RHABDOMYOSARCOMA OF THE HEAD AND NECK IN CHILDREN

Clinicopathological analysis of head and neck rhabdomyosarcoma: A series of 10 cases and literature review

Background

To describe the clinicopathological characteristics of a series of head and neck rhabdomyosarcoma (RMS) and to review the literature.

Material and Methods

Cases diagnosed as RMS affecting the head and neck region were retrospectively retrieved from the files of two Brazilian institutions from January 2006 to January 2017. Data on clinical features (sex, age and affected site), microscopic subtype, immunohistochemical results, treatment employed and follow-up status were obtained from the patient’s medical charts.

Results

During the period considered, 10 cases of RMS were identified. Females predominated (4M:6F), the mean age at diagnosis was 16.5 years-old and the orbit was the most affected site (4 cases). Microscopically, most cases were classified as embryonal RMS (6 cases) and the Desmin/Myogenin/Myo-D1 immunohistochemical positivity was useful to confirm the diagnosis. Chemotherapy and radiotherapy were applied to 9 and 8 patients respectively, whereas 2 patients were treated by surgery. Recurrences occurred in 3 patients and distant metastasis in 2 cases. Nine patients were alive in their last follow-up, 3 of them with disease, whereas 1 patient died due to the disease.

Conclusions

Head and neck RMS is an aggressive malignant neoplasm which demands especial concern to achieve early diagnosis and successful treatment.

Key words:Rhabdomyosarcoma, soft tissue tumors, head and neck, oral cavity, chemotherapy.

Rhabdomyosarcoma of the maxillary gingiva

BACKGROUND

Rhabdomyosarcoma is a malignant neoplasm of primitive mesenchyme exhibiting skeletal muscle differentiation. Oral rhabdomyosarcoma is rare and accounts for only 0.04% of all head and neck malignancies.

METHODS

A 33-year-old woman presented with an erythematous gingival mass involving the anterior maxillary gingiva. The lesion had been present for > or =13 months before presentation, and in recent months, it had become intermittently painful.

RESULTS

Clinical examination exhibited erythema and enlargement of the interdental papillae between the left maxillary canine, lateral incisor, and central incisor. The tissue was boggy and tender on palpation. Incisional biopsies were performed, and microscopic examination showed a cellular proliferation of spindle-shaped to ovoid cells with hyperchromatic, enlarged, and pleomorphic nuclei. Many of the tumor cells exhibited abundant eosinophilic cytoplasm. Immunohistochemical stains showed the tumor cells to be positive for desmin, myogenin, and myogenic differentiation 1 (MyoD1). A diagnosis of embryonal rhabdomyosarcoma was made. The patient was treated by surgical resection with postoperative chemotherapy and radiation. The patient had no evidence of disease at a follow-up examination 1 month after completion of therapy.

CONCLUSIONS

Oral rhabdomyosarcoma can develop insidiously. Pain is a variable presenting symptom, and early lesions may be mistaken for benign neoplastic, inflammatory, or infectious processes. Over several decades, a multidisciplinary treatment approach that includes surgical removal if resectable, in combination with multiagent chemotherapy and possibly radiation therapy, has improved survival rates.

Improved prognosis with intensive treatment of children with cranial soft tissue sarcomas arising in nonorbital parameningeal sites. A report from the Intergroup Rhabdomyosarcoma Study

In the first Intergroup Rhabdomyosarcoma Study (IRS-I), it was found that, of 57 patients with nonorbital cranial parameningeal sarcoma treated from 1972 to 1976, 20 patients (35%) developed meningeal sarcoma and 90% (18/20) died of this complication. Since about half of these 20 patients had received inadequate radiation therapy and all had radiation therapy delayed until week 6, the treatment program was modified in December 1977 to begin radiation therapy on day 0 to the entire neuraxis and the primary tumor for all patients presenting with one or more risk factors indicating a high risk of meningeal involvement, and to administer periodic intrathecal medications to the same patients. The risk factors were intracranial extension of tumor, bony erosion at the cranial base, and cranial nerve palsy. In this report, the prognoses of two groups of patients with nonorbital cranial parameningeal sarcoma are compared: 95 patients treated before modification of the protocol in December 1977 with chemotherapy and nonintensive meningeal radiotherapy (preintensive group) and 68 patients treated subsequently with intensive meningeal radiotherapy and chemotherapy (intensive group). All patients received vincristine and actinomycin D (dactinomycin) with or without cyclophosphamide and Adriamycin (doxorubicin), according to the protocol. Radiation therapy consisted of 4000 to 5500 rad to the primary tumor in 5 to 6 weeks for most patients. The intensively treated patients also received intrathecal drugs via lumbar puncture and whole cranial or craniospinal radiation when one or more meningeal risk factors were present. In the preintensive group, the complete remission rate was 68% (65/95); the percentages of patients tumor free or alive at 3 years were 33% and 41%, respectively. In intensively treated patients, the complete remission rate was 76% (52/68); the percentages of patients tumor free or alive at 3 years were 57% and 68%, respectively. The improvements in the percentages of intensively treated patients tumor free or surviving were highly statistically significant (P less than 0.01 for both comparisons). Within the intensive treatment group, meningeal involvement at diagnosis was an unfavorable prognostic sign, since patients with no meningeal involvement had much better tumor-free survival at 3 years (81% vs. 51%) and survival (90% vs. 57%) than patients with evidence of meningeal involvement; the differences were highly statistically significant (P = 0.01).

Three-year relapse-free survival rates in childhood rhabdomyosarcoma of the head and neck: report from the Intergroup Rhabdomyosarcoma Study

In 202 patients with rhabdomyosarcoma of the head and neck who registered in the first Intergroup Rhabdomyosarcoma Study, the primary lesions arose about the eye and orbit in 26%, in parameningeal sites in 46%, and in other head and neck areas in 28%. Histopathologically, 78% were embryonal-botryoid, 9% alveolar, 10% undifferentiated, and 3% extraosseous Ewing's types. Actual three-year relapse-free survival rates were calculated from data on 103 of these patients who were free of distant metastases at diagnosis and in whom follow-up had been completed for a three-year period. The actual relapse-free survival rates were 91% (21/23) for those with eye/orbit primaries, 46% (20/44) for those with parameningeal primaries, and 75% (27/36) for those with other head and neck sites affected. Among those with no clinical evidence of tumor activity at two years, 8% (6/75) had subsequent relapses.

Parameningeal rhabdomyosarcoma in the young

Forty cases of young patients with embryonal rhabdomyosarcoma or undifferentiated sarcoma in parameningeal sites of the head and neck were reviewed. All 40 were treated with radiation therapy in conjunction with surgery and 16 were also treated with adjuvant chemotherapy. The overall five year survival rate was 35%. A primary tumor dose of at least 5000 rad resulted in a significantly greater survival rate compared with lesser doses. Meningeal involvement at diagnosis was present in 20 patients (50%) and the 30% five year survival rate for this group was no different than that for patients without initial meningeal involvement (41%). At first or second relapse, meningeal involvement was present in six of 37 patients and in two patients this occurred as an isolated event with distant meningeal seeding; in four other patients, meningeal involvement was a manifestation of local recurrence. As of the time of the last follow-up examination, control of the primary tumor had been achieved in 22 of the 40 (55%). It is considered that primary tumor radiation treatment parameters may be critical in determining the incidence of subsequent meningeal relapse.

Rhabdomyosarcoma: report of a case with involvement of the angle of the mandible

The most common signs of a malignancy in the region of the head and neck are evidence of a mass or symptoms arising from it. In this report a patient is described with rhabdomyosarcoma of the mandible. An incidental x-ray taken some 3 months prior to the onset of clinical symptoms showed no evidence of bone involvement of the mandible. The onset of bone destruction of the angle and ascending ramus of the mandible as seen on a subsequent x-ray can be placed somewhere in this period of time.

Rhabdomyosarcoma of the middle ear and mastoid

A case of embryonal rhabdomyosarcoma of the middle ear and mastoid is presented. The patient was treated by irradiation and Actinomycin D, and survived 4-5 months.

Nonepithelial tumors of the nasal cavity paranasal sinuses, and nasopharynx: a clinicopathologic study. V. Skeletal muscle tumors (rhabdomyoma and rhabdomyosarcoma)

In a study of nonepithelial tumors involving the nasal cavity, paranasal sinuses, and nasopharynx, 19 lesions (three rhabdomyomas, 16 rhabdomyosarcomas) showed skeletal muscle differentiation. The clinical findings associated with these neoplasms are reviewed, the histologic features are illustrated, results of treatment are presented, and clinicopathologic correlations are discussed. The rhabdomyomas grew as localized masses in the nasopharynx, were excised locally, and behaved clinically like benign tumors. The rhabdomyosarcomas were found predominantly in children and were associated with a poor prognosis; most of the patients died within 2 years following diagnosis.

Rhabdomyosarcoma of the extremities and trunk: analysis of 150 patients treated by surgical resection

This report details the clinical experience of 150 patients with rhabdomyosarcomas treated by one group of surgeons. Of the 150 patients, 103 suffered from pleomorphic rhabdomyosarcomas, 40 patients had embryonal rhabdomyosarcomas, and 7 had alveolar cell type of rhabdomyosarcoma. The males suffered almost twice as much as the females from this form of cancer (96 males to 54 females). The fifth decade had the highest incidence of all rhabdomyosarcomas. The younger patients generally suffered from embryonal rhabdomyosarcomas and the older ones from pleomorphic rhabdomyosarcomas, although age was no barrier to the occurrence of embryonal rhabdomyosarcomas in some of the older patients and pleomorphic rhabdomyosarcomas in some of the younger patients. Caucasians were almost exclusively afflicted by this form of cancer (93% of this series). The lower extremity was the most frequent site of the lesion, occurring in 50.7% of the 150 cases. The upper extremity was the second most frequently involved site (28%), and the trunk was the least involved site (21.3%). Of the 150 patients studied, 40 were considered indeterminate. Thirteen patients are alive and free of cancer, but were treated less than 5 years ago; 12 patients reported for consultation only. There were 13 who were free of sarcomas at periods in excess of 2 years but were lost to follow-up. Two patients in this series died before the 5-year period, and autopsy revealed the death to be due to causes other than the rhabdomyosarcoma. Of the 110 determinate patients, 75 (68%) died as a result of the cancer. The 5-year survival rate equals 32%. The fact of the 30% 5-year survival after treatment for recurrences should help dismiss the pessimism which prevails once a recurrence is noted subsequent to major therapy. Age per se had no great effect on prognosis. The poorest results occurred in the 11-20 age range, with a 5-year survival of 15%. This value reflects on increased incidence of embryonal rhabdomyosarcomas which tend to be more malignant and metastasize earlier than do the pleomorphic type. The effect of location upon survival revealed that of 76 patients with involvement of the lower extremity, 34% survived 5 years or longer, and those with sarcomas of the trunk had the poorest survival (26%). The fact that the trunk, by virtue of its anatomy, limits the degree of surgery that can be perfomred, probably helps to explain this difference. The role of radiation therapy and chemotherapy awaits elucidation. Reports of combined surgery, radiation therapy, and chemotherapy are encouraging.

Rhabdomyosarcoma of the tongue in an infant: results of combined radiation and chemotherapy

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Embryonal sarcoma and embryonal rhabdomyosarcoma of the orbit

A series of 34 cases of embryonal sarcoma and embryonal rhabdomyosarcoma of the orbit has been placed histologically into three groups according to their maximum degree of differentiation at any stage: (a) embryonal sarcoma, (b) non-striated embryonal rhabdomyosarcoma, and (c) striated embryonal rhabdomyosarcoma. The patients were then followed up. This paper presents a summary of the clinical course of the whole series and an account of eight typical cases; the age and sex incidence and survival rates are shown and the histology, treatment, and prognosis are discussed.