1
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Leong SP, Witte MH. Cancer metastasis through the lymphatic versus blood vessels. Clin Exp Metastasis 2024:10.1007/s10585-024-10288-0. [PMID: 38940900 DOI: 10.1007/s10585-024-10288-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 04/10/2024] [Indexed: 06/29/2024]
Abstract
Whether cancer cells metastasize from the primary site to the distant sites via the lymphatic vessels or the blood vessels directly into the circulation is still under intense study. In this review article, we follow the journey of cancer cells metastasizing to the sentinel lymph nodes and beyond to the distant sites. We emphasize cancer heterogeneity and microenvironment as major determinants of cancer metastasis. Multiple molecules have been found to be associated with the complicated process of metastasis. Based on the large sentinel lymph node data, it is reasonable to conclude that cancer cells may metastasize through the blood vessels in some cases but in most cases, they use the sentinel lymph nodes as the major gateway to enter the circulation to distant sites.
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Affiliation(s)
- Stanley P Leong
- California Pacific Medical Center and Research Institute, University of California School of Medicine, San Francisco, USA.
| | - Marlys H Witte
- Department of Surgery, Neurosurgery and Pediatrics, University of Arizona College of Medicine-Tucson, Tucson, AZ, USA
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2
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Maeda C, Yamaoka Y, Shiomi A, Kagawa H, Hino H, Manabe S, Kai C, Nanishi K. Short-term and long-term outcomes after robotic radical surgery for rectal gastrointestinal stromal tumor. BMC Surg 2024; 24:141. [PMID: 38720315 PMCID: PMC11080177 DOI: 10.1186/s12893-024-02434-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 05/03/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND The optimal approach for ensuring both complete resection and preservation of anal function in rectal gastrointestinal stromal tumor (GIST) remains unknown. The aim of this study was to clarify short-term and long-term outcomes after robotic radical surgery for rectal GIST. METHODS A total of 13 patients who underwent robotic radical surgery for rectal GIST between December 2011 and April 2022 were included. All robotic procedures were performed using a systematic approach. A supplemental video of robotic radical surgery for rectal GIST is attached. The short-term outcome was the incidence of postoperative complications during the first 30 days after surgery. Surgical outcomes were retrieved from a prospective database. Long-term outcomes, including overall survival and recurrence-free survival, were determined in all patients. RESULTS Median distance from the tumor to the anal verge was 4.0 cm. Surgical margins were negative in all patients. Two patients underwent neoadjuvant imatinib therapy. All patients underwent sphincter-preserving surgery. None underwent conversion to open or laparoscopic surgery. The incidence of postoperative Clavien-Dindo grade II and grade ≥ III complications was 7.7% and 0%, respectively. The median postoperative hospital stay was 7 days. Twelve patients (92.3%) underwent stoma closure within 5 months of the initial surgery. Median follow-up time was 76 months. The 5-year overall survival and recurrence-free survival rates were both 100%. None of the patients had recurrence. CONCLUSION Short-term and long-term outcomes after radical robotic surgery for rectal GIST were favorable. Robotic surgery might be a useful surgical approach for rectal GIST.
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Affiliation(s)
- Chikara Maeda
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777, Japan
| | - Yusuke Yamaoka
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777, Japan.
| | - Akio Shiomi
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777, Japan
| | - Hiroyasu Kagawa
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777, Japan
| | - Hitoshi Hino
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777, Japan
| | - Shoichi Manabe
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777, Japan
| | - Chen Kai
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777, Japan
| | - Kenji Nanishi
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777, Japan
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Burkhard-Meier A, Jurinovic V, Berclaz LM, Albertsmeier M, Dürr HR, Klein A, Knösel T, Di Gioia D, Unterrainer LM, Schmidt-Hegemann NS, Ricke J, von Bergwelt-Baildon M, Kunz WG, Lindner LH. Differentiation of benign and metastatic lymph nodes in soft tissue sarcoma. Clin Exp Metastasis 2024; 41:131-141. [PMID: 38421522 PMCID: PMC10973039 DOI: 10.1007/s10585-024-10273-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 01/23/2024] [Indexed: 03/02/2024]
Abstract
Lymph node metastasis (LNM) occurs in less than 5% of soft tissue sarcoma (STS) patients and indicates an aggressive course of disease. Suspicious lymph nodes (LN) in staging imaging are a frequent topic of discussion in multidisciplinary tumor boards. Predictive markers are needed to facilitate stratification and improve treatment of STS patients. In this study, 56 STS patients with radiologically suspicious and subsequently histologically examined LN were reviewed. Patients with benign (n = 26) and metastatic (n = 30) LN were analyzed with regard to clinical, laboratory and imaging parameters. Patients with LNM exhibited significantly larger short axis diameter (SAD) and long axis diameter (LAD) vs. patients with benign LN (median 22.5 vs. 14 mm, p < 0.001 and median 29.5 vs. 21 mm, p = 0.003, respectively). Furthermore, the presence of central necrosis and high maximal standardized uptake value (SUVmax) in FDG-PET-CT scans were significantly associated with LNM (60 vs. 11.5% of patients, p < 0.001 and median 8.59 vs. 3.96, p = 0.013, respectively). With systemic therapy, a slight median size regression over time was observed in both metastatic and benign LN. Serum LDH and CRP levels were significantly higher in patients with LNM (median 247 vs. 187.5U/L, p = 0.005 and 1.5 vs. 0.55 mg/dL, p = 0.039, respectively). This study shows significant associations between LNM and imaging features as well as laboratory parameters of STS patients. The largest SAD, SUVmax in FDG-PET-CT scan, the presence of central necrosis, and high serum LDH level are the most important parameters to distinguish benign from metastatic LNs.
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Affiliation(s)
| | - Vindi Jurinovic
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Institute for Medical Information Processing, Biometry, and Epidemiology, University Hospital, LMU Munich, Munich, Germany
| | - Luc M Berclaz
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Markus Albertsmeier
- Department of General, Visceral and Transplantation Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Hans Roland Dürr
- Department of Orthopedics and Trauma Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Alexander Klein
- Department of Orthopedics and Trauma Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Thomas Knösel
- Institute of Pathology, University Hospital, LMU Munich, Munich, Germany
| | - Dorit Di Gioia
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Lena M Unterrainer
- Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany
| | | | - Jens Ricke
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | | | - Wolfgang G Kunz
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Lars H Lindner
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
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Ferron G, Bataillon G, Martinez A, Chibon F, Valentin T. Gynecological sarcomas, surgical management: primary, metastatic, and recurrent disease. Int J Gynecol Cancer 2024; 34:393-402. [PMID: 38438176 DOI: 10.1136/ijgc-2023-004582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024] Open
Abstract
Adult-type gynecological soft tissue and visceral sarcomas are rare tumors, with an estimated incidence of 13% of all sarcomas and 4% of all gynecological malignancies. They most often develop in the uterus (83%), followed by the ovaries (8%), vulva and vagina (5%), and other gynecological organs (2%). The objective of this review is to provide an overview of the current management of gynecological sarcomas, according to international guidelines. The management of gynecological sarcomas should follow the recommendations for the management of soft tissue and visceral sarcomas. Centralizing cases in expert centers improves patient survival, both for the diagnostic phase and for multidisciplinary therapeutic management. In the case of pelvic soft tissue sarcomas, a radiological biopsy is essential before any surgical decision is taken. In the case of a myometrial tumour which may correspond to a sarcoma, if conservative surgery such as myomectomy or morcellation is planned, an ultrasound-guided biopsy with pathological analysis including comparative genomic hybridization analysis must be carried out. In all cases, en bloc surgery, without rupture, is mandatory. Many rare histological subtypes require specific surgical management.
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Affiliation(s)
- Gwenael Ferron
- Surgical Oncology, Institut Universitaire du Cancer Toulouse Oncopole, Toulouse, France
- OncoSARC (Oncogenesis of Sarcoma), INSERM UMR1037, Toulouse, France
| | - Guillaume Bataillon
- Anatomopathology, Institut Universitaire du Cancer Toulouse Oncopole, Toulouse, France
| | - Alejandra Martinez
- Surgical Oncology, Institut Universitaire du Cancer Toulouse Oncopole, Toulouse, France
- T2i (Anti-tumour immunity and immunotherapy), INSERM UMR1037, Toulouse, France
| | - Frederic Chibon
- OncoSARC (Oncogenesis of Sarcoma), INSERM UMR1037, Toulouse, France
- Surgical Pathology, Institut Universitaire du Cancer Toulouse Oncopole, Toulouse, France
| | - Thibaud Valentin
- OncoSARC (Oncogenesis of Sarcoma), INSERM UMR1037, Toulouse, France
- Medical Oncology, Institut Universitaire du Cancer Toulouse Oncopole, Toulouse, France
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5
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Zidan M, Hassan E, Refaie M. A Successful Central Gastrectomy and Gastro-Gastric Anastomosis for a Large Gastric GIST. J Gastrointest Cancer 2024; 55:202-206. [PMID: 38008873 DOI: 10.1007/s12029-023-00992-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2023] [Indexed: 11/28/2023]
Abstract
PURPOSE Partial gastrectomy is always the preferred technique for GIST resection. Central gastrectomy is a practical technique that can be employed in many situations during the resection of both subepithelial stromal tumors and gastric tumors. CASE PRESENTATION A 53-year-old Egyptian female patient with a 15 × 19 cm large fungating gastric GIST managed by central gastrectomy. Central gastrectomy and gastro-gastric anastomosis were performed with negative resection margins, and the patient received post-operative imatinib, achieving disease control throughout an 8-month post-operative follow-up. CONCLUSION Central gastrectomy is an effective method of partial gastrectomy that can be considered in GIST resection; however, more studies are needed to evaluate the efficiency of central gastrectomy in terms of long-term follow-up and terms of R0 respectability in gastric cancer.
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Affiliation(s)
- Mohamed Zidan
- Department of Surgery, Alexandria University Hospital, Alexandria, 21568, Egypt.
- Alexandria Endoscopy Association, Alexandria, Egypt.
| | - Eslam Hassan
- Department of Surgery, Borg El Arab General Hospital, Alexandria, Egypt
| | - Mostafa Refaie
- Department of Surgery, Alexandria University Hospital, Alexandria, 21568, Egypt
- Faculty of Medicine, Alexandria University, Alexandria, 21568, Egypt
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Chmiel P, Krotewicz M, Szumera-Ciećkiewicz A, Bartnik E, Czarnecka AM, Rutkowski P. Review on Lymph Node Metastases, Sentinel Lymph Node Biopsy, and Lymphadenectomy in Sarcoma. Curr Oncol 2024; 31:307-323. [PMID: 38248105 PMCID: PMC10814427 DOI: 10.3390/curroncol31010020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 12/17/2023] [Accepted: 12/28/2023] [Indexed: 01/23/2024] Open
Abstract
Soft tissue sarcomas (STS) originating from connective tissue rarely affect the lymph nodes. However, involvement of lymph nodes in STS is an important aspect of prognosis and treatment. Currently, there is no consensus on the diagnosis and management of lymph node metastases in STS. The key risk factor for nodal involvement is the histological subtype of sarcoma. Radiological and pathological evaluation seems to be the most effective method of assessing lymph nodes in these neoplasms. Thus, sentinel lymph node biopsy (SLNB), which has been shown to be valuable in the management of melanoma or breast cancer, may also be a beneficial diagnostic option in some high-risk STS subtypes. This review summarizes data on the risk factors and clinical characteristics of lymph node involvement in STS. Possible management and therapeutic options are also discussed.
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Affiliation(s)
- Paulina Chmiel
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781 Warsaw, Poland; (P.C.); (M.K.); (P.R.)
| | - Maria Krotewicz
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781 Warsaw, Poland; (P.C.); (M.K.); (P.R.)
| | - Anna Szumera-Ciećkiewicz
- Department of Pathology, Maria Sklodowska Curie National Research Institute of Oncology, 02-781 Warsaw, Poland;
| | - Ewa Bartnik
- Institute of Genetics and Biotechnology, Faculty of Biology, University of Warsaw, 02-106 Warsaw, Poland;
- Institute of Biochemistry and Biophysics, Polish Academy of Sciences, 02-106 Warsaw, Poland
| | - Anna M. Czarnecka
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781 Warsaw, Poland; (P.C.); (M.K.); (P.R.)
| | - Piotr Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781 Warsaw, Poland; (P.C.); (M.K.); (P.R.)
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7
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Samenova D, Midlenko A, Khamzina Y, Kaldybayev M, Khamzina S. Primary Leiomyosarcoma of the Breast: A Successful Surgical Treatment in a 45-Year-Old Woman. AMERICAN JOURNAL OF CASE REPORTS 2023; 24:e939437. [PMID: 37599433 PMCID: PMC10450998 DOI: 10.12659/ajcr.939437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 07/17/2023] [Accepted: 06/28/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND Spindle cell carcinomas and sarcomas are 2 uncommon primary spindle cell malignant tumors of the breast. Histopathology and immunohistochemistry for cell phenotypic markers can identify the type of tumor. This report is of a 45-year-old woman with a primary leiomyosarcoma of the breast, successfully treated by surgical excision. CASE REPORT A 45-year-old woman presented to our clinic in February 2018 with a 10.5-cm tumor in the right breast with lateral invasion of the pectoralis minor and pectoralis major. When the tumor first appeared in 2016, it was 5 cm in size and was diagnosed pathologically as a sarcoma. On immunohistochemical examination, the tumor cells were positive for smooth muscle actin, and vimentin with Ki 67 index of 15-20%. Previous treatment with 10 cycles of Gemcitabine was unsuccessful and showed rapid tumor growth up to 18 cm in May 2018. The patient underwent total right mastectomy with excision of the pectoralis minor muscle and partial excision of pectoral major muscle with axillary lymph node dissection. Pathological assessment revealed a necrotic mass 21.0×16.0×12.0 cm in size with invasion into the overlying breast skin and pectoralis major muscle with 2 out of 20 axillary lymph nodes with tumor growth. CONCLUSIONS This study has demonstrated the value of immunohistochemistry and histology in the diagnosis of primary spindle cell malignant breast cancers. To decrease the chance of recurrence and improve patient outcomes, primary leiomyosarcoma of the breast should be removed with a sufficient excision margin.
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Affiliation(s)
- Dinara Samenova
- Department of Surgery, National Research Oncology Center, Astana, Kazakhstan
| | - Anna Midlenko
- Department of Surgery, Nazarbayev University School of Medicine, Astana, Kazakhstan
| | - Yekaterina Khamzina
- Department of Surgery, Nazarbayev University School of Medicine, Astana, Kazakhstan
| | - Muslim Kaldybayev
- Department of Pathomorphology with Cytology, National Research Oncology Center, Astana, Kazakhstan
| | - Saule Khamzina
- Department of Surgery, National Research Oncology Center, Astana, Kazakhstan
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Kasago IS, Chatila WK, Lezcano CM, Febres-Aldana CA, Schultz N, Vanderbilt C, Dogan S, Bartlett EK, D'Angelo SP, Tap WD, Singer S, Ladanyi M, Shoushtari AN, Busam KJ, Hameed M. Undifferentiated and Dedifferentiated Metastatic Melanomas Masquerading as Soft Tissue Sarcomas: Mutational Signature Analysis and Immunotherapy Response. Mod Pathol 2023; 36:100165. [PMID: 36990277 PMCID: PMC10698871 DOI: 10.1016/j.modpat.2023.100165] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 03/13/2023] [Accepted: 03/17/2023] [Indexed: 03/29/2023]
Abstract
The distinction between undifferentiated melanoma (UM) or dedifferentiated melanoma (DM) from undifferentiated or unclassifiable sarcoma can be difficult and requires the careful correlation of clinical, pathologic, and genomic findings. In this study, we examined the utility of mutational signatures to identify patients with UM/DM with particular attention as to whether this distinction matters for treatment because the survival of patients with metastatic melanoma has dramatically improved with immunologic therapy, whereas durable responses are less frequent in sarcomas. We identified 19 cases of UM/DM that were initially reported as unclassified or undifferentiated malignant neoplasm or sarcoma and submitted for targeted next-generation sequencing analysis. These cases were confirmed as UM/DM by harboring melanoma driver mutations, UV signature, and high tumor mutation burden. One case of DM showed melanoma in situ. Meanwhile, 18 cases represented metastatic UM/DM. Eleven patients had a prior history of melanoma. Thirteen of 19 (68%) of the tumors were immunohistochemically completely negative for 4 melanocytic markers (S100, SOX10, HMB45, and MELAN-A). All cases harbored a dominant UV signature. Frequent driver mutations involved BRAF (26%), NRAS (32%), and NF1 (42%). In contrast, the control cohort of undifferentiated pleomorphic sarcomas (UPS) of deep soft tissue exhibited a dominant aging signature in 46.6% (7/15) without evidence of UV signature. The median tumor mutation burden for DM/UM vs UPS was 31.5 vs 7.0 mutations/Mb (P < .001). A favorable response to immune checkpoint inhibitor therapy was observed in 66.6% (12/18) of patients with UM/DM. Eight patients exhibited a complete response and were alive with no evidence of disease at the last follow-up (median 45.5 months). Our findings support the usefulness of the UV signature in discriminating DM/UM vs UPS. Furthermore, we present evidence suggesting that patients with DM/UM and UV signatures can benefit from immune checkpoint inhibitor therapy.
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Affiliation(s)
- Israel S Kasago
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Walid K Chatila
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Cecilia M Lezcano
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Nikolaus Schultz
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Chad Vanderbilt
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Snjezana Dogan
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Edmund K Bartlett
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sandra P D'Angelo
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - William D Tap
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Samuel Singer
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marc Ladanyi
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York; Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Klaus J Busam
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Meera Hameed
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York.
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9
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Saoud C, Lam H, Ali SZ. Fine-Needle Aspiration of Sarcomas Metastatic to Lymph Nodes: A Cytomorphologic Study over a 10-Year Period. Acta Cytol 2023; 67:493-506. [PMID: 37497908 DOI: 10.1159/000531958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 07/13/2023] [Indexed: 07/28/2023]
Abstract
INTRODUCTION Metastasis of sarcomas to lymph nodes is an uncommon event in its natural history. We aimed to present our experience with fine-needle aspiration (FNA) of metastatic sarcomas to lymph nodes over a 10-year period. MATERIAL AND METHODS The cytopathology archives were searched for FNA of lymph nodes involved by metastatic sarcomas. Available clinicopathologic data were recorded. All slides were retrieved and reviewed. RESULTS Thirty-three lymph nodes, from 30 patients, with metastatic soft tissue sarcomas were identified. The lymph node metastases occurred in 16 males and 14 females (median age, 56 years). The size of the lymph nodes ranged from 1.2 to 7.5 cm (median size, 2.9 cm). The inguinal lymph nodes were the most commonly involved nodes, followed by thoracic and cervical neck nodes. The most common metastatic soft tissue sarcoma encountered was Kaposi sarcoma (n = 7, 23.3%), followed by angiosarcoma (n = 6, 20%) and rhabdomyosarcoma (n = 6, 20%). The most common site of primary soft tissue sarcoma was the head and neck (n = 8, 26.6%), followed by lower extremity (n = 7, 23.3%). The initial diagnosis of sarcoma was established in 6 cases. Seventen patients had metachronous involvement of lymph nodes, while the remaining patients had synchronous involvement. Seventen patients died of disease, and the survival after lymph node metastasis ranged from 1 to 43 months. CONCLUSION FNA is an accurate and effective method in the diagnosis of metastatic sarcoma to lymph nodes. Knowledge of clinical findings and primary tumor diagnosis along with careful assessment of the cytomorphology is extremely helpful for an accurate diagnosis of metastases.
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Affiliation(s)
- Carla Saoud
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,
| | - Hansen Lam
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Syed Z Ali
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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10
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Jhuang JY, Liu CY, Tseng MH, Chuang SS. Cytological Features of a Metastatic Angiosarcoma in the Lymph Node Diagnosed via Liquid-Based Cytology. Diagnostics (Basel) 2023; 13:2124. [PMID: 37371020 DOI: 10.3390/diagnostics13122124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/11/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
Angiosarcoma is a soft tissue sarcoma of vascular origin, with more than half of the cases arising in the skin and affecting primarily the face and scalp of elderly males. Furthermore, cutaneous angiosarcoma exhibits a higher incidence of lymph node metastases than other types of sarcomas. Angiosarcomas are rarely aspirated and are occasionally encountered on cytological samples. It is a diagnostic challenge in evaluating fine needle aspiration (FNA) from a metastatic angiosarcoma without the knowledge of prior history. We present a case of scalp angiosarcoma with disease progression to erythroderma and cervical lymphadenopathy 20 months after. FNA of the cervical node revealed vasoformative features, including hemophagocytosis, formation of an intracytoplasmic lumen/vacuole, endothelial wrapping, and cell grasping. The diagnosis of nodal metastasis by angiosarcoma was confirmed with immunohistochemistry (IHC) using two vascular markers on cell block sections. Our case demonstrates the recognizable cytomorphologic clues for this rare metastatic malignancy.
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Affiliation(s)
- Jie-Yang Jhuang
- Department of Pathology, Mackay Memorial Hospital, New Taipei City 251, Taiwan
| | - Chih-Yi Liu
- Division of Pathology, Sijhih Cathay General Hospital, New Taipei City 221, Taiwan
- School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City 221, Taiwan
| | - Min-Hui Tseng
- Department of Pathology, Chi-Mei Medical Center, Tainan 710, Taiwan
| | - Shih-Sung Chuang
- Department of Pathology, Chi-Mei Medical Center, Tainan 710, Taiwan
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11
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Hindi N, Laack N, Hong K, Hohenberger P. Local Therapies for Metastatic Sarcoma: Why, When, and How? Am Soc Clin Oncol Educ Book 2023; 43:e390554. [PMID: 37384855 DOI: 10.1200/edbk_390554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
Management of patients with advanced sarcoma has been evolving in recent decades, from a one-fit-all perspective to a more refined, personalized, and multidisciplinary approach. In parallel, the evolution of local therapies (radiotherapy, surgical and interventional radiology techniques) has contributed to the improvement of survival of patients with advanced sarcoma. In this article, we review the evidence regarding local treatments in advanced sarcoma, as well as its integration with systemic therapies, to provide the reader a wider and deeper perspective on the management of patients with metastatic sarcoma.
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Affiliation(s)
- Nadia Hindi
- Medical Oncology Department, Fundación Jimenez Díaz University Hospital and Hospital General de Villalba, Madrid, Spain
- Health Research Institute Fundación Jiménez Díaz (IIS-FJD, UAM), Madrid, Spain
| | - Nadia Laack
- Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Kelvin Hong
- Division of Vascular and Interventional Radiology, Johns Hopkins Hospital, Baltimore, MD
| | - Peter Hohenberger
- Mannheim University Medical Center, University of Heidelberg Germany, Mannheim, Germany
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12
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Li L, Bailiff OA, Blanchard B, Gardner JM. Primary Epithelioid Sarcoma of the Conchal Bowl in a 64-Year-Old Male: A Case Report and Review of the Literature. Am J Dermatopathol 2023; 45:383-387. [PMID: 37191372 DOI: 10.1097/dad.0000000000002423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
ABSTRACT Epithelioid sarcoma (ES) is a distinctive malignant mesenchymal neoplasm with atypical epithelioid cells palisading around a central zone of necrosis. ES is a rare entity even in soft tissue pathology. Immunohistochemically, tumors usually show diffuse epithelial membrane antigen and cytokeratin expression and loss of nuclear INI1 (SMARCB1) expression. Here, we report a case of a 64-year-old man with ES arising in the left conchal bowl. Given the clinical presentation including patient's age, sun-exposed area of skin, and slow-growing, asymptomatic, small pink pearly papule, this patient was initially misdiagnosed with basal cell carcinoma clinically and treated with topical imiquimod at an outside facility. The lesion continued to grow and eventually became symptomatic despite the treatment after which biopsy was obtained. Despite the unusual anatomic site and the patient's age, the microscopic and immunohistochemical findings were characteristic of conventional-type ES. Our case shows that ES can arise in rare locations and in older adults where it may be more easily misdiagnosed clinically and pathologically as a nonmelanoma skin cancer.
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Affiliation(s)
- Liping Li
- Department of Anatomic and Clinical Pathology, Geisinger Medical Center, Danville, PA
| | - Oksana A Bailiff
- Department of Dermatology, Geisinger Medical Center, Danville, PA; and
| | - Brielle Blanchard
- Department of Dermatology, Geisinger Medical Center Muncy, Muncy, PA
| | - Jerad M Gardner
- Department of Anatomic and Clinical Pathology, Geisinger Medical Center, Danville, PA
- Department of Dermatology, Geisinger Medical Center, Danville, PA; and
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Rutland CD, Bean GR, Charville GW. Contemporary diagnostic approach to atypical vascular lesion and angiosarcoma. Semin Diagn Pathol 2023:S0740-2570(23)00045-X. [PMID: 37121782 DOI: 10.1053/j.semdp.2023.04.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 04/24/2023] [Indexed: 05/02/2023]
Abstract
Vascular neoplasms account for a substantial fraction of cutaneous mesenchymal tumors, spanning from clinically indolent benign lesions to highly aggressive malignancies. These neoplasms present a distinctive challenge in terms of their diagnostic histopathology, both because of the breadth of their morphological manifestations and because of the significant histological overlap between different entities, even benign and malignant ones. The post-radiotherapy setting is particularly problematic diagnostically, insofar as radiation exposure predisposes not only to secondary angiosarcoma, but also to atypical vascular lesion, a largely benign proliferation of cutaneous blood vessels typically affecting the breast. To address these challenges, we explore the clinical, histological, and molecular features of malignant vascular neoplasia, including primary and secondary subtypes, through the comparative lens of atypical vascular lesion. In addition to highlighting the key morphological indicators of malignancy in superficial vasoformative tumors, we offer an approach that integrates clinical characteristics and molecular genetic profiling to facilitate accurate classification. With this current knowledge as our foundation, we also look ahead in an effort to frame some of the key unanswered questions regarding superficial vascular malignancies and their natural history, clinical management, and molecular underpinnings.
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Affiliation(s)
- Cooper D Rutland
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Gregory R Bean
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA.
| | - Gregory W Charville
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA.
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14
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Aldosari S, Ayman A, Almaiman L, Alzaid T, Alhossaini R, Amin T. Acute abdomen secondary to perforated jejunal gastrointestinal stromal tumor and imatinib-related isolated pericardial effusion in a 50-year-old female patient: A case report and review of literature. Int J Surg Case Rep 2023; 106:108197. [PMID: 37071957 PMCID: PMC10130195 DOI: 10.1016/j.ijscr.2023.108197] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 04/08/2023] [Accepted: 04/10/2023] [Indexed: 04/20/2023] Open
Abstract
INTRODUCTION Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal tract; occurring most often in the stomach and to a lesser extent in the jejunum. The majority of the tumors express activating mutations in either c-KIT or PDGFRA tyrosine kinases, which respond to tyrosine kinase inhibitors (TKI). Jejunal GIST is considered to be extremely rare and challenging to diagnose due to its non-specific presentation. As a result, patients usually present at an advance stage of the disease, making the prognosis poor and difficult to manage. CASE PRESENTATION In the present study, we report a 50-year-old female who was diagnosed with metastatic jejunal GIST. She was commenced on Imatinib (TKI) and shortly after she presented to the emergency department with an acute abdomen. A CT scan of the abdomen revealed ischemic changes in the jejunal loops and pneumoperitoneum. The patient required emergency laparotomy due to perforated GIST, and creation of pericardial window due to hemodynamic instability possibly secondary TKI-related isolated pericardial effusion. CONCLUSION Jejunal GIST is rare and usually presents as emergency due to obstruction, hemorrhage or rarely perforation. Although, systemic therapy with TKI is the principal treatment for advance disease, Jejunal GIST should be removed surgically. It is surgically challenging due to the anatomical complexity of the tumor. Surgeons treating such patients must be cautious for TKI side effects.
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Affiliation(s)
- Sarah Aldosari
- Department of Surgery, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia; College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
| | - Azzam Ayman
- Department of Surgical Oncology, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia; Department of General Surgery, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | | | - Tariq Alzaid
- Department of Pathology, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Rana Alhossaini
- Department of Surgery, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Tarek Amin
- Department of Surgical Oncology, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
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15
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Review of primary superficial soft tissue mesenchymal tumors of malignant or intermediate biological potential. Skeletal Radiol 2023; 52:435-445. [PMID: 35867123 DOI: 10.1007/s00256-022-04127-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 07/10/2022] [Accepted: 07/12/2022] [Indexed: 02/02/2023]
Abstract
The majority of the sarcomas are deep in location, larger than 5 cm in size, and heterogenous in imaging appearance. However, when sarcomas occur superficially, these typical features may be absent, failing to alert the radiologist to a malignancy and mimicking one of the more numerous benign superficial tumors that make up the bulk of soft tissue mass evaluations. This manuscript will discuss the current role of imaging in recognizing features concerning for superficial soft tissue sarcomas. Provided is an overview of the demographic, clinical, and imaging features of the most commonly encountered superficial soft tissue sarcomas, including undifferentiated pleomorphic, leiomyosarcoma, synovial sarcoma, liposarcoma, myxofibrosarcoma, dermatofibrosarcoma protuberans, epithelioid sarcoma, and angiosarcoma. A less common but primary superficial tumor, angiomatoid fibrous histiocytoma, is also reviewed as the diagnosis may be confounding both clinically and on imaging studies.
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16
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Gu H, Song R, Beeraka NM, Li T, Zhao D, Liu J, Fan R. SEER-Based Survival Nomogram (1998-2015) Based on 'Stage, Lymph Node Dissection, Tumor Size and Degree of Differentiation, and Therapies' for Prognosis of Primary Pulmonary Sarcoma. Technol Cancer Res Treat 2023; 22:15330338221150732. [PMID: 36740992 PMCID: PMC9903015 DOI: 10.1177/15330338221150732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Objective: Primary pulmonary sarcoma (PPS) is very rare in terms of incidence, henceforth, the clinical evidence pertinent to the prognosis of PPS is limited. The aim of this study was to construct a nomogram for evaluating the overall survival (OS) of patients diagnosed with PPS based on the stage, lymph node dissection, tumor size and degree of differentiation, and therapies. Methods: A total of 515 patients diagnosed with PPS during the period of 1998 to 2015 were obtained from the surveillance, epidemiology, and end results database and randomly segregated into 'training group' and 'validation group' with a ratio of 7:3. Regression analysis was executed for the training group to obtain the independent factors influencing prognosis of PPS patients. A nomogram was constructed as per the results obtained through multivariate Cox regression analysis subsequently validated using C index, receiver operating characteristic (ROC) curve, and calibration curves. Results: Age, tumor size, histology type, lymph node surgery, summary stage and differentiation grade were independent factors affecting the prognosis. C index was 0.775 and 0.737 for both training group, and validation group, respectively. Areas under the ROC curve of 1-year, 3-year, and 5-year OS were 87.6 (95% CI: 83.8-91.3), 90.1 (95% CI: 86.2-94.0) and 90.6 (95% CI: 85.8-95.4), respectively, in training group. Area under the curve values of 1-year, 3-year, and 5-year OS in the validation group were 83.1 (95% CI: 75.8-90.5), 82.9 (95% CI: 73.2-92.7) and 87.0 (95% CI: 75.9-98.1), respectively. Based on the nomogram, patients were segregated into low-risk group and high-risk group (degree of risk: cutoff score 193). OS of low-risk group was significantly higher when compared to high-risk group (P < .001) in the training group and validation group. Radiotherapy was a risk factor for the low-risk group and adjuvant chemotherapy has not exhibited influence on OS pertinent to low-risk group. However, adjuvant radiotherapy or chemotherapy both significantly improved the prognosis of PPS patients (P < .001) in the high-risk group. Conclusion: Constructed nomogram could have a strong predictive ability with higher accuracy for the prognosis of patients with PPS. Patients at low risk could not benefit from adjuvant radiotherapy or chemotherapy, while the prognosis clearly improved in the high-risk populations treated with either radiotherapy or chemotherapy.
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Affiliation(s)
- Hao Gu
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ruixia Song
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Narasimha M. Beeraka
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China,I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia,JSS College of Pharmacy, JSS Academy of Higher Education and Research (JSS AHER), Mysuru, Karnataka, India
| | - Tingxuan Li
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Di Zhao
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Junqi Liu
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China,Junqi Liu, Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Erqi District, Zhengzhou 450000, Henan Province, China.
| | - Ruitai Fan
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China,Ruitai Fan, Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Erqi District, Zhengzhou 450000, Henan Province, China.
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17
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Witt RG, Voss RK, Chiang YJ, Nguyen S, Scally CP, Lin PP, Torres KE, Moon BS, Satcher RL, Hunt KK, Bird JE, Feig BW, Lewis VO, Roland CL, Keung EZ. Practice Pattern Variability in the Management of Regional Lymph Node Metastasis in Extremity and Trunk Soft Tissue Sarcoma: A Survey of the Society of Surgical Oncology and Musculoskeletal Tumor Society Membership. Ann Surg Oncol 2023; 30:3668-3676. [PMID: 36723723 DOI: 10.1245/s10434-023-13142-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 01/09/2023] [Indexed: 02/02/2023]
Abstract
BACKGROUND Regional lymph node metastasis in extremity and trunk soft tissue sarcoma (ETSTS) is rare with no standardized management. We sought to determine management patterns for regional lymph node metastasis in ETSTS. METHODS A survey regarding the management of ETSTS lymph node metastasis was distributed to the membership of the Musculoskeletal Tumor Society (MSTS) and the Society of Surgical Oncology (SSO) in January 2022. The survey queried the type of training (surgical oncology, orthopedic oncology), details of their practice setting, and management decisions of hypothetical ETSTS scenarios that involved potential or confirmed lymph node metastasis. RESULTS The survey was distributed to 349 MSTS members (open rate of 63%, completion rate 21%) and 3026 SSO members (open rate of 55%, completion rate 4.7%) and was completed by 214 respondents, of whom 73 (34.1%) and 141 (65.9%) were orthopedic oncology and surgical oncology fellowship-trained, respectively. The majority of respondents practiced in an academic setting (n = 171, 79.9%) and treat >10 extremity sarcoma cases annually (n = 138, 62.2%). In scenarios with confirmed nodal disease for clear cell and epithelioid sarcoma, surgical oncologists were inclined to perform lymphadenectomy, while orthopedic oncologists were inclined to offer targeted lymph node excision with adjuvant radiation (p < 0.001). There was heterogeneity of responses regarding the management of nodal disease regardless of training background. CONCLUSION Self-reported management of nodal disease in ETSTS was variable among respondent groups with differences and similarities based on training background. These data highlight the variability of practice for nodal disease management and the need for consensus-based guidelines.
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Affiliation(s)
- Russell G Witt
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rachel K Voss
- Department of Sarcoma Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Yi-Ju Chiang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sa Nguyen
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christopher P Scally
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Patrick P Lin
- Department of Orthopaedic Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keila E Torres
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bryan S Moon
- Department of Orthopaedic Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Robert L Satcher
- Department of Orthopaedic Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kelly K Hunt
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Justin E Bird
- Department of Orthopaedic Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Barry W Feig
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Valerae O Lewis
- Department of Orthopaedic Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christina L Roland
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Emily Z Keung
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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18
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Keung EZ, Krause KJ, Maxwell J, Morris CD, Crago AM, Houdek MT, Kane J, Lewis V, Callegaro D, Miller B, Lazar AJ, Gladdy R, Raut CP, Fabbri N, Al-Refaie W, Fairweather M, Wong SL, Roland CL. Sentinel Lymph Node Biopsy for Extremity and Truncal Soft Tissue Sarcomas: A Systematic Review of the Literature. Ann Surg Oncol 2023; 30:958-967. [PMID: 36307665 DOI: 10.1245/s10434-022-12688-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 10/04/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Regional lymph node metastasis (RLNM) occurs infrequently in patients with soft tissue sarcoma (STS), although certain STS subtypes have a higher propensity for RLNM. The identification of RLNM has significant implications for staging and prognosis; however, the precise impact of node-positive disease on patient survival remains a topic of controversy. Although the benefits of sentinel lymph node biopsy (SLNB) are well documented in patients with melanoma and breast cancer, whether this procedure offers a benefit in STS is controversial. METHODS A systematic literature search was performed and articles reviewed to determine if SLNB in patients with extremity/truncal STS impacts disease-free or overall survival. RESULTS Six studies were included. Rates of sentinel lymph node positivity were heterogeneous (range 4.3-50%). The impact of SLNB on patient outcomes remains unclear. The overall quality of available evidence was low, as assessed by the Grading of Recommendations, Assessment, Development, and Evaluation system. CONCLUSIONS The literature addressing the impact of nodal basin evaluation on the staging and management of patients with extremity/truncal STS is confounded by heterogeneous patient cohorts and clinical practices. Multicenter prospective studies are warranted to determine the true incidence of RLNM and whether SLNB could benefit patients with clinically occult RLNM at diagnosis.
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Affiliation(s)
- Emily Z Keung
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Kate J Krause
- Research Medical Library, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jessica Maxwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Carol D Morris
- Department of Orthopedic Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Aimee M Crago
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Matthew T Houdek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - John Kane
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Valerae Lewis
- Department of Orthopedic Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Dario Callegaro
- Department of Surgery, Sarcoma Service, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Benjamin Miller
- Department of Orthopedic Surgery, University of Iowa, Iowa City, IA, USA
| | - Alexander J Lazar
- Department of Pathology and Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rebecca Gladdy
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Chandrajit P Raut
- Department of Surgery, Brigham and Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Nicola Fabbri
- Department of Orthopedic Surgery, NYU Langone Grossman School of Medicine, New York, NY, USA
| | - Waddah Al-Refaie
- Department of Surgery, Georgetown University Medical Center, Washington, DC, USA
| | - Mark Fairweather
- Department of Surgery, Brigham and Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Sandra L Wong
- Department of Surgery, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Christina L Roland
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Alvarez E, He J, Spunt SL, Hayes-Jordan A, Kao SC, Parham DM, Million L, Weiss AR, Barkauskas DA. Lymph node metastases in paediatric and young adult patients with non-rhabdomyosarcoma soft tissue sarcoma (NRSTS): Findings from Children's Oncology Group (COG) study ARST0332. Eur J Cancer 2023; 180:89-98. [PMID: 36566574 PMCID: PMC9940640 DOI: 10.1016/j.ejca.2022.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 10/31/2022] [Accepted: 11/14/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE The aim of this paper is to better define the clinical features and outcomes of young patients with non-rhabdomyosarcoma soft tissue sarcoma (NRSTS) with regional and distant lymph node (LN) metastases treated in a standardised fashion, we analysed LN involvement in COG study ARST0332, which evaluated a risk-based treatment strategy for young patients with all stages of NRSTS. PATIENTS AND METHODS Patients <30 years old with newly diagnosed NRSTS and LN metastases enrolled on ARST0332 were studied. Regional LN sampling was required for those with epithelioid sarcoma, clear cell sarcoma or clinically/radiographically enlarged LNs. Tumour features and extent of pre-enrolment resection determined treatment, including chemotherapy, radiotherapy, and delayed surgery. Recommendations for LN metastases included LN dissection at the time of primary tumour resection and dose-adapted radiotherapy based on extent of LN resection. RESULTS Twenty of 529 eligible and evaluable ARST0332 patients with NRSTS had LN metastases; epithelioid sarcoma had the highest incidence (18%, 5 of 28). Pre-treatment imaging identified LN enlargement in 19 of 20 patients; 1 had no pre-treatment LN imaging. At 6.9 years median follow-up for surviving patients, 5-year overall survival was 85.7% (95% CI: 33.4%, 97.9%) for seven patients with isolated LN metastases and 15.4% (95% CI: 2.5%, 38.8%) for 13 patients with additional extranodal metastases. LN recurrence occurred in only one patient without LNs sampled at initial diagnosis. CONCLUSION LN metastases occur in about 4% of paediatric/young adult NRSTS, are limited to a few histologic subtypes, and are rare in patients who did not have clinical or imaging evidence of lymphadenopathy, suggesting that biopsies of non-enlarged LNs are not necessary to identify occult involvement. Patients with isolated LN metastases have high 5-year overall survival (∼85%) and should be treated with curative intent. CLINICALTRIALS GOV REGISTRY NO NCT00346164.
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Affiliation(s)
- Elysia Alvarez
- Department of Pediatrics, University of California Davis School of Medicine, Davis, CA, USA.
| | - Jiayi He
- Department of Population and Public Health Sciences, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Sheri L Spunt
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Simon C Kao
- Department of Radiology, The University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - David M Parham
- Department of Pathology and Laboratory Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Lynn Million
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Aaron R Weiss
- Department of Pediatrics, Maine Medical Center, Portland, ME, USA
| | - Donald A Barkauskas
- Department of Population and Public Health Sciences, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
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20
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Ivanov V, Dimov L, Strashilov S, Milkov D, Dzalov N, Chervenkov L. Robotic gastrointestinal stromal tumors surgery - initial results. Folia Med (Plovdiv) 2022; 64:884-888. [PMID: 36876566 DOI: 10.3897/folmed.64.e91448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 09/15/2022] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Gastrointestinal stromal tumors (GISTs) usually present as an exophytic mass localized in stomach. Years ago, conventional surgery was the only option. Laparoscopic and robotic procedures have risen to prominence in recent decades as technology and surgical techniques have advanced.
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Affiliation(s)
| | | | | | - Denis Milkov
- Medical University of Plovdiv, Plovdiv, Bulgaria
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21
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Tong Y, Pi Y, Cui Y, Jiang L, Gong Y, Zhao D. Early distinction of lymph node metastasis in patients with soft tissue sarcoma and individualized survival prediction using the online available nomograms: A population-based analysis. Front Oncol 2022; 12:959804. [PMID: 36568161 PMCID: PMC9767978 DOI: 10.3389/fonc.2022.959804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 11/16/2022] [Indexed: 12/12/2022] Open
Abstract
Background The presence of metastatic tumor cells in regional lymph nodes is considered as a significant indicator for inferior prognosis. This study aimed to construct some predictive models to quantify the probability of lymph node metastasis (LNM) and survival rate of patients with soft tissue sarcoma (STS) with LNM. Methods Research data were extracted from the Surveillance, Epidemiology, and End Results (SEER) database between 2004 and 2017, and data of patients with STS from our medical institution were collected to form an external testing set. Univariate and multivariate logistic regression analyses were used to determine the independent risk factors for developing LNM. On the basis of the identified variables, we developed a diagnostic nomogram to predict the risk of LNM in patients with STS. Those patients with STS presenting with LNM were retrieved to build a cohort for identifying the independent prognostic factors through univariate and multivariate Cox regression analysis. Then, two nomograms incorporating the independent prognostic predictors were developed to predict the overall survival (OS) and cancer-specific survival (CSS) for patients with STS with LNM. Kaplan-Meier (K-M) survival analysis was conducted to study the survival difference. Moreover, validations of these nomograms were performed by the receiver operating characteristic curves, the area under the curve, calibration curves, and the decision curve analysis (DCA). Results A total of 16,601 patients with STS from the SEER database were enrolled in our study, of which 659 (3.97%) had LNM at the initial diagnosis. K-M survival analysis indicated that patients with LNM had poorer survival rate. Sex, histology, primary site, grade, M stage, and T stage were found to be independently related with development of LNM in patients with STS. Age, grade, histology, M stage, T stage, chemotherapy, radiotherapy, and surgery were identified as the independent prognostic factors for OS of patients with STS with LNM, and age, grade, M stage, T stage, radiotherapy, and surgery were determined as the independent prognostic factors for CSS. Subsequently, we constructed three nomograms, and their online versions are as follows: https://tyxupup.shinyapps.io/probabilityofLNMforSTSpatients/, https://tyxupup.shinyapps.io/OSofSTSpatientswithLNM/, and https://tyxupup.shinyapps.io/CSSofSTSpatientswithLNM/. The areas under the curve (AUCs) of diagnostic nomogram were 0.839 in the training set, 0.811 in the testing set, and 0.852 in the external testing set. For prognostic nomograms, the AUCs of 24-, 36-, and 48-month OS were 0.820, 0.794, and 0.792 in the training set and 0.759, 0.728, and 0.775 in the testing set, respectively; the AUCs of 24-, 36-, and 48-month CSS were 0.793, 0.777, and 0.775 in the training set and 0.775, 0.744, and 0.738 in the testing set, respectively. Furthermore, calibration curves suggested that the predicted values were consistent with the actual values. For the DCA, our nomograms showed a superior net benefit across a wider scale of threshold probabilities for the prediction of risk and survival rate for patients with STS with LNM. Conclusion These newly proposed nomograms promise to be useful tools in predicting the risk of LNM for patients with STS and individualized survival prediction for patients with STS with LNM, which may help to guide clinical practice.
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Affiliation(s)
- Yuexin Tong
- Department of Orthopedics, The China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - Yangwei Pi
- Department of Orthopedics, The China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - Yuekai Cui
- The Second Clinical Medical School of the Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Liming Jiang
- Department of Orthopedics, The China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - Yan Gong
- Department of Orthopedics, The China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - Dongxu Zhao
- Department of Orthopedics, The China-Japan Union Hospital of Jilin University, Changchun, Jilin, China,*Correspondence: Dongxu Zhao,
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22
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Yang S, Liao Z, Li T, Liu H, Ren Z, Wu H, Zhao J, Teng S, Xing R, Yang Y, Yang J. Clinicopathologic features, prognostic factors, and outcomes of visceral sarcomas: A retrospective 12-year single-center study. Front Oncol 2022; 12:1029913. [DOI: 10.3389/fonc.2022.1029913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 10/17/2022] [Indexed: 11/09/2022] Open
Abstract
BackgroundVisceral sarcomas are a rare form of soft tissue sarcoma. This study aimed to evaluate the survival and prognostic factors and effective treatments for visceral sarcomas.MethodsAll patients with visceral sarcoma referred to our center between January 2010 and December 2021 were retrospectively analyzed. The Kaplan-Meier method and a log-rank test were used for survival analysis.ResultsA total of 53 patients with visceral sarcoma were analyzed in this study with the median age at diagnosis of 57 (range, 24-77) years. Among them, 37 (69.8%) and 16 (30.2%) patients had localized and metastatic diseases at the initial presentation, respectively, and 44 patients underwent surgical resection. The median follow-up, event-free survival (EFS) and overall survival (OS) were 63.0 (range, 2-130), 42.0 months (95% confidence interval [CI] 10.879-73.121) and 45.0 months (95% CI 9.938-80.062), respectively. The 5-year EFS and OS rates were 44% and 46%, respectively. Univariate analysis of prognostic indicators illustrated that metastasis at presentation, surgery, surgical margin and the types of surgery were significantly associated with OS and EFS. In this study, combined chemotherapy or radiotherapy had no effects on EFS and OS.ConclusionPrimary visceral sarcoma is an uncommon and aggressive malignant tumor with a higher rate of local recurrence. In the largest cohort of visceral sarcomas in China to date, we identified metastases at presentation, surgery, surgical margin, and the types of surgery as independent predictors of survival. The combination of chemotherapy and radiotherapy did not affect survival.
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Witt RG, Cope B, Erstad DJ, Chiang YJ, Nassif EF, Scally CP, Torres KE, Hunt KK, Feig BW, Roland CL, Keung EZ. Sentinel Lymph Node Biopsy and Formal Lymphadenectomy for Soft Tissue Sarcoma: A Single Center Experience of 86 Consecutive Cases. Ann Surg Oncol 2022; 29:7092-7100. [PMID: 35501583 DOI: 10.1245/s10434-022-11803-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 04/04/2022] [Indexed: 01/16/2023]
Abstract
BACKGROUND Lymph node metastases (LNMs) are rare in patients with soft tissue sarcoma (STS), and there is limited evidence to guide clinical management. We describe our experience with sentinel lymph node biopsy (SLNB) and lymphadenectomy in STS patients. METHODS A single-center, retrospective review was performed for patients with STS treated with SLNB and/or lymphadenectomy from 1994 to 2018. Clinicopathologic characteristics, multimodality treatment, regional/distant recurrence-free survival (RFS), and overall survival (OS) were examined. RESULTS Eighty-six patients underwent SLNB (n = 34) and/or lymphadenectomy (n = 60) for STS. The most frequent histologic subtypes were epithelioid, clear cell, and undifferentiated pleomorphic sarcoma. Eight of 34 (23.5%) patients had a positive SLNB with 5-year OS of 71.4% compared with 71.9% for those with a negative SLNB. Eight of the 26 SLN-negative patients (30.8%) eventually developed nodal recurrence (n = 2) and/or (n = 6) distant metastasis with an estimated 5-year OS of 50%. Of patients undergoing lymphadenectomy, estimated 5-year OS was 44.6% and median RFS was 12 months. Eight (13.3%) had distant disease at time of lymphadenectomy, 20 (33.3%) developed distant recurrence after lymphadenectomy, and 6 (10%) developed regional-only recurrence. Patients with regional-only recurrence after lymphadenectomy had an estimated 5-year OS of 66.7% compared with 29.1% for those who recurred distantly. CONCLUSIONS Patients with positive SLNB had similar survival to those with negative SLNB. Lymphadenectomy for isolated nodal disease is associated with poor RFS but reasonable 5-year OS when recurrence is regional-only. In STS, regional disease appears clinically distinct from distant metastatic disease and has better outcomes.
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Affiliation(s)
- Russell G Witt
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brandon Cope
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Derek J Erstad
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yi-Ju Chiang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elise F Nassif
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christopher P Scally
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keila E Torres
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kelly K Hunt
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Barry W Feig
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christina L Roland
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Emily Z Keung
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Brennan MF, Singer S. Five decades of sarcoma care at Memorial Sloan Kettering Cancer Center. J Surg Oncol 2022; 126:896-901. [PMID: 36087086 DOI: 10.1002/jso.27032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 07/02/2022] [Indexed: 11/07/2022]
Abstract
Early studies of the management of soft tissue sarcoma at Memorial Sloan Kettering Cancer Center were influenced by development of robust prospective long-term databases. Increasing capacity for molecular diagnostics has identified a myriad of subtypes with definable natural history. Accurate identification of tissue-specific risk of recurrence and disease-specific survival have increasingly allowed selective use of surgery, radiation therapy, and target-specific cytotoxic and immune therapies.
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Affiliation(s)
- Murray F Brennan
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Samuel Singer
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Liu H, Zhang H, Zhang C, Liao Z, Li T, Yang T, Zhang G, Yang J. Pan-Soft Tissue Sarcoma Analysis of the Incidence, Survival, and Metastasis: A Population-Based Study Focusing on Distant Metastasis and Lymph Node Metastasis. Front Oncol 2022; 12:890040. [PMID: 35875111 PMCID: PMC9303001 DOI: 10.3389/fonc.2022.890040] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 06/13/2022] [Indexed: 12/02/2022] Open
Abstract
Background The rarity and complexity of soft tissue sarcoma (STS) make it a challenge to determine the incidence, survival, and metastasis rates. In addition, the clinicopathological risk factors for lymph node metastasis have rarely been reported. Methods Data on patients diagnosed with STS in the SEER database from 2000 to 2018 were extracted by SEER*Stat 8.3.9.1, and the incidence trend was calculated by Joinpoint 4.9 software. The KM method was used to calculate the survival curve, and the log-rank method was used to compare differences in the survival curves. The clinicopathological risk factors for lymph node metastasis were screened by logistic regression. Results Among the 35987 patients, 4299 patients (11.9%) had distant metastasis. The overall lymph node metastasis rate was 6.02%, which included patients suffering from both lymph node and distant metastasis. Considering that some lymph node metastases might be accompanying events of distant metastasis, the rate of only lymph node metastasis in STS patients decreased to 3.42% after excluding patients with distant metastasis. Patients with only lymph node metastases (N1/2M0) had a significantly worse prognosis than those without metastases (N0M0) but a better prognosis than those with only distant metastases (N0M1) (p<0.0001). In the multivariate logistic analysis, STS patients with larger tumors located in the head and neck, viscera, retroperitoneum, and certain specific pathological subtypes (compared with the liposarcoma), such as undifferentiated pleomorphic sarcoma, rhabdomyosarcoma, endometrial stromal sarcoma, gastrointestinal stromal tumor, synovial sarcoma, and angiosarcoma, had a higher risk of lymph node metastasis. Conclusions Lymph node metastasis is rare in STS, and the metastasis rate is significantly different among the different pathological types. Tumor size, location, and pathological subtype are significantly associated with the risk of lymph node metastasis. The overall survival of patients with lymph node metastasis is better than that of patients with distant metastasis, which suggests a more precise prognosis evaluation should be performed in these AJCC stage IV STS patients.
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Affiliation(s)
- Haotian Liu
- Department of Bone and Soft Tissue Tumor, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin’s Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Hongliang Zhang
- Department of Bone and Soft Tissue Tumor, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin’s Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- Orthopedic Surgery Department, Tianjin Hospital, Tianjin University, Tianjin, China
| | - Chao Zhang
- Department of Bone and Soft Tissue Tumor, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin’s Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Zhichao Liao
- Department of Bone and Soft Tissue Tumor, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin’s Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Ting Li
- Department of Bone and Soft Tissue Tumor, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin’s Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Tielong Yang
- Department of Bone and Soft Tissue Tumor, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin’s Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Gengpu Zhang
- Department of Bone and Soft Tissue Tumor, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin’s Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Jilong Yang
- Department of Bone and Soft Tissue Tumor, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin’s Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- *Correspondence: Jilong Yang,
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Devaud N, Vornicova O, Abdul Razak AR, Khalili K, Demicco EG, Mitric C, Bernardini MQ, Gladdy RA. Leiomyosarcoma: Current Clinical Management and Future Horizons. Surg Oncol Clin N Am 2022; 31:527-546. [PMID: 35715148 DOI: 10.1016/j.soc.2022.03.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Leiomyosarcomas are soft tissue tumors that are derived from smooth muscle mainly in the pelvis and retroperitoneum. Percutaneous biopsy is paramount to confirm diagnosis. Imaging is necessary to complete clinical staging. Multimodal treatment should be directed by expert sarcoma multidisciplinary teams that see a critical volume of these rare tumors. Surgery is the mainstay of curative intent treatment; however due to its high metastatic progression, there may be a benefit for neoadjuvant systemic treatment. Adjuvant systemic treatment has no proven disease-free survival, and its main role is in the palliative setting to potentially prolong overall survival.
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Affiliation(s)
- Nicolas Devaud
- Instituto Oncologico Fundacion Arturo Lopez Perez (FALP), Santiago, Chile
| | - Olga Vornicova
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | | | - Korosh Khalili
- Joint Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth G Demicco
- Department of Laboratory Medicine and Pathobiology, Sinai Health System, University of Toronto, Toronto, Ontario, Canada
| | - Cristina Mitric
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
| | - Marcus Q Bernardini
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
| | - Rebecca A Gladdy
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Division of General Surgery, Sinai Health System, University of Toronto, Toronto, Ontario, Canada.
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Weller JH, Westermann C, Patel P, Beckman RM, Pratilas CA, Morris CD, Rhee DS. Trends of lymph node sampling and metastasis in pediatric and young adult patients with clear cell, epithelioid, and synovial sarcomas. Pediatr Blood Cancer 2022; 69:e29455. [PMID: 35466567 DOI: 10.1002/pbc.29455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 10/07/2021] [Accepted: 10/27/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Clear cell sarcoma of soft tissue (CCS), epithelioid sarcoma, and synovial sarcoma are rare tumors historically identified as high risk for lymph node metastasis. This study investigates incident nodal metastasis and associated survival in children and young adults with these subtypes. PROCEDURE Using the National Cancer Database (2004-2015), we created a retrospective cohort of 1303 patients (aged ≤25 years) who underwent local control therapy for CCS, epithelioid sarcoma, and synovial sarcoma. Kaplan-Meier curves estimated overall survival (OS) by subtype. Stratifying on subtype, Cox regressions assessed OS by lymph node sampling status and nodal metastasis. RESULTS There were 103 (7.9%) patients with CCS, 221 (17.0%) with epithelioid sarcoma, and 979 (75.1%) with synovial sarcoma. Lymph node sampling was more frequent in patients with CCS (56.3%) and epithelioid sarcoma (52.5%) versus synovial sarcoma (20.5%, p < .001). Synovial sarcoma metastasized to lymph nodes less frequently than CCS or epithelioid sarcoma (2.1% vs. 14.6% and 14.9%, p < .001). Across all subtypes, lymph node metastasis was associated with inferior OS (HR 2.02, CI 1.38-2.95, p < .001). Lymph node sampling was associated with improved OS in CCS (HR 0.35, CI: 0.15-0.78, p = .010), inferior OS in synovial sarcoma (HR 1.60, CI: 1.13-2.25, p = .007), and no statistical association with OS in epithelioid sarcoma. CONCLUSIONS Lymph node metastasis is rare in children and young adults with synovial sarcoma. Lymph node sampling procedures were not consistently performed for patients with CCS or epithelioid sarcoma, but improved OS supports routine lymph node sampling in children and young adults with CCS.
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Affiliation(s)
- Jennine H Weller
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Carly Westermann
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Palak Patel
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ross M Beckman
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christine A Pratilas
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Carol D Morris
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Daniel S Rhee
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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28
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Witt RG, Roland CL, Keung EZ. ASO Author Reflections: Lymph Node Disease in Soft Tissue Sarcoma: A Problematic Clinical Dilemma. Ann Surg Oncol 2022; 29:7101. [PMID: 35486264 DOI: 10.1245/s10434-022-11825-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 04/14/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Russell G Witt
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christina L Roland
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Emily Z Keung
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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29
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An Uncommon Presentation of Carcinosarcoma of the Stomach and a Minimally Invasive Approach for Treatment. Case Rep Gastrointest Med 2022; 2022:1047334. [PMID: 35433062 PMCID: PMC9010185 DOI: 10.1155/2022/1047334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/02/2022] [Accepted: 03/24/2022] [Indexed: 11/17/2022] Open
Abstract
Carcinosarcoma is a rare malignant neoplasm that is composed of both epithelial and mesenchymal tumor components. Gastric carcinosarcoma is even more rare and is often diagnosed at a late stage. In this report, we investigate a case of early gastric carcinosarcoma with regional lymph node metastasis in a 78-year-old woman. The patient underwent partial gastrectomy, lymphadenectomy, and splenectomy. The tumor was confined to the gastric submucosa, and a biopsy specimen led to a histological diagnosis of carcinosarcoma with adenocarcinoma, squamous-cell carcinoma, and undifferentiated pleomorphic sarcoma components. Metastasis was present in one lymph node and displayed osteosarcomatous differentiation. Vigilant monitoring for recurrence and metastatic disease will be required for this patient.
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30
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Imaging of Oligometastatic Disease. Cancers (Basel) 2022; 14:cancers14061427. [PMID: 35326586 PMCID: PMC8946296 DOI: 10.3390/cancers14061427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/03/2022] [Accepted: 03/08/2022] [Indexed: 11/22/2022] Open
Abstract
Simple Summary The imaging of oligometastatic disease (OMD) is challenging as it requires precise loco-regional staging and whole-body assessment. The combination of imaging modalities is often required. The more accurate imaging tool will be selected according to tumor type, the timing with regard to measurement and treatment, metastatic location, and the patient’s individual risk for metastasis. The most commonly used modalities are contrast-enhanced computed tomography (CT), magnetic resonance imaging and metabolic and receptor-specific imaging, particularly, 18F-fluorodesoxyglucose positron emission tomography/CT, used alone or in combination. Abstract Oligometastatic disease (OMD) is an emerging state of disease with limited metastatic tumor burden. It should be distinguished from polymetastatic disease due the potential curative therapeutic options of OMD. Imaging plays a pivotal role in the diagnosis and follow-up of patients with OMD. The imaging tools needed in the case of OMD will differ according to different parameters, which include primary tumor type, timing between measurement and treatment, potential metastatic location and the patient’s individual risk for metastasis. In this article, OMD is defined and the use of different imaging modalities in several oncologic situations are described in order to better understand OMD and its specific implication for radiologists.
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Jacob LA, A. S, Ninutha S, Dasappa L, MC SB, KN L, AH R, LK R, Saldanha S. Soft Tissue Sarcomas with Special Reference to Molecular Aberration, Chemotherapy, and Recent Advances: A Review Article. Indian J Med Paediatr Oncol 2022. [DOI: 10.1055/s-0041-1740324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
AbstractSoft tissue sarcomas (STS) are a diverse group of rare solid tumors of mesenchymal cell origin with distinct clinical and pathological features. They account for less than 1% of all adult malignancies and 15% of pediatric neoplasms. They include over hundreds of different histological subtypes. Many of these subtypes can occur at any age and are not confined to a specific site. Each subtype displays variable clinical behavior. Low incidence, variable presentation, behavior, and long-term outcomes further make it challenging to treat. There are multiple ongoing trials that focus on the anatomic site and histologic subtype to tailor the treatment. Further rarity of each histotype is a major barrier to recruit patients to randomized controlled trials. A multidisciplinary approach is mandatory in all cases of soft tissue sarcomas.The purpose of this review is to thoroughly understand the existing literature on history, incidence, epidemiology, etiology, histology, pathogenesis, diagnostic modalities, prognosis, management, and post treatment surveillance of STS. Uterine sarcomas, gastrointestinal stromal tumors (GIST), and pediatric sarcomas are not included here. It briefly highlights various molecular aberrations, changes in staging as per the American Joint Committee on Cancer (AJCC) 8, drugs that are used off-label in specific subtypes of sarcoma along with the recent advances. The classification of STS is undergoing continuous evolution. A wide variety of subtypes can only be diagnosed accurately with sophisticated molecular diagnostic tests and with the involvement of expert geneticists and pathologists to interpret it.There is no clarity on tailoring the treatment of STS to date. There is always a question on how best we can incorporate chemotherapy and radiotherapy along with surgery as a part of multimodality treatment. The heterogeneity of STS has hindered the development of robust, evidence-based treatment strategies, and our therapeutic approach is neither histology-specific nor widely standardized. Increased knowledge about sarcoma biology could help to discover new and more effective treatment strategies and help overcome the therapeutic challenge imposed by this deadly disease. Continued collaboration among various sarcoma centers globally will be of prime importance to optimize STS management. This will allow studies to be both sufficiently large and reasonably focused to generate evidence that is clinically meaningful in specific STS patient populations.
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Affiliation(s)
- Linu Abraham Jacob
- Department of Medical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, India
| | - Sreevalli A.
- Department of Medical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, India
| | - Shwetha Ninutha
- Department of Medical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, India
| | - Lokanatha Dasappa
- Department of Medical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, India
| | - Suresh Babu MC
- Department of Medical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, India
| | - Lokesh KN
- Department of Medical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, India
| | - Rudresha AH
- Department of Medical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, India
| | - Rajeev LK
- Department of Medical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, India
| | - Smitha Saldanha
- Department of Medical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, India
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Surgical resection of regional lymph node metastases in soft tissue sarcoma may not result in improved long-term survival. EUROPEAN JOURNAL OF PLASTIC SURGERY 2022. [DOI: 10.1007/s00238-021-01930-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Woo HY. Biphasic synovial sarcoma with a striking morphological divergence from the main mass to lymph node metastasis: A case report. Medicine (Baltimore) 2022; 101:e28481. [PMID: 35029897 PMCID: PMC8735718 DOI: 10.1097/md.0000000000028481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 12/16/2021] [Indexed: 12/02/2022] Open
Abstract
RATIONALE Synovial sarcoma accounts for 5% to 10% of all soft tissue sarcomas and involves almost any anatomic site, particularly the deep soft tissue of the extremities of young adults. The incidence rate of lymph node metastases in synovial sarcoma is 3% to 7%, but the detailed morphological features of the metastatic tumors in the lymph node have not been documented. PATIENT CONCERNS A 64-year-old Korean man presented with a huge mass in the left lower thorax and multiple hypermetabolic lymph nodes along the mediastinal, supraclavicular, internal mammary, and retrocrural regions. DIAGNOSES The patient was diagnosed with primary pleuropulmonary biphasic synovial sarcoma with lymph node metastases, where the main mass mostly comprised spindle cells (>95%) and the metastatic lymph nodes comprised only epithelial cells. INTERVENTIONS Left lower lobe lobectomy with the resection of the chest wall (including left ribs 8-10) and diaphragm and mediastinal lymph node dissection were performed. OUTCOMES In the 2-month follow-up period, there have been no complications so far, and the attending physician is currently planning for the adjuvant chemotherapy. LESSONS The main mass and the metastatic lesion can be clearly different morphologically. In tumors with biphasic differentiation, such as synovial sarcoma, cells that constitute only a small fraction of the main mass may appear as the dominant cells in metastatic lesions.
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Affiliation(s)
- Ha Young Woo
- Department of Pathology, National Cancer Center, Goyang, Republic of Korea
- Department of Pathology, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Republic of Korea
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Qiu X, He H, Zeng H, Tong X, Liu Q. The Role of Radiotherapy in Soft Tissue Sarcoma on Extremities With Lymph Nodes Metastasis: An IPTW Propensity Score Analysis of the SEER Database. Front Oncol 2021; 11:751180. [PMID: 34745979 PMCID: PMC8566919 DOI: 10.3389/fonc.2021.751180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 09/30/2021] [Indexed: 11/13/2022] Open
Abstract
Background Soft tissue sarcomas on extremities with regional lymph nodes metastasis (STSE-RLNM) is a devastating situation. Optimizing therapeutic approaches is vital but hampered by a shortage of randomized trials. We used a population-level database to evaluate radiotherapy’s impact on sarcoma-specific survival (SSS) and overall survival (OS) for surgery for STSE-RLNM. Methods We retrospectively screened data from the SEER database (2004–2015), and 265 patients with STSE-RLNM who received surgery, with (134) or without (131) radiotherapy, were enrolled in this study. A propensity-score-matched analysis with the inverse probability of treatment weighting (IPTW) Kaplan–Meier curve was created. The log-rank test and Cox regression analysis were performed to compare SSS and OS in patients with and without radiotherapy. Further analysis of radiotherapy time was conducted, and the Kaplan–Meier curve and the log-rank test were done. Landmark analysis was introduced to attenuate the immortal bias. Results In the original unadjusted cohort, the radiotherapy + surgery group is associated with improved SSS [hazard ratio (HR), 0.66; 95% CI, 0.47–0.91; p = 0.011] and OS (HR, 0.64; 95% CI, 0.47–0.88; p = 0.006). This significant treatment effect was also noted in IPTW-adjusted Cox regression either on SSS (HR, 0.65; 95% CI, 0.45–0.93; p = 0.020) or on OS (HR, 0.64; 95% CI, 0.46–0.91; p = 0.013). The Kaplan–Meier curve and log-rank test showed that pre- and postoperative radiotherapy was not related to SSS (p = 0.980 or OS (p = 0.890). Conclusion Radiotherapy and surgery has a significant benefit on the prognosis of patients with STSE-RLNM compared to surgery alone. These findings should be considered when making treatment decisions for them.
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Affiliation(s)
- Xinzhu Qiu
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
| | - Hongbo He
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
| | - Hao Zeng
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
| | - Xiaopeng Tong
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
| | - Qing Liu
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
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Saharan N, Gupta N, Loordudasan L, Nahar Saikia U, Khare S. Fine needle aspiration cytology from an axillary lymph node: Finessing the fine distinctions. Diagn Cytopathol 2021; 49:1257-1260. [PMID: 34708939 DOI: 10.1002/dc.24894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/05/2021] [Accepted: 10/19/2021] [Indexed: 11/09/2022]
Affiliation(s)
- Neha Saharan
- Department of Cytology and Gynaecological Pathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nalini Gupta
- Department of Cytology and Gynaecological Pathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Loomila Loordudasan
- Department of Cytology and Gynaecological Pathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Uma Nahar Saikia
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Siddhant Khare
- Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Guedes A, Oliveira MBDR, Costa FM, de Melo AS. Updating on Bone and Soft Tissue Sarcomas Staging. Rev Bras Ortop 2021; 56:411-418. [PMID: 34483382 PMCID: PMC8405264 DOI: 10.1055/s-0040-1710331] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 02/20/2020] [Indexed: 10/27/2022] Open
Abstract
Bone and soft tissue sarcomas consist of a heterogeneous group of malignant tumors of mesenchymal origin that can affect patients from any age. The precise staging of these lesions determines the best therapeutic strategies and prognosis estimates. Two staging systems are the most frequently used: the system proposed by the University of Florida group, led by Dr. William F. Enneking (1980) and adopted by the Musculoskeletal Tumor Society (MSTS), and the system developed by the American Joint Committee on Cancer (AJCC) (1977), currently in its 8 th edition (2017). This paper updates the reader on the staging of bone and soft tissue sarcomas affecting the musculoskeletal system.
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Affiliation(s)
- Alex Guedes
- Serviço de Ortopedia, Hospital Santa Izabel, Santa Casa de Misericórdia da Bahia, Salvador, BA, Brasil
| | - Marcelo Bragança dos Reis Oliveira
- Serviço de Traumato-ortopedia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - Flávia Martins Costa
- Departamento de Radiologia, Universidade Federal Fluminense, Niterói, RJ, Brasil
| | - Adelina Sanches de Melo
- Serviço de Medicina Nuclear, Hospital Santa Izabel, Santa Casa da Misericórdia da Bahia, Salvador, BA, Brasil
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American Brachytherapy Society (ABS) consensus statement for soft-tissue sarcoma brachytherapy. Brachytherapy 2021; 20:1200-1218. [PMID: 34303600 DOI: 10.1016/j.brachy.2021.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 05/17/2021] [Accepted: 05/21/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Growing data supports the role of radiation therapy in the treatment of soft tissue sarcoma (STS). Brachytherapy has been used for decades in the management of STS and can be utilized as monotherapy or as a boost to external beam radiation. We present updated guidelines from the American Brachytherapy Society regarding the utilization of brachytherapy in the management of STS. METHODS AND MATERIALS Members of the American Brachytherapy Society with expertise in STS and STS brachytherapy created an updated clinical practice guideline including step-by-step details for performing STS brachytherapy based on a literature review and clinical experience. RESULTS Brachytherapy monotherapy should be considered for lower-recurrence risk patients or after a local recurrence following previous external beam radiation; a brachytherapy boost can be considered in higher-risk patents meeting implant criteria. Multiple dose/fractionation regimens are available, with determination based on tumor location and treatment intent. Techniques to limit wound complications are based on the type of wound closure; wound complication can be mitigated with a delay in the start of brachytherapy with immediate wound closure or by utilizing a staged reconstruction technique, which allows an earlier treatment start with a delayed wound closure. CONCLUSIONS These updated guidelines provide clinicians with data on indications for STS brachytherapy as well as guidelines on how to perform and deliver high quality STS brachytherapy safely with minimal toxicity.
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Abstract
Most tumors of the hand and the wrist are benign; however, malignant conditions can mimic benign tumors and must be worked up accordingly.
Advanced imaging should be followed by biopsy before definitive treatment of tumors of unknown diagnosis. The most common soft-tissue masses in the hand and the wrist are ganglion cysts, whereas the most common bone tumors are enchondromas.
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Affiliation(s)
- Sophia A Strike
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mark E Puhaindran
- Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore
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Benz MR, Crompton JG, Harder D. PET/CT variants and pitfalls in bone and soft tissue sarcoma. Semin Nucl Med 2021; 51:584-592. [PMID: 34238508 DOI: 10.1053/j.semnuclmed.2021.06.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Sarcomas are rare tumors of mesenchymal origin and comprise only around 1% of adult cancers. The abundance of sarcoma histiotypes, with distinct imaging characteristics, biology, clinical behavior and treatment strategy, result in a complex disease presentation, requiring management by multidisciplinary specialized sarcoma centers. Oncologic and musculoskeletal radiology guidelines provide minimal guidance and only fragmentary information on the indications of 18F-FDG PET/CT in sarcoma. Therefore, knowledge of various phenotypes with preference for bone and lymph node metastases or higher incidence of local and distant recurrence is essential to select the appropriate diagnostic imaging tests and its interpretation. Benign and malignant soft tissue and bone tumors often share common radiographic and metabolic imaging characteristics. In addition, metastases of various histiotypes might exhibit a spectrum of atypical imaging appearances. Therefore, imaging specialists need to be aware of these variants and associated pitfalls of sarcoma imaging.
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Affiliation(s)
- Matthias R Benz
- Ahmanson Translational Theranostics Division, Department of Molecular and Medical Pharmacology, University of California, Los Angeles, CA; Department of Radiology, University of California, Los Angeles, CA; Department of Nuclear Medicine, University of Duisburg-Essen, Essen, Germany.
| | - Joseph G Crompton
- Division of Surgical Oncology, University of California, Los Angeles, CA
| | - Dorothee Harder
- Clinic of Radiology and Nuclear Medicine, University Hospital of Basel, Switzerland
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Gulati M, Mittal A, Barwad A, Pandey R, Rastogi S, Dhamija E. Imaging and Pathological Features of Alveolar Soft Part Sarcoma: Analysis of 16 Patients. Indian J Radiol Imaging 2021; 31:573-581. [PMID: 34790300 PMCID: PMC8590546 DOI: 10.1055/s-0041-1735501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Context Alveolar soft part sarcoma (ASPS) is a rare soft tissue tumor most commonly occurring in deep intramuscular plane of lower extremities of adolescents and young adults. It is a highly vascular, slow growing tumor with malignant potential having lung as the most common site of metastases at the time of presentation. Aims The aim is to review the imaging findings of ASPS and determine characteristic imaging features of this rare tumor. Materials and Methods Sixteen patients having histopathological diagnosis and preoperative imaging of ASPS attending the dedicated sarcoma clinic at our institute were included in the study. The demographic, clinical, and imaging data were retrieved from the case records and then evaluated for characteristic imaging features which may raise suspicion of ASPS. Results The patients ranged from 3 to 72 years of age and with a slight male preponderance. Of the eight CECTs evaluated, 62.5% tumors showed well-defined lobulated margins, 87.5% cases showed intense enhancement with presence of feeder vessels. On CEMRI of 10 patients, 70% had well circumscribed lobulated margins with intense enhancement and tortuous flow voids in most of them. All cases showed T2 hyperintense signal. Fourteen of 16 (87.5%) patients had metastatic disease with lung as the most common site (92.8%). Conclusion ASPS is a rare soft tissue sarcoma seen in children and young adults. Imaging may mimic a vascular malformation due to the presence of tortuous feeders. Misdiagnosis at an early stage may lead to later metastatic presentation of the disease, thus emphasizing the need to suspect it on imaging.
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Affiliation(s)
- Malvika Gulati
- Department of Radiodiganosis, Dr. B. R. A. IRCH, All India Institute of Medical Sciences, New Delhi, India
| | - Abhenil Mittal
- Department of Medical Oncology, Dr. B. R. A. IRCH, All India Institute of Medical Sciences, New Delhi, India
| | - Adarsh Barwad
- Department of Pathology, Dr. B. R. A. IRCH, All India Institute of Medical Sciences, New Delhi, India
| | - Rambha Pandey
- Department of Radiation Oncology, Dr. B. R. A. IRCH, All India Institute of Medical Sciences, New Delhi, India
| | - Sameer Rastogi
- Department of Medical Oncology, Dr. B. R. A. IRCH, All India Institute of Medical Sciences, New Delhi, India
| | - Ekta Dhamija
- Department of Radiodiganosis, Dr. B. R. A. IRCH, All India Institute of Medical Sciences, New Delhi, India
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Dammerer D, VAN Beeck A, Schneeweiss V, Schwabegger A. Follow-up Strategies for Primary Extremity Soft-tissue Sarcoma in Adults: A Systematic Review of the Published Literature. In Vivo 2021; 34:3057-3068. [PMID: 33144410 DOI: 10.21873/invivo.12140] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 09/14/2020] [Accepted: 09/21/2020] [Indexed: 01/22/2023]
Abstract
AIM Follow-up strategies for primary extremity soft-tissue sarcomas (eSTS) in adults were evaluated in a systematic review of the published literature. MATERIAL AND METHODS The published literature was reviewed using PubMed. Of 136,646 studies published between 1985 and 2019, 78 original articles met the inclusion criteria. Articles were selected on the basis of the PRISMA guidelines. The selected articles were then cross-searched to identify further publications. August 1, 2019 was used as the concluding date of publication. RESULTS A variety of follow-up schedules have been reported in recently published literature. Two official guidelines have been approved by international societies. The guidelines distinguish between high- and low-grade STS, but mention a wide range of follow-up intervals. Established tools of follow-up include computed tomograph, X-rays of the chest, and magnetic resonance imaging of the primary tumor site in addition to clinical observation and physical examination. CONCLUSION Further research will be needed to establish evidence-based guidelines and schedules for follow-up strategies in patients with eSTS.
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Affiliation(s)
- Dietmar Dammerer
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Viktoria Schneeweiss
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Anton Schwabegger
- Department of Plastic Surgery, Medical University of Innsbruck, Innsbruck, Austria
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Lo S, Foster N, Campbell L, White J, Nixon I, Mansell J, McCleery M, Whyte L, Cowie F. A need for clarity on surgical management of breast sarcoma: Scottish sarcoma network guidelines and regional audit. J Plast Reconstr Aesthet Surg 2021; 74:1180-1192. [PMID: 33308991 DOI: 10.1016/j.bjps.2020.10.072] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 09/05/2020] [Accepted: 10/22/2020] [Indexed: 12/14/2022]
Abstract
Currently, there are no comprehensive breast sarcoma guidelines in the UK. There is therefore a need for guidelines to clarify surgical management, which we have based on data from our regional audit, current evidence, and consensus between West of Scotland Breast Cancer and Scottish Sarcoma Managed Clinical Networks. Methods and results: From 2007 to 2019, 46 patients were treated with breast sarcoma in the West of Scotland. Sarcoma Centre versus Peripheral Hospitals: Incomplete excision rate was 0% at sarcoma centre and 50% at peripheral hospitals (p = 0.0002, Odds Ratio 43). For angiosarcoma, 0% positive margin at the sarcoma centre versus 62.5% at the peripheral unit (p = 0.0036, odds ratio 39.3). Tumours treated at the sarcoma centre were larger than those treated at peripheral hospitals (92.5 versus 39.7 mm, p = 0.0009). WLE (wide local excision) versus mastectomy: Out of eight WLE patients, seven (87.5%) had positive margins, with 6 of these patients proceeding to mastectomy (i.e. 75% WLE patients ultimately had a mastectomy). The positive margin rate was significantly higher in WLE (87.5%) than in mastectomy (10.3%) (p = 0.0001, odds ratio 60.7). Survival: No difference was noted between the sarcoma centre and peripheral hospitals for overall survival (p = 0.43), stratified for tumours <5 cm (p = 0.16), and disease-free survival (p = 0.45). Conclusions: Our data strongly suggest that specific guidelines are needed for breast sarcoma, and that managing these patients according to breast carcinoma protocols in peripheral hospitals is sub-optimal. We recommend centralisation of breast sarcoma patient care to a specialist sarcoma centre, with WLE not recommended as a firstline surgical option given both the high rates of incomplete excision and subsequent need for completion mastectomy.
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Affiliation(s)
- Steven Lo
- Canniesburn Regional Plastic Surgery and Burns Unit, Glasgow Royal Infirmary, Castle Street, Glasgow, UK. G4 0SF.
| | - Naomi Foster
- Canniesburn Regional Plastic Surgery and Burns Unit, Glasgow Royal Infirmary, Castle Street, Glasgow, UK. G4 0SF
| | | | - Jeff White
- The Beatson West of Scotland Cancer Centre, 1053 Great Western Road, Glasgow, G12 0YN, UK
| | - Ioanna Nixon
- The Beatson West of Scotland Cancer Centre, 1053 Great Western Road, Glasgow, G12 0YN, UK
| | - James Mansell
- Department of General Surgery, University Hospital Wishaw, 50 Netherton St, Lanarkshire, ML2 0DP, UK
| | - Mark McCleery
- Department of Radiology, Glasgow Royal Infirmary, Castle St, G4 0SF, UK
| | - Lynsey Whyte
- Pathology Department, Queen Elizabeth University Hospital, Glasgow, UK G51 4TF
| | - Fiona Cowie
- The Beatson West of Scotland Cancer Centre, 1053 Great Western Road, Glasgow, G12 0YN, UK
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Maduekwe UN, Herb JN, Esther RJ, Kim HJ, Spanheimer PM. Pathologic nodal staging for clinically node negative soft tissue sarcoma of the extremities. J Surg Oncol 2021; 123:1792-1800. [PMID: 33751586 PMCID: PMC11022073 DOI: 10.1002/jso.26465] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/15/2021] [Accepted: 03/09/2021] [Indexed: 11/12/2022]
Abstract
BACKGROUND AND OBJECTIVES Synovial, clear cell, angiosarcoma, rhabdomyosarcoma, and epithelioid (SCARE) soft tissue sarcoma are at risk for nodal involvement, although the nodal positivity rates and impact on prognostication in clinically node negative patients are not well described. METHODS Patients with extremity SCARE sarcoma without clinical nodal involvement undergoing surgical resection in the National Cancer Database (2004-2017) were included. Logistic regression was used to evaluate the likelihood of nodal surgery and nodal positivity. Kaplan-Meier method and Cox regression were used to assess associations of nodal status to overall survival. RESULTS We included 4158 patients, and 669 patients (16%) underwent regional lymph node surgery (RLNS). On multivariable logistic analysis, patients with epithelioid (odds ratio [OR]: 3.77; p < .001) and clear cell (OR: 6.38; p < .001) were most likely to undergo RLNS. Forty-five patients (7%) had positive nodes. Clear cell sarcoma (14%) and angiosarcoma (13%) had the highest rates of nodal positivity. Patients with positive nodes had reduced 5-year overall survival, and the stratification was largest in clear cell and angiosarcoma. CONCLUSION Discordance exists between selection for pathologic nodal evaluation and factors associated with nodal positivity. Clinically node negative patients with clear cell and angiosarcoma should be considered for pathologic nodal evaluation.
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Affiliation(s)
- Ugwuji N. Maduekwe
- Department of Surgery, University of North Carolina, Chapel Hill, NC
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Joshua N. Herb
- Department of Surgery, University of North Carolina, Chapel Hill, NC
- Cecil G. Sheps Center for Health Services Research, Chapel Hill, NC
| | - Robert J. Esther
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC
- Department of Orthopaedics, University of North Carolina, Chapel Hill, NC
| | - Hong Jin Kim
- Department of Surgery, University of North Carolina, Chapel Hill, NC
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Philip M. Spanheimer
- Department of Surgery, University of North Carolina, Chapel Hill, NC
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC
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Alexander L. Epithelioid Sarcoma of Upper Extremity: Diagnostic Dilemma With Therapeutic Challenges. Cureus 2021; 13:e14156. [PMID: 33936870 PMCID: PMC8078144 DOI: 10.7759/cureus.14156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2021] [Indexed: 11/13/2022] Open
Abstract
Epithelioid sarcoma is a rare, slow-growing, malignant tumor with multivariate presentation and a high rate of recurrence following surgery. Diagnosis is often missed or delayed due to its infrequent nature and confusing clinical and pathological presentation. This is compounded by the fact that this tumor is aggressive with a propensity for metastases without being detected. The treatment of this deadly tumor is controversial with no clear-cut consensus. The author presents a case of epithelioid sarcoma in the finger of a young patient with subsequent recurrence after surgery and a review of current literature pertaining to this aggressive tumor. This report would like to stress the importance of a multimodal approach in combatting this tumor as prompt diagnosis and aggressive therapy can significantly reduce the poor outcomes associated with this disease.
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Affiliation(s)
- Leon Alexander
- Plastic & Reconstructive Surgery, Sheikh Khalifa Medical City, Abu Dhabi, ARE
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Maekawa A, Matsunobu T, Nabeshima A, Fukushima S, Makihara K, Hisaoka M, Iwamoto Y. Cardiac Tamponade as an Unusual Initial Clinical Manifestation of CIC-DUX4 Sarcoma. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e929349. [PMID: 33640895 PMCID: PMC7931773 DOI: 10.12659/ajcr.929349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Patient: Male, 48-year-old Final Diagnosis: Cardiac tamponade Symptoms: Hypotension • tachycardia Medication: — Clinical Procedure: — Specialty: Oncology
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Affiliation(s)
- Akira Maekawa
- Department of Orthopedic Surgery, Kyushu Rosai Hospital, Kitakyushu, Fukuoka, Japan
| | - Tomoya Matsunobu
- Department of Orthopaedic Surgery, Kyushu Rosai Hospital, Kitakyushu, Fukuoka, Japan
| | - Akira Nabeshima
- Department of Orthopaedic Surgery, Kyushu Rosai Hospital, Kitakyushu, Fukuoka, Japan
| | - Suguru Fukushima
- Department of Musculoskeletal Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Kosuke Makihara
- Department of Pathology, Kyushu Rosai Hospital, Kitakyushu, Fukuoka, Japan
| | - Masanori Hisaoka
- Department of Pathology and Oncology, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
| | - Yukihide Iwamoto
- Department of Orthopedic Surgery, Kyushu Rosai Hospital, Kitakyushu, Fukuoka, Japan
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Ng M, Pascoe J, Kugathasan G, Parsons B. Paratesticular liposarcoma: a rare cause of scrotal lump. BMJ Case Rep 2021; 14:14/2/e240008. [PMID: 33568414 PMCID: PMC7878152 DOI: 10.1136/bcr-2020-240008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Paratesticular tumours are tumours arising from within the scrotum not of testicular origin. They may originate from the epididymis, spermatic cord, tunica vaginalis and other supporting structures. Preoperative diagnosis can be difficult as benign and malignant cases are often indistinguishable and may be confused with other benign or malignant pathology (testicular tumours or hernias).We describe the presentation and management of a patient managed at our centre (a tertiary referral teaching hospital).A high index of suspicion for malignancy should be considered when managing atypical scrotal lumps to ensure optimal management. This is particularly important when managing sarcomas due to the risk of local recurrence and spread.
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Affiliation(s)
- Michael Ng
- Urology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | | | - Gana Kugathasan
- Radiology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Brian Parsons
- Urology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
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Gusho CA, Fice MP, O'Donoghue CM, Gitelis S, Blank AT. A Population-based Analysis of Lymph Node Metastasis in Extremity Soft Tissue Sarcoma: An Update. J Surg Res 2021; 262:121-129. [PMID: 33561723 DOI: 10.1016/j.jss.2021.01.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 01/04/2021] [Accepted: 01/06/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND Soft tissue sarcomas (STSs) are mesenchymal tumors that may rarely metastasize to lymph nodes. This investigation sought to evaluate regional lymph node metastasis (RLNM) in extremity STS using a national cohort. MATERIALS AND METHODS This study was a retrospective review of the Surveillance, Epidemiology, and End Results database from 1975 to 2016. A Cox proportional hazards model was used to identify prognostic factors associated with disease-specific survival (DSS). RESULTS RLNM was present in 3.7% (n = 547) of extremity STS. The rate of RLNM was highest in rhabdomyosarcoma (26.7%), clear cell sarcoma (18.8%), epithelioid sarcoma (14.5%), angiosarcoma (8.1%), spindle cell sarcoma (5.0%), and synovial sarcoma (3.2%). The 5-year DSS probability without RLNM was 69% (standard error: 1.3%) compared to 26% (standard error: 3.6%) with RLNM (P < 0.001). For the historically high-risk extremity STS, advanced age (hazard ratio (HR), 1.036; 95% confidence interval (CI), 1.0-1.04; P < 0.001), higher grade tumors (HR, 1.979; 95% CI, 1.3-3.0; P < 0.001), tumor size greater than 10 cm (HR, 1.892; 95% CI, 1.3-2.7; P < 0.001), primary site surgery (HR, 0.529; 95% CI, 0.3-0.8; P = 0.006), distant metastasis (HR, 4.585; 95% CI, 3.0-6.8; P < 0.001), and RLNM (HR, 2.153; 95% CI, 1.3-3.5; P = 0.003) were each independent disease-specific prognostic factors. CONCLUSIONS The prognosis of RLNM in historically high-risk extremity STS is poor with a 5-year DSS of 26%. These data support a staging system of STS inclusive of nodal involvement and contribute to the growing body of evidence that characterizes the rates of RLNM in STS.
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Affiliation(s)
- Charles A Gusho
- Department of Orthopedic Surgery, Division of Orthopedic Oncology, Rush University Medical Center, Chicago, Illinois
| | - Michael P Fice
- Department of Orthopedic Surgery, Division of Orthopedic Oncology, Rush University Medical Center, Chicago, Illinois
| | | | - Steven Gitelis
- Department of Orthopedic Surgery, Division of Orthopedic Oncology, Rush University Medical Center, Chicago, Illinois
| | - Alan T Blank
- Department of Orthopedic Surgery, Division of Orthopedic Oncology, Rush University Medical Center, Chicago, Illinois.
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48
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Wu B, Tay JKX, Loh WS, Petersson F. Epithelioid Sarcoma of the External Auditory Canal: An Uncommon Tumor at an Unusual Site and a Brief Overview of the Literature. Head Neck Pathol 2021; 15:1328-1334. [PMID: 33394376 PMCID: PMC8633210 DOI: 10.1007/s12105-020-01275-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 12/12/2020] [Indexed: 01/01/2023]
Abstract
We present a case (41 years old pregnant female) with epithelioid sarcoma arising in the left external auditory canal. On immunohistochemistry, the tumor cell diffusely expressed cytokeratins and showed patchy expression of ERG and CD34. The neoplastic cells demonstrated uniform loss of INI1-expression. Epithelioid sarcoma arising in the external auditory canal is rare. Awareness that ES may rarely arise at unusual sites is of critical importance in order to apply a broad enough panel in the immunohistochemical study, so a misdiagnosis of carcinoma can be avoided.
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Affiliation(s)
- Bingcheng Wu
- grid.410759.e0000 0004 0451 6143Department of Pathology, National University Health System, 5 Lower Kent Ridge Road, Singapore, 119074 Singapore
| | - Joshua Kai Xun Tay
- grid.410759.e0000 0004 0451 6143Department of Otolaryngology, National University Health System, Singapore, Singapore
| | - Woei Shyang Loh
- grid.410759.e0000 0004 0451 6143Department of Otolaryngology, National University Health System, Singapore, Singapore
| | - Fredrik Petersson
- grid.410759.e0000 0004 0451 6143Department of Pathology, National University Health System, 5 Lower Kent Ridge Road, Singapore, 119074 Singapore
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49
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Siegel NM, Lozano-Calderón SA, El Abiad JM, Morris CD, Levin AS. Lymphadenopathy in Fungating Extremity Soft-Tissue Sarcoma: Metastasis or Reactive? Ann Surg Oncol 2021; 28:4695-4705. [PMID: 33393032 DOI: 10.1245/s10434-020-09305-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 10/10/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Patients with fungating extremity soft-tissue sarcoma (STS) can develop lymphadenopathy, which can represent nodal metastasis or benign reactive adenopathy. METHODS In 1787 patients with STS, 67 (3.7%) had fungating extremity STS. In the 62 patients who met our inclusion criteria, we evaluated prevalence and histopathology of lymphadenopathy, factors associated with lymphadenopathy and nodal metastasis, and prevalence of and factors associated with lung metastasis and survival time from fungation. Logistic regression and Cox proportional-hazards models were used to analyze node pathology, lung metastasis, and survival duration with α = 0.05. RESULTS Lymphadenopathy occurred in 11 of 62 patients (18%), 6 with nodal metastasis and 5 with reactive adenopathy. The only factor associated with lymphadenopathy was location of primary tumor in the upper extremity (p = 0.02). No tumor characteristics were associated with nodal metastasis. In all five patients with reactive adenopathy, the condition was recognized within 3 days after tumor fungation. Lymphadenopathy recognized more than 3 days after tumor fungation was likely to be nodal metastasis. Forty-one percent of patients developed lung metastasis, which was not associated with presence of lymphadenopathy or any patient or tumor characteristic. Age, tumor size, and Black and Asian race were independently associated with greater risk of death. CONCLUSIONS Eighteen percent of patients with fungating extremity STS developed lymphadenopathy. Approximately half of cases represented nodal metastasis, and half represented reactive adenopathy. Lymphadenopathy that develops within 3 days after tumor fungation should increase suspicion for reactive adenopathy versus nodal metastasis.
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Affiliation(s)
- Nicholas M Siegel
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Jad M El Abiad
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Carol D Morris
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Adam S Levin
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Chander S, Ngan C, Choong PFM. Management of Metastatic Sarcoma. Sarcoma 2021. [DOI: 10.1007/978-981-15-9414-4_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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