Cutaneous leiomyosarcoma

[Cutaneous and subcutaneous primary leiomyosarcoma: A retrospective cohort of 26 cases examining clinical data and treatments]

BACKGROUND

Superficial leiomyosarcoma is a rare malignant soft tissue tumor arising from smooth muscle cells, accounting for 2-3% of superficial sarcomas, with limited literature available on the subject. It is typically observed in patients aged 50-60 years and affects both men and women equally in the subcutaneous subtype, whereas the cutaneous subtype predominantly affects men.

OBJECTIVE

This study aims to examine the clinicopathological features and therapeutic outcomes of patients with leiomyosarcoma.

METHOD

This is a descriptive retrospective study of 26 cases of cutaneous and subcutaneous leiomyosarcomas, with histological confirmation.

RESULTS

We identified 10 (38.5%) subcutaneous leiomyosarcomas and 16 (61.5%) cutaneous leiomyosarcomas. The majority of tumors were located in the lower limbs, accounting for 13 (50%) cases. During follow-up, 6 patients experienced recurrence, and 7 developed metastases, including 2 of the 7 patients who had R0 resection margins. Among these, 3 out of the 6 recurrent cases and 3 out of the 7 metastatic cases were subcutaneous leiomyosarcomas. The average time to recurrence was 6.2 years.

CONCLUSION

The observed risk of metastases and recurrences, despite clear surgical margins, in both cutaneous and subcutaneous leiomyosarcomas, along with the delayed onset of these events, justifies prolonged patient follow-up. The lungs, bones and liver have been identified as the most common site of metastasis.

Proteomic characterization identifies clinically relevant subgroups of soft tissue sarcoma

Soft tissue sarcoma is a broad family of mesenchymal malignancies exhibiting remarkable histological diversity. We portray the proteomic landscape of 272 soft tissue sarcomas representing 12 major subtypes. Hierarchical classification finds the similarity of proteomic features between angiosarcoma and epithelial sarcoma, and elevated expression of SHC1 in AS and ES is correlated with poor prognosis. Moreover, proteomic clustering classifies patients of soft tissue sarcoma into 3 proteomic clusters with diverse driven pathways and clinical outcomes. In the proteomic cluster featured with the high cell proliferation rate, APEX1 and NPM1 are found to promote cell proliferation and drive the progression of cancer cells. The classification based on immune signatures defines three immune subtypes with distinctive tumor microenvironments. Further analysis illustrates the potential association between immune evasion markers (PD-L1 and CD80) and tumor metastasis in soft tissue sarcoma. Overall, this analysis uncovers sarcoma-type-specific changes in proteins, providing insights about relationships of soft tissue sarcoma.

Subcutaneous Leiomyosarcoma: An Aggressive Malignancy Portending a Significant Risk of Metastasis and Death

Subcutaneous leiomyosarcoma (LMS) is a rare, poorly understood variant. The current literature on the subject is sparse, consisting of isolated case reports and small clinicopathologic studies compromised by the inclusion of both its more common and indolent counterpart, cutaneous LMS (atypical intradermal smooth muscle neoplasm), as well as highly aggressive deep-seated tumors. Thus, precise clinicopathologic characterization is limited. Cases of subcutaneous LMS reviewed at the University of Michigan and Cleveland Clinic from 1994 to 2022 were included in this retrospective study. A total of 39 cases were identified. The mean age was 61 years, and the cohort was predominantly male (23/39; 59%). Tumors averaged 4.2 cm and most commonly arose on the extremities (32/39; 82%). The majority (38/39; 97%) were diagnosed at an early pathologic stage (pT1 or pT2). Histopathologically, most tumors were well-circumscribed and were assigned a Fédération Nationale des Centers de Lutte Contre le Cancer grade of either 1 or 2 (24/39; 62%). The majority (22/39; 56%) appeared to arise in association with a blood vessel. Of the 36 cases with accessible clinical data and follow-up (mean 34 mo, range 0 to 94 mo), 12 (33%) were noted to have metastasized, with the lung representing the most common anatomic location. One case recurred locally. Six of 36 patients (17%) died from the disease at an average of 47 months after diagnosis (range 16 to 94 mo). Metastasis or death from disease was significantly associated with the Fédération Nationale des Centers de Lutte Contre le Cancer grade ( P =0.0015), the presence of necrosis ( P =0.032), tumor size ( P =0.049), and AJCC tumor stage ( P =0.036). These data demonstrate that subcutaneous LMS are more aggressive than dermal-based tumors and have a prognosis akin to that of deep-seated LMS.

Frontal cutaneous leiomyosarcoma: A case report and review of the literature

Sarcomas are a heterogeneous group of mesenchymal tumours that can affect the skin. They are dominated by Kaposi's sarcoma and dermatofibrosarcoma. Cutaneous leiomyosarcoma is a very rare entity. We report the case of a 78-year-old patient who presented with a primary frontal cutaneous leiomyosarcoma treated surgically with a good outcome at the last follow-up. The objective of this work is to identify the epidemiological, clinical, anatomopathological, therapeutic and prognostic particularities of this pathology through a review of the literature.

Clinical update on cutaneous and subcutaneous sarcomas

BACKGROUND

Cutaneous sarcomas are uncommon cancers that can have a wide range of clinical symptoms and lead to considerable cutaneous as well as systemic morbidity.

AIM

The objective of this review article is to discuss epidemiology, clinical features, diagnosis, and therapy of different types of cutaneous sarcomas.

MATERIAL AND METHODS

Literature was screened to retrieve articles from PubMed/Medline and Google Scholar and related websites. Cross-references from the relevant articles were also considered for review. Review articles, clinical studies, systematic reviews, meta-analyses, and relevant information from selected websites were included.

RESULTS AND DISCUSSION

Cutaneous sarcomas have a negative effect on the quality of life. In their diagnosis, clinical presentation and histological evaluation are crucial. Complete surgical removal is the solution for more or less all cutaneous and subcutaneous sarcomas. The prognosis for cutaneous sarcomas is generally favorable since they tend to recur locally with distant metastases only on rare occasions. Patients having advanced disease should be treated in the setting of clinical trials if possible; choices include radiation therapy and systemic medicines. The value of innovative immunotherapy cannot be determined decisively at this time due to a paucity of relevant trials.

CONCLUSION

As cutaneous sarcomas are rarely diagnosed based on clinical findings, histology plays an important role in the diagnosis. They have a relatively favorable prognosis if treated properly. Patients should be treated at specialized centres.

A Multidisciplinary Approach to Complex Dermal Sarcomas Ensures an Optimal Clinical Outcome

Primary dermal sarcomas (PDS) belong to a highly clinically, genetically and pathologically heterogeneous group of rare malignant mesenchymal tumours primarily involving the dermis or the subcutaneous tissue. The tumours are classified according to the mesenchymal tissue from which they originate: dermal connective tissue, smooth muscle or vessels. Clinically, PDS may mimic benign soft tissue lesions such as dermatofibromas, hypertrophic scarring, etc. This may cause substantial diagnostic delay. As a group, PDS most commonly comprises the following clinicopathological forms of dermal sarcomas: dermatofibrosarcoma protuberans (DFSP), atypical fibroxanthoma (AFX), dermal undifferentiated pleomorphic sarcoma (DUPS), leiomyosarcoma (LMS), and vascular sarcomas (Kaposi’s sarcoma, primary angiosarcoma, and radiation-induced angiosarcoma). This clinical entity has a broad spectrum regarding malignant potential; however, local aggressive behaviour in some forms causes surgical challenges. Preoperative, individualised surgical planning with complete free margins is pivotal along with a multidisciplinary approach and collaboration across highly specialised surgical and medical specialties. The present review gives a structured overview of the most common forms of dermal sarcomas including surgical recommendations and examples for advanced reconstructions as well as the current adjunctive medical treatment strategies. Optimal aesthetic and functional outcomes with low recurrence rates can be achieved by using a multidisciplinary approach to complex dermal sarcomas. In cases of extended local tumour invasion in dermal sarcomas, advanced reconstructive techniques can be applied, and the interdisciplinary microsurgeon should be an integral part of the sarcoma board.

A Case of Submandibular Leiomyosarcoma, Mimicking an Abscess, in a Ball Python (Python regius)

A two-year-old ball python with a submandibular mass was evaluated. Fine needle aspiration resulted in debris containing purulent materials and bacterial cells on cytology. Radiography demonstrated multi-focal radiopaque lesions in the mass, which were suspected to be mineralization; there was an absence of mandibular invasion or lung involvement. Gross examination of the surgically excised mass revealed a multi-nodular, well-circumscribed lesion with purulent material. The postoperative recovery was uneventful. The histopathological examination followed by immunohistochemistry analysis gave a diagnosis of leiomyosarcoma. As tumors containing purulent materials can be confused with an abscess, diagnostic confirmation with various diagnostical tools should be considered.

Piloleiomyosarcoma in cats: Histological and immunohistochemical features

This study describes the histomorphology and immunohistochemical profile of 9 cases of feline piloleiomyosarcoma. Cats ranged in age from 7 to 16 years (mean 10), and tumors were 7 to 24 mm in diameter (mean 15). Tumors were composed of fusiform cells that were haphazardly arranged or in variably sized interwoven bundles. Neoplastic cells had eosinophilic and fibrillar cytoplasm, and elongated blunt-ended nuclei. Entrapment of hair follicles and absence of vascular components support an origin from the smooth muscle cells of the arrector pili. Additional findings included bizarre nuclei and giant cells (7/9 cases), atypical mitoses (7/9 cases), ulceration (3/9 cases), and intratumoral necrosis (6/9 cases). Neoplastic cells expressed calponin, desmin, α-smooth muscle actin, and vimentin, but not CD18, CD31, cytokeratins, glial fibrillary acidic protein, neuron-specific enolase, Melan A, p63, or S-100 protein. Surgical excision was curative in 6/9 cases, with local recurrence in 2/9 cases and metastasis to local lymph nodes in 1/9 case. Clinical outcome was influenced by mitotic count, infiltration of subcutaneous tissue, and intensity of nuclear immunolabeling for p53.

Primary Cutaneous Leiomyosarcoma of the Lower Extremity: A Case Report and Literature Review

Cutaneous leiomyosarcoma is a rare soft-tissue sarcoma that appears non-specific clinically and often is misdiagnosed as squamous cell carcinoma. We report the case of a 59-year-old Caucasian male with a grade I leiomyosarcoma tumor on his lower extremity with no previous history of local trauma. The tumor is composed of highly atypical spindle cells with pleomorphic nuclei and mitotic activity on hematoxylin and eosin stains. The diagnosis is confirmed with immunohistochemistry staining positive for smooth muscle actin, vimentin, and desmin. Due to high recurrence rates, the prognosis for leiomyosarcomas remains poor and requires close follow-up to prevent progression.

Cutaneous Sarcomas

Cutaneous sarcomas represent a rare group of tumors presenting in the head and neck. In this article, we discuss specific sarcoma tumor types and their presentation, pathogenesis, histologic findings, and management recommendations. Tumors to be reviewed include dermatofibrosarcoma protuberans, atypical fibroxanthoma, pleomorphic dermal sarcoma, cutaneous leiomyosarcoma, and angiosarcoma.

Cutaneous leiomyosarcoma: dermal and subcutaneous

BACKGROUND AND OBJECTIVES

Leiomyosarcoma of skin (LMS) can be sub-classified on pathology appearances as Dermal or Subcutaneous. The aim of this study was to provide treatment recommendations for these uncommon tumours.

METHODS

A retrospective review of all patients with dermal and subcutaneous leiomyosarcoma managed at the Peter MacCallum Cancer Centre, Australia from January 2003 to December 2018 was performed. Eighty-three patients were identified (64 dermal leiomyosarcoma, 19 subcutaneous leiomyosarcoma).

RESULTS

Subcutaneous leiomyosarcoma were larger (median size 14 mm dermal, 49 mm subcutaneous, P = 0.01). No patient with a dermal leiomyosarcoma developed metastatic disease compared to 4 of the 19 subcutaneous leiomyosarcoma (5-year overall survivals, 98% and 88%, respectively, P = 0.03). The most common site of metastasis was to the lung. No difference in risk of local recurrence was apparent (5-year recurrence-free survivals were 85% and 78%, respectively, P = 0.17). Adjuvant radiotherapy was used in 16 (25%) dermal leiomyosarcoma patients and 13 (68%) subcutaneous leiomyosarcoma patients (P < 0.001). Local recurrence was uncommon in both tumour subtypes when patients received definitive surgical excision (minimum histological margins of 10 mm as per institutional protocol) regardless of whether radiotherapy was used. The 5-year local recurrence-free survival for dermal leiomyosarcoma treated with radiotherapy was 93% versus 83% without radiotherapy (P = 0.7) and for subcutaneous leiomyosarcoma was 69% and 100%, respectively (P = 0.9).

CONCLUSIONS

Dermal leiomyosarcoma have an excellent prognosis, particularly after definitive surgical excision with margins of at least 10 mm. Subcutaneous leiomyosarcoma has poorer outcomes and should be managed by wider excision and considered for adjuvant radiotherapy.

Clear-cell variant of superficial cutaneous leiomyosarcoma associated with RB1 mutation: Clinical, dermoscopic, and histopathological characteristics

Leiomyosarcoma is a relatively rare soft tissue tumor whose clear-cell variant has only been reported in leiomyosarcomas of the uterus. We report here for the first time a primary cutaneous clear-cell leiomyosarcoma in the trunk skin of a 49-year-old man, characterized by a very indolent clinical and dermoscopic presentation, mimicking a dermatofibroma. Genetic analysis of the otherwise healthy patient revealed a germline mutation in the retinoblastoma 1 gene (RB1); the same mutation was found in his son, who had previously developed retinoblastoma. Moreover, the mother of the patient had died of uterine leiomyosarcoma with clear-cell changes. Mutations in the RB1 gene occur commonly in human neoplasms. In this patient, we were able to link his clear-cell variant of cutaneous leiomyosarcoma with the loss of retinoblastoma protein expression, as revealed by immunohistochemical staining analysis.

Leiomyosarcoma of the skin: review of the literature with an emphasis on prognosis and management

Leiomyosarcoma (LMS) of the skin is rare, and no management guideline currently exists. Although LMS is historically classified as either dermal (cutaneous) or subcutaneous, definition for its classfication is inconsistent in the literature. Studies on the managenent of LMS are scarce, and there is no consensus on the appropriate surgical margin for the treatment of LMS. While a 1 cm margin may be sufficient in cutaneous LMS, wider margins may be required for subcutaneous tumors. Mohs micrographic surgery is a promising surgical modality for the treatment of cutaneous LMS. In this review, current knowledge on LMS is summarized and a practical approach to the management of this rare neoplasm is proposed.

Leiomyosarcoma and Pleomorphic Dermal Sarcoma: Guidelines for Diagnosis and Treatment

There are 3 types of leiomyosarcoma of the skin: dermal, subcutaneous, and metastatic cutaneous. Dermal leiomyosarcoma arises from smooth muscle fibers in arrector pili muscles, genital dartos muscles, and the nipple-areola complex. It is an intermediate-grade tumor associated with a tendency for local recurrence (24%) and low metastatic potential (4%). Subcutaneous leiomyosarcoma originates from smooth muscle in blood vessel walls and has higher rates of local recurrence (37%) and metastasis (43%). Plemorphic dermal sarcoma typically affects elderly patients and arises in sun-exposed areas (e.g., the scalp). Its histologic and immunohistochemical characteristics are similar to those of atypical fibroxanthoma, but it is more aggressive (metastasis rate of 10-20%). Histologically, it can be distinguished from atypical fibroxanthoma by the observation of subcutaneous tissue invasion, perineural invasion, and foci of necrosis.

Cutaneous Smooth Muscle Tumors: A Review

Smooth muscle tumors occur infrequently in the skin. They consist of a diverse group of lesions representing hamartomas as well as benign and malignant neoplasms. They may arise from arrector pili muscle, specialized smooth muscle of the genitalia, or vascular smooth muscle. Although rare, accurate diagnosis and classification of cutaneous smooth muscle proliferations is important as they can exhibit a range of clinical behavior and may be associated with underlying syndromes. This review summarizes the clinicopathologic spectrum of smooth muscle tumors involving the skin.

Immunoexpression of p53 in cutaneous and subcutaneous leiomyosarcomas

The diagnosis of malignancy in cutaneous and subcutaneous smooth muscle tumors is based on subtle criteria. Therefore, any ancillary technique useful in this differential diagnosis is always welcome. In this report, we study the immunoexpression of p53 in 19 malignant smooth muscle tumors of the skin (15 cutaneous leiomyosarcomas, 2 subcutaneous leiomyosarcomas, and 2 cutaneous metastases of leiomyosarcoma), as well as in 1 leiomyoma with cellular atypia, therefore complementing a previous study on p53 immunoexpression in leiomyomas of the skin. The p53 staining was positive in 12 (63.16%) of 19 leiomyosarcomas. Percentages of immunostaining in the positive cases varied from 2% to 95%. Ten (66.66%) of 15 cutaneous leiomyosarcomas were positive for p53, and in 4 of these cases, immunoexpression was demonstrated by more than 50% of the cells. Five (33.33%) cutaneous leiomyosarcomas did not show any expression of p53. Of the 2 subcutaneous leiomyosarcomas, one was negative for p53 and the other expressed the marker in 70% of the cells. The only atypical leiomyoma included in the study did not express p53. Of the 2 cutaneous metastases of leiomyosarcoma, one was negative and the other expressed p53 in 20% of the cells. The current study supports our previous conclusions that p53 immunoexpression in more than 1% of the cells in a cutaneous smooth muscle tumor is indicative of malignancy. However, we believe that additional studies on atypical leiomyoma are needed.

Primary Cutaneous Leiomyosarcoma: A Clinicopathological and Immunohistochemical Study of 7 Cases

Primary cutaneous leiomyosarcomas are rare tumors, few series being reported in the current literature. A retrospective study of 7 cases was undertaken to understand the clinicopathological characteristics of these neoplasms and some of their molecular mutations. Histologically, a well-differentiated proliferation of cells of smooth muscle derivation was evident in all cases. The number of mitoses was considered the most important criterion of malignancy (more than 2 for 10 HPF). Smooth muscle actin, desmin, and vimentin were positive in all cases. Immunohistochemical analysis also revealed a positivity for p53 in 3 cases and no reaction for retinoblastoma protein. Research for Epstein-Barr virus was negative in all cases. Three patients developed local recurrences owing to incomplete surgical excision. Recurrent tumors were more atypical and located deeper. No distant metastases were observed. Our results emphasize that cutaneous leiomyosarcomas have an indolent biological course if treated by surgical excision with wide margins. Molecular abnormalities involving tumor suppressor genes are probably involved.

Cutaneous metastasis from anaplastic thyroid carcinoma exhibiting exclusively a spindle cell morphology. A case report and review of literature

Anaplastic thyroid carcinoma is a highly aggressive cancer accounting for 1-2% of thyroid malignancies. Cutaneous metastases from anaplastic thyroid carcinoma are exceedingly rare. We report a 65-year-old woman with anaplastic thyroid carcinoma (BRAF V600E mutation) who had lymph node metastases (pT4 N1b) treated by total thyroidectomy, postoperative radiotherapy, adjuvant chemotherapy (paclitaxel and pazopanib) and targeted therapy (vemurafenib). Nine months after initial diagnosis, radiographic studies revealed multiple pulmonary metastases. A dermatologic examination showed a solitary 1.2-cm chest nodule. Skin biopsy from this nodule revealed infiltrative dermal spindle cells arranged in poorly formed fascicles. Immunohistochemical studies demonstrated the tumor cells to be PAX-8 (+), pancytokeratin (+, focally), TTF-1 (-) and SOX-10 (-). Comparison with the patient's primary anaplastic thyroid carcinoma revealed focal areas of poorly differentiated spindle cells morphologically similar to the malignant spindle cells in the skin biopsy. Together, these findings confirmed the diagnosis of anaplastic thyroid carcinoma metastatic to skin. Cutaneous metastasis of anaplastic thyroid carcinoma composed exclusively of spindle cells broadens the histologic differential diagnosis of cutaneous spindle cell malignancies and presents further diagnostic challenges. PAX-8 may be useful in discerning the spindle cell component of anaplastic thyroid carcinoma from other spindle cell malignancies in the skin.

Cardiac tumors: leiomyosarcoma - a case report

We present a case report of a 60-year-old woman with a long history of leiomyosarcoma in different locations. She was admitted to the clinic due to a left ventricular tumor diagnosed in ECHO examination. The patient was qualified for radical tumor resection. The early postoperative period was complicated due to low cardiac output syndrome and bradyarrhythmia requiring temporary cardiac pacing. Optimized pharmacological therapy resulted in a gradual reduction of symptoms and a clinical improvement of congestive heart failure (NYHA III - NYHA II). Due to the radical nature of the surgery, the patient was not referred for supplementary treatment. The follow-up currently exceeds 12 months - no new metastases have been found. This case provides an example of how to diagnose and treat heart tumors.

Giant subcutaneous leiomyosarcoma of anterior abdominal wall

Subcutaneous leiomyosarcomas are rare tumors accounting for 1% to 2% of all superficial soft tissue malignancies. Although they may arise anywhere in the body, they most frequently occur in the lower extremities. The incidence of subcutaneous LMS affecting the anterior abdominal wall is very rare. We herein report the case of a patient with a giant subcutaneous leiomyosarcoma arising in the anterior abdominal wall. It was diagnosed by histopathology and immunohistochemistry and treated accordingly.

Symplastic leiomyomas of the scrotum: a comparative study to usual leiomyomas and leiomyosarcomas

Smooth muscle tumors of the scrotum are very uncommon, and those with degenerative-appearing atypia, variably designated as "atypical," "symplastic," or "bizarre" leiomyomas, are extremely rare with only 11 cases in the literature. Given their rarity, the diagnostic criteria and prognosis of symplastic leiomyomas are not well established. We describe 9 cases of scrotal symplastic leiomyomas and compare their histopathologic characteristics to 10 usual leiomyomas and 5 leiomyosarcomas of the scrotum. The preoperative diagnosis was scrotal tumor or cyst in all cases. The mean age was 46 years (range, 32 to 60 y) for usual, 59 (range, 48 to 79) for symplastic leiomyomas, and 57 (range, 49 to 65) for leiomyosarcoma. Submitting diagnoses for symplastic leiomyomas were: atypical spindle cell lesion (n=3); probably leiomyosarcoma (n=1); leiomyosarcoma (n=1); and none given (n=4). Symplastic leiomyomas were diagnosed when there was moderate-severe cytologic atypia, yet was degenerative-appearing with multinucleation or smudged chromatin in the setting of low nuclear/cytoplasmic ratio, low cellularity, and no mitotic activity. The mean size was 1.0 cm for usual leiomyomas, 1.0 cm for symplastic leiomyomas, and 2.0 cm for leiomyosarcomas. Leiomyosarcomas had high nuclear/cytoplasmic ratio, high cellularity, nuclear pleomorphism, and hyperchromasia. Five of 10 usual and 3/9 symplastic leiomyomas showed at least 1 ill-defined border simulating infiltrative growth. Three leiomyosarcomas were grade 1, and 2/5 were grade 2. Resection margins were positive in 5/10 usual and 3/9 symplastic leiomyomas and in 1/5 leiomyosarcoma. Ki67 labeling in usual leiomyomas was on average 2.4% (range, 1% to 5%) and in symplastic leiomyomas was 1.8% (range, 1% to 5%). Mitoses were absent in all cases of usual and symplastic leiomyomas. Mitotic figures averaged 4.7 (range, 1 to 7) and 13.5 (range, 7 to 20) per 10 HPF for the grade 1 and 2 leiomyosarcomas, respectively. None of the symplastic leiomyomas recurred after a median follow-up of 27 months. The 2 patients with grade 2 leiomyosarcoma had no evidence of metastases at 6 and 7 months follow-up, respectively. Scrotal symplastic leiomyomas may have an ill-defined infiltrative border, which along with their atypia mimic malignancy. Ki67 is low in symplastic leiomyomas, which along with their favorable follow-up and experience in other organs justifies a benign diagnosis. High cellularity and high mitotic activity are the most reliable features for the diagnosis of scrotal leiomyosarcoma.

Cutaneous Pleomorphic Rhabdomyosarcoma Occurring on Sun-Damaged Skin: A Case Report

Rhabdomyosarcoma (RMS) is a malignant soft tissue tumor with skeletal muscle differentiation that can rarely present as a primary cutaneous tumor. There are 3 main subtypes of RMS: embryonal, alveolar, and pleomorphic. Primary cutaneous pleomorphic RMS is extremely rare, there being only 9 reported cases in the literature, 2 of which are radiation induced. We present a case of primary pleomorphic RMS occurring on the sun-damaged skin of the face of an 89-year-old woman. The tumor was diagnosed by histology, immunohistochemistry, and electron microscopy. The patient was treated by surgery and adjuvant radiotherapy. The tumor recurred rapidly after surgical excision. She died 2 months after the diagnosis from complications of treatment, local symptoms of tumor, and concurrent illnesses. Primary cutaneous pleomorphic RMS is a rare tumor of adults and pursues an aggressive clinical course.

Cutaneous leiomyosarcoma: treatment and outcomes with a standardized margin of resection

BACKGROUND

Cutaneous leiomyosarcoma is primarily a low-grade malignancy that affects elderly male Caucasians. It is a rare dermal-based tumor for which treatment algorithms have been poorly defined.

METHODS

We retrospectively reviewed the use of a median 1-cm margin for resection to treat patients with cutaneous leiomyosarcoma referred for treatment between 2005 and 2010.

RESULTS

Thirty-three patients with cutaneous leiomyosarcoma were treated. Of these, 76% were male, 97% were Caucasian (median age: 63.5 years), and 67% of tumors were located on the extremities. Preoperative staging was negative for distant metastasis in all patients. A majority of the tumors (88%) were low grade (median size: 1.3 cm). All of the tumors were positive for smooth-muscle actin. A total of 94% of patients underwent primary surgical resection with a median margin of 1 cm. Final resection margin was negative in 97% of patients. Adjuvant radiotherapy was used in 15%. No metastatic spread or recurrences were present, and 100% of patients were alive at last follow-up (median: 15.5 months).

CONCLUSIONS

Good oncological control and excellent outcomes are possible with a 1-cm resection margin in most cases of cutaneous leiomyosarcoma.

Melanotic and non-melanotic malignancies of the face and external ear - A review of current treatment concepts and future options

Skin has the highest incidence and variety of tumors of all organs. Its structure is of great complexity, and every component has the potential to originate a skin neoplasm (SN). Because of its exposed nature, skin is vulnerable to carcinogenic stimuli such as UV radiation. Various entities can cause SN. Nonmelanotic skin cancers (NMSC) are the most common of all cancers, with over one million cases diagnosed annually in the US. Basal cell carcinoma (BCC) accounts for approximately 80% of all NMSC, most of the remaining 20% being squamous cell carcinoma (SCC). The skin of the head and neck is the most common site for tumors, accounting for more than 80% of all NMSC. BCC, SCC, and malignant melanomas (MM) represent 85-90% of all SN. Merkel cell tumors (MCC), lymphoepithelioma-like carcinomas of the skin (LELCS), dermato-fibro-sarcomas, leiomyosarkomas, and Kaposi-sarcomas are less frequent in the facial skin region and the external ear. Based on data from the German Federal Cancer Registry (2003/2004), 140,000 people in Germany were affected by SN (100,000 BCC, 22,000 SCC, 22,000 MM). This number increases considerably if malignant precursors, such as actinic keratosis, are included. Each year, the frequency of SN diagnosis rises by 3-7%. Among all known malignant tumors, MM exhibits the highest rate of increase in incidence. In the past, SN was primarily diagnosed in people aged 50 years or older. However, recently, the risk for developing SN has shifted, and younger people are also affected. Early diagnosis is significantly correlated with prognosis. Resection of SN creates defects that must be closed with local or microvascular flaps to avoid functional disturbing scar formation and deflection of the nose, eyelids, or lips. All therapeutic strategies for SN, the current standard for adjuvant and systemic treatment, and the management of the increasing number of patients under permanent blood thinner medication are described with regard to the treatment of SN.

Smooth muscle tumors of soft tissue and non-uterine viscera: biology and prognosis

Smooth muscle tumors are here considered an essentially dichotomous group composed of benign leiomyomas and malignant leiomyosarcomas. Soft tissue smooth muscle tumors with both atypia and mitotic activity are generally diagnosed leiomyosarcomas acknowledging potential for metastasis. However, lesions exist that cannot be comfortably placed in either category, and in such cases the designation 'smooth muscle tumor of uncertain biologic potential' is appropriate. The use of this category is often necessary with limited sampling, such as needle core biopsies. Benign smooth muscle tumors include smooth muscle hamartoma and angioleiomyoma. A specific category of leiomyomas are estrogen-receptor positive ones in women. These are similar to uterine leiomyomas and can occur anywhere in the abdomen and abdominal wall. Leiomyosarcomas can occur at any site, although are more frequent in the retroperitoneum and proximal extremities. They are recognized by likeness to smooth muscle cells but can undergo pleomorphic evolution ('dedifferentiation'). Presence of smooth muscle actin is nearly uniform and desmin-positivity usual. This and the lack of KIT expression separate leiomyosarcoma from GIST, an important problem in abdominal soft tissues. EBV-associated smooth muscle tumors are a specific subcategory occurring in AIDS or post-transplant patients. These tumors can have incomplete smooth muscle differentiation but show nuclear EBER as a diagnostic feature. In contrast to many other soft tissue tumors, genetics of smooth muscle tumors are poorly understood and such diagnostic testing is not yet generally applicable in this histogenetic group. Leiomyosarcomas are known to be genetically complex, often showing 'chaotic' karyotypes including aneuploidy or polyploidy, and no recurrent tumor-specific translocations have been detected.

Primary cutaneous leiomyosarcoma: A rare malignant neoplasm

Primary cutaneous leiomyosarcoma (PCL) is an exceedingly uncommon malignant superficial soft tissue sarcoma with a predilection for middle-aged to elderly male. Morphologic differential diagnosis includes a host of other malignant spindle cell neoplasms, thereby necessitating the use of a panel of immunohistochemical markers to arrive at a definitive diagnosis. We report a case of PCL arising in the right leg of a 70-year-old male.

Huge and rapidly growing superficial cutaneous leiomyosarcoma on the face: rare location and unusual presentation

Superficial leiomyosarcoma has an incidence of less than 3% of the cutaneous soft-tissue sarcomas, and 1% to 5% of the tumors occur on the face. Because of its rarity and unusual location, preoperative misdiagnosis is common. An 82-year-old woman visited with a preauricular huge and hemorrhagic mass. The mass developed 4 months ago and showed rapid progression. First impressions of the tumor were squamous cell carcinoma and keratoacanthoma. However, the biopsy indicated a high degree of suspicion of leiomyosarcoma. On the metastasis workup, there was no metastatic lesion. The patient underwent a wide excision with 3-cm margin, and the raw surface was covered with split-thickness skin graft. All resection margins were free of tumor, and the stage was IA according to the American Joint Committee on Cancer grading system. The skin graft was well taken, and the patient is well with no evidence of disease recurrence or metastasis after 18 months.

Atypical pilar leiomyomatosis: an unusual presentation of multiple atypical cutaneous leiomyomas

Cutaneous leiomyomas are relatively common benign smooth muscle tumors that may arise as solitary or multiple lesions. Rare forms with cytologic atypia, and features similar to symplastic leiomyomas of the uterus, have been described. We report a case of multiple cutaneous atypical leiomyomas occurring in a 43-year-old man with long history of lesions of the right lower leg and a family history of leiomyomatosis. Twenty of the lesions were excised due to pain and were examined histopathologically. All the lesions exhibited features described in atypical leiomyomas of the skin including increased cellularity, nuclear atypia and pleomorphism, and low mitotic activity. The biologic potential of cutaneous atypical leiomyomas is uncertain. Only a few case reports exist in the literature with the majority occurring as solitary lesions. Most of the reported atypical leiomyomas have behaved in a benign fashion. However, a rare account of transformation to leiomyosarcoma emphasizes the need for long-term follow up of these patients. Herein, we describe a case of multiple atypical cutaneous leiomyomas arising in the setting of familial leiomyomatosis.

Cutaneous metastases from internal malignancies: a clinicopathologic and immunohistochemical review

Skin metastases occur in 0.6%-10.4% of all patients with cancer and represent 2% of all skin tumors. Skin metastases from visceral malignancies are important for dermatologists and dermatopathologists because of their variable clinical appearance and presentation, frequent delay and failure in their diagnosis, relative proportion of different internal malignancies metastasizing to the skin, and impact on morbidity, prognosis, and treatment. Another factor to take into account is that cutaneous metastasis may be the first sign of clinically silent visceral cancer. The relative frequencies of metastatic skin disease tend to correlate with the frequency of the different types of primary cancer in each sex. Thus, women with skin metastases have the following distribution in decreasing order of frequency of primary malignancies: breast, ovary, oral cavity, lung, and large intestine. In men, the distribution is as follows: lung, large intestine, oral cavity, kidney, breast, esophagus, pancreas, stomach, and liver. A wide morphologic spectrum of clinical appearances has been described in cutaneous metastases. This variable clinical morphology included nodules, papules, plaques, tumors, and ulcers. From a histopathologic point of view, there are 4 main morphologic patterns of cutaneous metastases involving the dermis, namely, nodular, infiltrative, diffuse, and intravascular. Generally, cutaneous metastases herald a poor prognosis. The average survival time of patients with skin metastases is a few months. In this article, we review the clinicopathologic and immunohistochemical characteristics of cutaneous metastases from internal malignancies, classify the most common cutaneous metastases, and identify studies that may assist in diagnosing the origin of a cutaneous metastasis.

Primary cutaneous leiomysarcoma

Primary cutaneous leiomyosarcoma of the skin is a rare soft tissue neoplasm, accounting for about 2–3% of all superficial soft tissue sarcomas. It arises between the ages of 50 and 70 years, and shows a greater predilection for the lower extremities. Clinically, it presents with solitary, well-circumscribed nodule and, microscopically, consists of fascicles of spindle-shaped cells with “cigar–shaped” nuclei. Local recurrence is known in this tumor. We document a case of primary cutaneous leiomyosarcoma in a 77-year-old man and discuss the histological features and immunohistochemical profile of this uncommon neoplasm.

Cutaneous leiomyosarcoma on the trunk

Cutaneous leiomyosarcoma is a relatively uncommon tumor that accounts for 7% of all soft tissue sarcomas. It occurs more frequently in males between 50-70 years and only 10-15% of cases are located on the trunk. Radiotherapy and previous trauma have been implied as risk factors. We report the case of a 57 year-old male with an eight-month history of a hard painless erythematous-violaceous tumor on the presternal region. Histopathology evidenced a malignant spindle cell tumor, "cigar" shaped, with pleomorphic nuclei and a high mitotic index that occupied the entire dermal thickness. Immunohistochemical staining of the tumor cells was positive for smooth muscle actin, desmin and vimentin and negative for S-100 protein and pan-cytokeratin, which supported the diagnosis of dermal leiomyosarcoma. Radical surgery was performed to remove the tumor.

Primary desmoplastic cutaneous leiomyosarcoma associated with high MIB-1 labeling index: a teaching case giving rise to diagnostic difficulties on a small biopsy specimen

A case of primary desmoplastic cutaneous leiomyosarcoma is reported. A flat and elevated tan plaque, measuring 30 mm × 20 mm, was noticed in the left back of a 74-year-old Japanese male 6 months before the resection. The biopsy specimen showed an overgrowth of desmoplastic fibrocollagenous stroma, focally admixed with a less cellular proliferation of spindle cells having mildly pleomorphic nuclei, but no mitotic figures, arranged in small clusters or appearing as individual cells. Based on these features, we interpreted it as a benign keloid-like lesion. A local resection was done, and gross examination revealed a poorly demarcated grayish tumor lesion, replacing the entire dermis and extending into the subcutis. Microscopic findings demonstrated a sparsely cellular proliferation of atypical spindle cells having cigar-shaped or multi-nucleated pleomorphic nuclei and abundant eosinophilic cytoplasm with few mitotic hot spots, arranged in interlacing bundles, alternating with scattered tumor cells within an abundant desmoplastic stroma. Immunohistochemically, these atypical cells were positive for α-smooth muscle actin, HHF-35, desmin, and caldesmon, and MIB-1 labeling index was greater than 10%. Therefore, we finally made a diagnosis of desmoplastic leiomyosarcoma as a very rare variant of cutaneous leiomyosarcoma. We should be aware that owing to its characteristic features, pathologists might misinterpret it as benign when examining only small or inadequate specimens. It is thus suggested that a large panel of antibodies including smooth muscle cell markers and MIB-1 in immunohistochemistry are useful and adjunctive diagnostic aids for recognizing malignancy, especially in diagnostically difficult cases such as ours.

Spindle cell squamous cell carcinoma not expressing stratified but simple epithelial cytokeratin: efficacy of simple epithelial cytokeratin immunoreactivity

We present two cases of spindle cell squamous cell carcinoma, which were derived from solar keratosis and burn scar in two elderly Japanese patients, respectively. The tumors involved the whole dermis and subcutis in connection with the overlying epidermis. They were composed mainly of anaplastic spindle cells partially forming storiform patterns. The tumor cells were diffusely positive for vimentin and cytokeratin 8/18 (clone CAM5.2, simple epithelial cytokeratin), but negative for cytokeratin 1/5/10/14 (clone 34βE12, stratified epithelial cytokeratin). Ultrastructural analysis of a patient demonstrated desmosomes and tonofilaments in the tumor cells. Although spindle cell squamous cell carcinoma is usually positive for vimentin, detailed cytokeratin profile is controversial. The present cases revealed immunohistochemistry not expressing stratified but simple epithelial cytokeratin and vimentin. We should be reminded of the efficacy of simple epithelial cytokeratin immunoreactivity in spindle cell squamous cell carcinoma.