sarcomas (UPS) are one of the most common soft tissue sarcomas which have relatively high potentials of recurrence and metastasis. Surgery remains the mainstream treatment for UPS patients. However, in modern medicine, doctors nowadays lack proper models to tell patients the exact prognosis of individuals after they have undergone primary surgery. In this work, we for the first time develop two nomograms that are able to predict 3- and 5-year overall survival (OS) and time to recurrence (TTR) for UPS patients. These nomograms show relatively good accuracy and practicability which may contribute a lot to the modern medical decision-making process.

Abstract

Background: Undifferentiated pleomorphic sarcomas (UPS) were one of the most common soft tissue sarcomas. As UPS had relatively high potentials of recurrence and metastasis, we designed two nomograms to better predict the overall survival (OS) and time to recurrence (TTR) for patients who underwent primary surgery. Methods: The data of UPS patients who underwent primary surgery were extracted from Shanghai Cancer Center, Fudan University. Multivariate analyses were performed using Cox proportional hazards regression to identify independent prognostic factors. Kaplan–Meier analysis was used to compare differences for patients who underwent primary surgery in OS and TTR. Nomograms were designed with the help of R software and validated using calibration curves and receiver operating characteristic curves (ROC). Results: Kaplan–Meier curves showed that patients with older ages (p = 0.0024), deeper locations (p = 0.0422), necrosis (p < 0.0001), G3 French Federation Nationale des Centres de Lutte Contre le Cancer (FNCLCC) classification (p < 0.0001), higher Ki-67 (p < 0.0001), higher mitotic index (p < 0.0001), R1/R2 resections (p = 0.0002) and higher invasive depth (p = 0.0099) had shorter OS than the other patients while patients with older ages (p = 0.0108), necrosis (p = 0.0001), G3 FNCLCC classification (p < 0.0001), higher Ki-67 (p = 0.0006), higher mitotic index (p < 0.0001) and R1/R2 resections (p < 0.0001) had shorter TTR compared with those without. Multivariate analyses demonstrated that mitotic rates and surgical margin were independent factors for TTR while age and invasive depth were independent factors for OS. Three parameters were adopted to build the nomograms for 3- and 5-year OS and TTR. The Area Under Curve (AUC) of this nomogram at 3- and 5-year TTR reached 0.802, 0.814, respectively, while OS reached 0.718, 0.802, respectively. Calibration curves for the prediction of 3- and 5-year OS and TTR showed excellent agreement between the predicted and the actual survival outcomes. Conclusions: Some important parameters could be used to predict the outcome of individual UPS patients such as mitotic age, rates, surgical margin, and invasive depth. We developed two accurate and practicable nomograms that could predict 3- and 5-year OS and TTR for UPS patients, which could be involved in the modern medical decision-making process.

Nomogram for predicting cancer-specific survival in undifferentiated pleomorphic sarcoma: A Surveillance, Epidemiology, and End Results -based study

INTRODUCTION

The purpose of this study was to construct and validate a nomogram for predicting cancer-specific survival (CSS) in undifferentiated pleomorphic sarcoma (UPS) patients at 3, 5, and 8 years after the diagnosis.

METHODS

Data for UPS patients were extracted from the SEER (Surveillance, Epidemiology, and End Results) database. The patients were randomly divided into a training cohort (70%) and a validation cohort (30%). The backward stepwise Cox regression model was used to select independent prognostic factors. All of the factors were integrated into the nomogram to predict the CSS rates in UPS patients at 3, 5, and 8 years after the diagnosis. The nomogram' s performance was then validated using multiple indicators, including the area under the time-dependent receiver operating characteristic curve (AUC), consistency index (C-index), calibration curve, decision-curve analysis (DCA), integrated discrimination improvement (IDI), and net reclassification improvement (NRI).

RESULTS

This study included 2,009 UPS patients. Ten prognostic factors were identified after analysis of the Cox regression model in the training cohort, which were year of diagnosis, age, race, primary site, histological grade, T, N, M stage, surgery status, and insurance status. The nomogram was then constructed and validated internally and externally. The relatively high C-indexes and AUC values indicated that the nomogram has good discrimination ability. The calibration curves revealed that the nomogram was well calibrated. NRI and IDI values were both improved, indicating that our nomogram was superior to the AJCC (American Joint Committee on Cancer) system. DCA curves demonstrated that the nomogram was clinically useful.

CONCLUSIONS

The first nomogram for predicting the prognosis of UPS patients has been constructed and validated. Its usability and performance showed that the nomogram can be applied to clinical practice. However, further external validation is still needed.

The clinical outcomes of undifferentiated pleomorphic sarcoma (UPS): A single-centre experience of two decades with the assessment of PD-L1 expressions

INTRODUCTION

Little is known about undifferentiated pleomorphic sarcoma (UPS) because of the low incidence and heterogeneous diagnosis of sarcoma. We investigated the oncologic outcomes of patients with UPS in a real-practice setting in association with adjuvant treatments and assessment of PD-L1 expression.

MATERIALS AND METHODS

We retrospectively reviewed consecutive patients who were diagnosed with UPS in Asan Medical Center between January 1995 and December 2016. PD-L1 staining was performed using formalin-fixed paraffin-embedded tumour tissue by immunohistochemistry, and positive PD-L1 expression was defined as staining in ≥1% of tumour cells. The PD-L1 H-score, which was calculated for statistical analysis as intensity (0-3) multiplied by proportion (0-100), ranged from 0 to 300.

RESULTS

Of 205 patients included in our analysis, 176 underwent a curative-intent operation for localised disease. The five-year disease-free survival (DFS) rate of resected UPS patients was 54.3%. Administration of adjuvant therapy did not overcome the poor prognostic factors such as primary tumour size (>5 cm) and locations, especially the abdomen and pelvis. The PD-L1 analysis was available for 114 patients, and 83 (72.8%) showed immunoreactivity for PD-L1 with weak (44/83), intermediate (29/83), and strong (10/83) staining intensities. The positive PD-L1 expression seemed to be associated with prolonged DFS, though no statistical significance was observed.

CONCLUSION

Complete surgical resection was the most important UPS treatment strategy, and adjuvant radio- or chemotherapy was insufficient to improve survival. Our results raise the possibility that immunotherapy could be a breakthrough in the treatment of UPS patients.

Undifferentiated Pleomorphic Sarcoma: Long-Term Follow-Up from a Large Institution

Purpose

Our study aimed to describe the clinical features of undifferentiated pleomorphic sarcoma (UPS) and identify the predictors of poor outcomes.

Patients and methods

The clinicopathological variables and treatment strategies of 100 UPS patients who underwent surgical resections at a single institution between November 2004 and July 2016 were reviewed. Kaplan–Meier and Cox regression method were conducted for survival analysis.

Results

The median follow-up time was 94 months (range, 1.5–154 months). R0 resection was applied for 72 cases, and the median tumor size was 5.75cm (range, 1–30cm). Tumor grades of 45 patients were intermediate grade (G2), and 54 patients were with advanced stage (stage III/IV). Twenty-seven patients presented with tumors involving important structures, in which the nerve was the most frequently invaded structure (n=12). During the follow-up, 40 patients suffered from postoperative local recurrence, and distant metastasis was observed in 25 patients which mainly metastasized to the lung (n=14). The 5-year OS rate, 5-year LRFS rate, and 5-year MFS rate was 53%, 55%, and 70%, respectively. Multivariate analysis revealed that tumor presentation, tumor size, and important structures involved (p=0.033, p=0.004, and p=0.033, respectively) were independent prognostic factors associated with OS. Meanwhile, age, resection quality and tumor grade were independent prognostic factors for LRFS (p=0.033, p=0.045, and p=0.007, respectively) and tumor depth was significantly associated with MFS (p=0.050) in multivariate analysis.

Conclusion

Primary treatment of UPS should be conducted by experts in large sarcoma center. Wide surgical margin provides sufficient control of the disease recurrence.

Predicting the prognosis of undifferentiated pleomorphic soft tissue sarcoma: a 20-year experience of 266 cases

BACKGROUND

Undifferentiated pleomorphic sarcoma (UPS) is a rare malignant tumour of mesenchymal origin, which was conceived following re-classification of malignant fibrous histiocytoma (MFH). The objective of this study is to determine prognostic factors for the outcome of UPS, following multi-modal treatment.

METHODS

Data of UPS tumours from 1996 to 2016 were collected, totalling 266 unique UPS patients. Median follow-up was 7.8 years. All tumours were retrospectively analysed for prognostic factors of the disease, including local recurrence (LR) and metastatic disease (MD) at diagnosis, tumour size, grade, location and depth, patient age, adjuvant therapy and surgical margin. Overall survival (OS), post-treatment LR and metastatic-free survival were assessed as outcomes.

RESULTS

The 5- and 10-year OS rates for all ages were 60% and 48%, respectively, with a median survival time of 10.1 years. Multivariate analysis revealed that the adverse prognostic factors associated with decreased OS were older age (P < 0.001; hazard ratio 1.03) and MD at diagnosis (P = 0.001; 2.89), with upper extremity tumours being favourable (P = 0.043; 2.30). Poor prognosis for post-operative LR was associated with older age (P = 0.046; 1.03) and positive surgical margins (P = 0.028; 2.68). Increased post-treatment MD was seen in patients with large tumours (5-9 cm (P < 0.001; 4.42), ≥10 cm (P < 0.001; 6.80)) and MD at diagnosis (P < 0.001; 3.99), adjuvant therapy was favourable, shown to reduce MD (P < 0.001; 0.34).

CONCLUSIONS

UPS is a high-grade soft tissue sarcoma, for which surgery striving for negative margins, with radiotherapy, is the treatment of choice. Older age, lower extremity location, MD at presentation, large size and positive surgical margins, were unfavourable.

Management of undifferentiated high-grade pleomorphic sarcoma of parotid region in elderly women

Undifferentiated high-grade pleomorphic sarcoma is a slow-growing tumor rarely localized in the head and neck region. The treatment of UHPS should be based on large surgical resections in free margins associated with neck dissection. Postoperative radiotherapy improves local control of the disease and the prognosis quod vitam.

Malignant fibrous histiocytoma in a patient presenting with urinary system symptoms

Malignant fibrous histiocytoma is a rare tumor. It is most commonly seen in individuals between the fifth and seventh decades of life, in extremities, and less frequently in the retroperitoneum. Although its etiology is not clearly known, radiotherapy, chemical agents, previous history of surgery, trauma and fracture, and Hodgkin lymphoma have been blamed. Leiomyosarcoma, liposarcoma and rhabdomyosarcoma should be taken into account in differential diagnosis. It is seen on computed tomography as a mass lesion with irregular borders and density similar to that of the surrounding muscle tissue. Necrotic and hemorrhagic components in the mass are characterized as heterogeneous low density areas. Fluid-fluid levels can be detected by computed tomography and magnetic resonance imaging.

Evaluation of prognostic factors in localized high-grade undifferentiated pleomorphic sarcoma: report of a multi-institutional experience of Anatolian Society of Medical Oncology

Most data on prognostic factors for patients with high-grade undifferentiated pleomorphic sarcoma (HGUPS) is obtained from analyses of soft tissue sarcomas. The purpose of this study was to evaluate the clinicopathologic features and their impact on outcomes specifically in patients diagnosed with HGUPS. In this multicenter trial, we retrospectively analyzed 112 patients who were diagnosed and treated at 12 different institutions in Turkey. We collected data concerning the patients, tumor characteristics, and treatment modalities. There were 69 males (61.6 %) and 43 females (38.4 %). Median age was 56 years (19-90). The most common anatomic site of tumor origin was the upper extremity. Pleomorphic variant was the predominant histological subtype. Median tumor size was 8.2 cm (0.6-30 cm). Tumors were mainly deeply seated (57.1 %). Fifty-seven patients (50.9 %) were stage II and the remainder were stage III at the time of diagnosis. Median follow-up was 30 months (2-160). The primary site of distant metastasis was the lung (73.5 %) and the second most common site was the liver (11.7 %). The 5-year overall survival, distant metastasis-free survival, and local recurrence-free survival rates were 56.3, 53.4, and 67.2 %, respectively. Multivariate analysis showed that Eastern Cooperative Oncology Group (ECOG) performance score of II (p = 0.033), deep tumor location (p = 0.000), and development of distant metastasis (p = 0.004) were negatively correlated with overall survival, and perioperative radiotherapy and negative microscopic margins were significant factors for local control rates (p = 0.000 for each). Deep tumor location (p = 0.003) was the only adverse factor related to distant metastasis-free survival. Deep tumor location, ECOG performance score of II, and development of distant metastasis carry a poor prognostic implication on overall survival. These will aid clinicians in predicting survival and treatment decision.

Role of matrix metalloproteinase (MMP) 2 and MMP-9 in soft tissue sarcoma

Background

We investigated the expression of matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) in malignant fibrous histiocytoma (MFH), and determined whether these could be useful as prognostic factors.

Methods

Among patients treated from 1993 to 2007, 30 cases of MFH were evaluated. Immunohistochemical staining was performed for MMP-2, MMP-9, TIMP-1, and TIMP-2 using paraffin wax-embedded blocks of MFH tissues. Reverse transcriptase polymerase chain reaction (RT-PCR) and Western blot and zymography were performed using fresh tissues obtained from 17 of the 30 cases. The levels of MMP and TIMP expression were compared between the MFH and normal control groups, and between non-metastatic and metastatic MFH groups.

Results

Expression levels of MMP-2, MMP-9, TIMP-1, and TIMP-2 were higher in the MFH group than the control group by RT-PCR, Western blotting, and zymography. Immunohistochemical staining revealed that MMP-2 and MMP-9 protein expression was higher in the metastatic than in the non-metastatic group. The expression levels of MMP-2 and TIMP-1 were significantly higher in the metastatic than in the non-metastatic group (p < 0.05) by RT-PCR. By Western blot analysis, the expression levels of MMP-2, TIMP-1, and TIMP-2 were higher in the metastatic group (p < 0.05), but MMP-9 showed only a slight increase in the metastatic group compared with the non-metastatic group (p > 0.05). Finally, gelatin zymography analysis showed that the expression levels of the pro- and active forms of MMP-2 were significantly higher in the metastatic group (p < 0.05), but the expression of the pro- and active forms of MMP-9 showed a slight decrease in the metastatic group (p > 0.05).

Conclusions

These results suggest that MMP-2, MMP-9, TIMP-1, and TIMP-2 may have important roles in the development and progression of MFH, and that the degree of expression of these metalloproteinases and their inhibitors, especially MMP-2, could be useful as prognostic factors related to metastasis in MFH.

Surgical treatment and prognosis in patients with high-grade soft tissue malignant fibrous histiocytoma of the extremities

BACKGROUND

Malignant fibrous histiocytoma (MFH) of soft tissue is one of the most common sarcoma in adulthood. However, only a few series have separately studied the clinical behavior and prognosis of this malignancy.

METHODS

We retrospectively reviewed 61 patients treated for extremity soft tissue high-grade MFH. Four patients had a history of another malignancy and were excluded from analysis. In 12 referred patients with incomplete excision, re-excision of the tumor bed was offered. Clinical and treatment variables were analyzed for their impact on treatment complications, local recurrence (LR), metastatic disease (MD) and overall survival (OS).

RESULTS

Four patients underwent primary amputation. Twenty-three patients necessitated a primary reconstructive procedure for wound closure. Wound healing complication (WHC) developed in 28.3 % of the limb sparing group of patients. LR developed in 11 patients (19.3 %), while 6 of them had second LR. Eighteen patients (31.5 %) developed MD, involving lung at least. Patients who developed MD <12  vs >12 months, died within 19.3 vs 8 months mean time (p < 0.05). Overall survivorship was 66.7 % at 5 years. No statistically significant variables were identified for LR, while multivariate analysis for MD revealed tumor size >5 cm as the only statistically significant variable. For OS, development of MD and age >70 years emerged as independent prognostic factors.

CONCLUSIONS

The overall prognosis is poor. LR, although can be managed with tumor re-excision, has high second recurrence rate. Increased tumor size is associated with shorter metastasis-free interval which significantly decreases survival.

Conservative treatment of malignant fibrous histiocytoma of the kidney: a case report

Primary renal malignant fibrous histiocytoma is an extremely rare disease. There are neither clinical nor radiological signs to distinguish it from the most common renal cell carcinoma. Its prognosis is poor because of its tendency to locally recur and metastasize. Therefore, early diagnosis and proper treatment are very important. We present the case of a 66-year-old woman diagnosed with primary renal malignant fibrous histiocytoma who underwent partial nephrectomy. After 41 months' follow-up, there was no evidence of any recurrence. To our knowledge, this is the first reported case of conservative surgery for this kind of tumor.

Malignant fibrous histiocytoma of the head and neck: CT and MR imaging findings

BACKGROUND AND PURPOSE

Malignant fibrous histiocytoma (MFH) is uncommon in the head and neck. The purpose of this study was to investigate CT and MR imaging features of 13 cases of MFH of this area.

MATERIALS AND METHODS

Two head and neck radiologists, in consensus, retrospectively reviewed CT (n = 11) and MR (n = 9) images in 13 patients (9 men and 4 women; mean age, 45 years) with histologically proved MFH of the head and neck, paying attention to the location and extent, size, margin, internal architecture, and pattern and degree of enhancement of the lesion. We also investigated if there were any differences in signal-intensity characteristics on MR images, according to different histologic subtypes.

RESULTS

All lesions were seen as well-defined (n = 2) or ill-defined (n = 11), aggressive masses with a mean size of 4.9 cm. The tumors were primarily located in the sinonasal cavity in 6, the soft tissue of the face and neck in 5, the oral cavity in 1, and the orbital roof in 1. One lesion arose in the bones with background fibrous dysplasia. Twelve lesions invaded the adjacent soft tissues, and bone destruction was seen in 11 lesions. The attenuation, signal intensity, and enhancement pattern of the lesions were nonspecific except for those of myxoid MFH.

CONCLUSIONS

Although rare, MFH of the head and neck is an aggressive tumor that arises most commonly in the sinonasal tract and is frequently associated with soft-tissue invasion and bone destruction on CT and MR images.

Malignant fibrous histiocytoma of the bucca: a case report

Malignant fibrous histiocytoma (MFH) is the most common soft-tissue sarcoma, but is relatively uncommon in head and neck area. Histologically, it is difficult to distinguish this tumor from other sarcomas and carcinomas. Surgery is the most reliable treatment for MFH, but the 5-year survival rate for cases of this tumor in the head and neck is low in comparison with MFH of the extremities and trunk. In the case reported here, the patient was a 61-year-old man who presented with swelling and pain of the left bucca. A CT scan demonstrated a 2.5 cm x 5.0 cm inhomogeneous lesion. In MRI, the tumor displayed an inhomogeneous isointense signal on T1-weighted images and a high-intensity signal on T2-weighted images. Fine-needle aspiration (FNA) was performed twice but we were unable to reach a definitive diagnosis histologically. MFH was subsequently diagnosed by open biopsy, and external radiotherapy with 38 Gy of radiation was performed. However, the tumor enlarged after this therapy, and therefore CyberKnife therapy was performed twice, after which the tumor gradually reduced in size. The patient is alive after a follow-up period of 22 months, and therefore we suggest that CyberKnife treatment may be useful for head and neck MFH.

Surgical management of sarcomas

Nearly all bone and soft tissue sarcomas will require surgical management. Early consultation with a surgeon who is experienced in sarcomas, before a biopsy is performed, will avoid potential errors that may complicate subsequent surgery. Advances in imaging, neoadjuvant therapies, and reconstructive techniques have improved the ability to resect adequately most bone and soft tissue sarcomas. The use of oncologic and functional outcomes assessment tools facilitates the development of improved treatments for sarcoma patients. Results from major centers reveal that most patients who have a nonmetastatic bone or soft tissue sarcoma will survive 5 years after surgery when combined with either chemotherapy or radiation.