Can Abdominal Computed Tomography Imaging Help Accurately Identify a Dedifferentiated Component in a Well-Differentiated Liposarcoma?

A case report of retroperitoneal liposarcoma

BACKGROUND

Retroperitoneal liposarcoma is a rare and complex tumor originating from the mesenchymal tissues, with no specific manifestations in the early stage, and a large tumor size in the late stage. Patients often consult a physician because of large abdominal mass, increased abdominal circumference, and abdominal pain, and rarely because of leukocytosis.

PATIENT CONCERNS

A 54-year-old female presented to our hospital with complaints of "abdominal distension for over 3 months, left lumbar pain for over 2 months." Considering the comprehensive symptoms, examinations, computed tomography scans, and pathological results, the possibility of retroperitoneal liposarcoma is high.

DIAGNOSES

Retroperitoneal liposarcoma with leukocytosis.

INTERVENTIONS

Open retroperitoneal mass excision along with transcystoscopic left ureteral Double-J Ureterl Stent Insertion tube placement and left nephrectomy.

OUTCOMES

The postoperative pathological findings of the abdominal mass, combined with morphological and immunohistochemical results, are consistent with retroperitoneal liposarcoma. The patient had no recurrence in 7 months of postoperative follow-up conducted on the telephone and is now in continued follow-up.

CONCLUSION

Retroperitoneal liposarcoma is highly malignant and prone to recurrence. Radical surgery is currently the primary treatment modality for patients with this condition. Analogous to cancer patients, those with elevated white blood cell counts and retroperitoneal liposarcoma may have poor prognoses, with a high likelihood of local recurrence and distant metastasis. Close postoperative follow-up is necessary. Therefore, regular postoperative review of blood routine may be a relatively economical and convenient method for the early detection of recurrence and metastasis of retroperitoneal liposarcoma.

Analysis of recurrence and metastasis patterns and prognosis after complete resection of retroperitoneal liposarcoma

Objective

To analyze the recurrence and metastasis patterns and prognosis after complete resection of retroperitoneal liposarcoma.

Methods

The clinical postoperative follow-up data and results of patients who underwent complete resection of retroperitoneal liposarcoma from September 10, 2014, to September 8, 2021, at Hebei Medical University hospital were collected retrospectively.

Results

A total of 60 patients with complete resection of retroperitoneal liposarcoma, including 33 cases of retroperitoneal liposarcoma recurrence, 2 cases of liver metastasis, and 1 case of lung metastasis, were included. The results showed that 100% of the recurrent sites were located in the primary region of the tumor, with most recurrences located near the kidney, paracolic sulci, and iliac vessels. Three patients had distant metastasis without obvious recurrence on imaging examination. The pathological type of retroperitoneal liposarcoma, Ki67 expression, and presence of serum albumin were risk factors for recurrence and metastasis after complete resection of retroperitoneal liposarcoma. The malignancy and Ki67 expression were independent risk factors for recurrence and metastasis as well as for overall survival of patients undergoing complete resection of retroperitoneal liposarcoma.

Conclusion

Complete resection remains the most effective method to treat retroperitoneal liposarcoma. Patients with pathological types of retroperitoneal liposarcoma showing dedifferentiation, pleomorphism, mixed type, and high Ki67 expression should be closely monitored and observed after complete resection, especially for imaging changes in the primary tumor area.

Which modality is better to diagnose high-grade transformation in retroperitoneal liposarcoma? Comparison of computed tomography, positron emission tomography, and magnetic resonance imaging

BACKGROUND

Survival in patients with retroperitoneal liposarcoma (RPLS) depends on the surgical management of the dedifferentiated foci. The present study investigated the diagnostic yield of contrast-enhanced CT, ¹⁸F-fluorodeoxyglucose positron emission tomography (PET), and diffusion-weighted MRI in terms of dedifferentiated foci within the RPLS.

METHODS

Patients treated with primary or recurrent RPLS who underwent the above imaging between January 2010 and December 2021 were retrospectively reviewed. The diagnostic accuracy of the three modalities for histologic subtype of dedifferentiated liposarcoma (DDLS) and French Federation of Cancer Center (FNCLCC) grade 2/3 were compared using receiver operating characteristic curves and areas under the curves (AUCs).

RESULTS

The cohort involved 32 patients with 53 tumors; 30 of which exhibited DDLS and 31 of which did FNCLCC grades 2/3. The optimal thresholds for predicting DDLS were mean CT value of 31 Hounsfield Unit (HU) (AUC = 0.880, 95% CI 0.775-0.984; p < 0.001), maximum standardized uptake value (SUVmax) of 2.9 (AUC = 0.865 95% CI 0.792-0.980; p < 0.001), while MRI failed to differentiate DDLS. The cutoff values for distinguishing FNCLCC grades 1 and 2/3 were a mean CT value of 24 HU (AUC = 0.858, 95% CI 0.731-0.985; p < 0.001) and SUVmax of 2.9 (AUC = 0.885, 95% CI 0.792-0.978; p < 0.001). MRI had no sufficient power to separate these grades.

CONCLUSIONS

Contrast-enhanced CT and PET were useful for predicting DDLS and FNCLCC grade 2/3, while MRI was inferior to these two modalities.

Retrospective evaluation of the role of gemcitabine-docetaxel in well-differentiated and dedifferentiated liposarcoma

OBJECTIVE

Well-differentiated (WDLPS) and dedifferentiated liposarcoma (DDLPS) account for the majority of liposarcomas. Although gemcitabine-docetaxel is used as second-line treatment in soft tissue sarcomas, its efficacy in WDLPS/DDLPS is not established. This study retrospectively analyzed the efficacy of gemcitabine regimens in WDLPS/DDLPS.

METHODS

All patients with WDLPS or DDLPS who received gemcitabine-based chemotherapy at our institution between September 2002 and January 2021 were included. Response was evaluated by an independent radiologist using RECIST 1.1. The Kaplan-Meier method was used to estimate distributions of survival outcomes and log-rank tests were used to compare survival outcomes between subgroups.

RESULTS

Sixty-five WDLPS/DDLPS patients were included. Seven patients (10.8%) received a gemcitabine-based regimen more than once, totaling 72 treatments. The median age at the start of treatment was 66 years (range 32-80 years). Sixty-five (90.3%) regimens were gemcitabine-docetaxel, and 7 (9.7%) were gemcitabine alone. Majorities of treatments were for disease that was recurrent/metastatic (86.1%), was abdominal/retroperitoneal (83.3%), and had DDLPS components (88.9%), while 25.0% of treatments were for multifocal disease. The overall response rate was 9.7% (7/72). All responses were in patients with documented DDLPS. The median time to progression was 9.2 months (95% CI 5.3-12.3 months). The median overall survival from the start of therapy was 18.8 months (95% CI 13.1-32.4 months).

CONCLUSION

Gemcitabine-docetaxel is an efficacious second-line treatment for DDLPS. Though cross study comparisons are not advisable, response to gemcitabine-docetaxel compares favorably to current standard options trabectedin and eribulin. This combination is a valid comparator arm for future second-line trials in DDLPS.

MRI findings to differentiate musculoskeletal dedifferentiated liposarcoma from atypical lipomatous tumor

OBJECTIVE

This study aimed to assess the efficacy of using MRI findings for differentiating musculoskeletal dedifferentiated liposarcoma (DDLP) from atypical lipomatous tumor (ALT).

MATERIALS AND METHODS

This study included 22 patients with histopathologically proven DDLP and 35 with ALT in the musculoskeletal areas. All DDLPs were immunohistochemically positive for MDM2. MRI findings for both pathologies were retrospectively reviewed and compared.

RESULTS

The maximum lesion diameter was significantly lower in DDLPs than in ALTs (p < 0.01). Ill-defined margin, peritumoral edema, and tail sign were more frequently observed in DDLPs than in ALTs (p < 0.01, respectively). The fatty component was less frequently observed in DDLPs than in ALTs (27 vs. 100%; p < 0.01), whereas the non-fatty component was more frequently observed in DDLPs than in ALTs (100 vs. 11%; p < 0.01). The occupation rate by non-fatty components was significantly higher in DDLPs than in ALTs (p < 0.01). No significant differences were observed in imaging findings associated with fatty component; however, necrosis within the non-fatty component on the contrast-enhanced image was more frequently observed in DDLPs than in ALTs (72 vs. 0%, p < 0.05).

CONCLUSION

DDLPs always had a non-fatty component, whereas ALTs always had fatty component. Ill-defined margin, peritumoral edema, tail sign, and necrosis within non-fatty components were useful MRI features for differentiating musculoskeletal DDLP from ALT.

An integrative ultrasound-pathology approach to improve preoperative phyllodes tumor classification: A pilot study

OBJECTIVE

Preoperative diagnosis of phyllodes tumor (PT) is challenging, core-needle biopsy (CNB) has a significant rate of understaging, resulting in suboptimal surgical planification. We hypothesized that the association of imaging data to CNB would improve preoperative diagnostic accuracy compared to biopsy alone.

METHODS

In this retrospective pilot study, we included 59 phyllodes tumor with available preoperative imaging, CNB and surgical specimen pathology.

RESULTS

Two ultrasound features: tumor heterogeneity and tumor shape were associated with tumor grade, independently of CNB results. Using a machine learning classifier, the association of ultrasound features with CNB results improved accuracy of preoperative tumor classification up to 84%.

CONCLUSION

An integrative approach of preoperative diagnosis, associating ultrasound features and CNB, improves preoperative diagnosis and could thus optimize surgical planification.

Imaging of Soft Tissue Tumors

Differentiation of malignant from benign soft tissue tumors is challenging with imaging alone, including that by magnetic resonance imaging and computed tomography. However, the accuracy of this differentiation has increased owing to the development of novel imaging technology. Detailed patient history and physical examination remain essential for differentiation between benign and malignant soft tissue tumors. Moreover, measurement only of tumor size based on Response Evaluation Criteria In Solid Tumors criteria is insufficient for the evaluation of response to chemotherapy or radiotherapy. Change in metabolic activity measured by ¹⁸F-fluorodeoxyglucose positron emission tomography or dynamic contrast enhanced-derived quantitative endpoints can more accurately evaluate treatment response compared to change in tumor size. Magnetic resonance imaging can accurately evaluate essential factors in surgical planning such as vascular or bone invasion and "tail sign". Thus, imaging plays a critical role in the diagnosis and treatment of soft tissue tumors.

T4 retroperitoneal liposarcoma. Challenges of big size sarcomas surgical treatment

Our article presents some of the challenges of the surgical treatment of T4 (>15 cm) retroperitoneal liposarcomas (up to 65∕56∕30 cm, 25.5 kg) series of cases treated by the Department of Surgical Oncology, Prof. Dr. Ion Chiricuţă Oncology Institute, Cluj-Napoca (IOCN), Romania, with illustrations, insisting on important blood vessels and nerves dissection and preservation and discussions of strategies with references to important articles from the last 10 years specialty literature. Challenges do not come only from intraoperative difficulties but also from establishing the right attitude from the extent of resection and oncological safety point of view, the role of the pathologist being very important because histological subtype and completeness of the resections are the most important prognostic factors for such tumors. Despite all today available aids in decision making, like nomograms or high-resolution imagery, sometimes this decision is to be taken intraoperative based on surgeon's expertise and skills. That is why is strongly advised that such cases to be treated in high-volume specialized tertiary centers of surgical oncology.

Renal Angiomyolipoma Mimicking a Well-Differentiated Retroperitoneal Liposarcoma

A 37-year-old Burmese woman presented with an incidentally found retroperitoneal fat-containing tumor. The tumor was 9 cm in the longest diameter, surrounding the right kidney, and composed of homogenous adipose tissue with thickened septum-like structures and spotty nonadipose structures, which were enhanced on contrast-enhanced computed tomography and magnetic resonance imaging. The tumor did not show either a beak sign or synchronous angiomyolipoma-like lesion in the kidneys. The tumor had irregular septa, thin blood vessels, and spotty small soft-tissue nodules. The tumor did not contain any heterogeneously enhanced solid lesions suspicious for dedifferentiated liposarcomas. Based on these imaging findings, a clinical diagnosis of a well-differentiated liposarcoma was made. Under the consensus of a multidisciplinary cancer board, she was recommended to undergo core-needle biopsy to confirm the clinical diagnosis. However, she declined to undergo biopsy for financial reasons. She underwent kidney-sparing retroperitoneal tumor resection. Histopathologically, the tumor was an angiomyolipoma with positive immunostaining for HMB45 and Melan A. The present case suggests the importance of core-needle biopsy prior to surgical intervention for retroperitoneal fat-containing tumors.

PET/CT Imaging as a Diagnostic Tool in Distinguishing Well-Differentiated versus Dedifferentiated Liposarcoma

Distinguishing well-differentiated liposarcoma (WDLPS) from dedifferentiated liposarcoma (DDLPS) is essential given distinct treatment paradigms and chemosensitivity. Percutaneous biopsy has a low sensitivity for detecting DDLPS. We sought to identify the diagnostic utility of positron emission tomography/computed tomography (PET/CT) in identifying WDLPS versus DDLPS. An independent radiologist reviewed PET/CT images to identify target lesions and determine the maximum standardized uptake value (SUVmax). An independent pathologist review confirmed WDLPS or DDLPS histology. A binary cutoff point of SUVmax was identified using a classification and regression trees (CART) algorithm. We identified 20 patients with WDLPS or DDLPS with 26 PET/CTs performed for separate recurrences that were followed by surgical sampling. Of the 26 records, 12 were DDLPS (46%) and 14 were WDLPS (54%). Patients with DDLPS had significantly higher SUVmax than those with WDLPS (p value = 0.0035). A SUVmax of 4 was identified as the cutoff point. Using this cutoff, the sensitivity of SUVmax identifying a case as DDLPS was 83.3% (95% CI: 51.6%, 97.9%) and the specificity was 85.7% (95% CI: 57.2%, 98.2%). PET/CT is a sensitive and specific diagnostic tool to identify the presence of dedifferentiation within the tumor.

Ischiorectal fossa: benign and malignant neoplasms of this "ignored" radiological anatomical space

PURPOSE

To review the pertinent anatomy and the imaging features of common and uncommon benign and malignant neoplasms and masses of the ischiorectal fossa.

RESULTS

The ischiorectal or ischioanal fossa is the largest space in the anorectal region. The benign neoplasms that develop in the ischiorectal originate from the different components that forms the fossa including vascular tumors such as aggressive angiomyxoma or hemangioma; neural tumors as plexiform neurofibroma or schwannoma; fat tumors as lipoma; skin/skin appendages tumors as hidradenoma papilliferum; smooth or skeletal muscle tumors as solitary fibrous tumor. The malignant neoplasms that develop in the ischiorectal fossa also originate from different components that forms the fossa including vascular tumors such as angiosarcoma, neural tumors as malignant granular cell tumor and malignant peripheral nerve sheath tumor; fat tumors as liposarcoma; smooth or skeletal muscle tumors as leiomyosarcoma, rhabdomyosarcoma, malignant PEComa, or undifferentiated pleomorphic sarcoma. Additionally, the ischiorectal fossa can also harbor secondary hematogenous metastases and be affected by direct invasion from neoplasms of adjacent pelvic organs and structures. Furthermore, other miscellaneous masses can occur in the ischiorectal fossa including congenital and developmental lesions, and inflammatory and infectious processes.

CONCLUSION

Knowledge of the anatomy, and the spectrum of imaging findings of common and uncommon benign and malignant neoplasms of the ischiorectal fossa is crucial for the radiologists during interpretation of images allowing them to make contributions to the diagnosis and better patient management.

Preoperative diagnosis and surgical treatment for giant retroperitoneal liposarcoma: A case report

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Surgery should be tailored paying attention to noble structures.

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Damage or organ involvement requires an aggressive surgery.

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Sometimes close margins are necessary to preserve critical structures.

Introduction

The purpose of this article is to present the diagnostic and surgical approach for a giant retroperitoneal sarcoma and to highlight the difficulty of a precise preoperative diagnosis and the extention of surgical resection.

Presentation of case

A 63-year-old female patient was admitted at our department with light diffuse abdominal pain, fever and gradual increase of abdominal girth. A CT scan showed a giant fatty tumor occupying left hemiabdomen and indirect findings of renal damage, probably sustained by ureter stretching and urine stasis. At surgical exploration, no cleavage plane was discovered between the mass and the surrounding organs. The severe pielonephritis and the apparent intraoperatively involvement of surrounding tumour structures lead to an aggressive surgery. An “en-bloc” resection of tumor mass, left colon, spleen, pancreatic tail, left annex, left kidney and adrenal gland was performed. Histology revealed a well differentiated liposarcoma with large areas of high grade of dedifferentiation.

Discussion

Liposarcoma is an histologic subtype of soft tissue sarcoma and the most common type of sarcoma arising in retroperitoneum. It is difficult to make an accurate preoperative diagnosis through a percutaneous biopsy. Although it is required to obtain negative resection margins, literature shows that surgical radicality is not a primary endpoint if noble structures are strictly close. In some cases surgery must be more aggressive because of the apparent organ involvement or damage.

Conclusion

This is a rare case of a giant liposarcoma involging many organs. Surgery should be tailored according to intraoperative findings and organ damage.

Curative endoscopic treatment of intussusception due to a giant colonic lipoma using a wedged balloon and ligation with detachable snares

A 67-year-old woman presented with symptoms of bowel obstruction. Radiographic and ultrasonographic findings suggested colo-colonic intussusception caused by a colonic lipoma. Colonoscopy with an endoscope tip balloon was performed for reduction. The intussusception was partially reduced by injecting dilute contrast media with a wedged inflated balloon at the endoscope tip. For definitive treatment of the polyp, ischemia was induced using a detachable snare. The abdominal pain well improved after endoscopic treatment. However, ultrasonography suggested a residual lesion. Another detachable snare was applied to the stalk on day 6. A large amount of dark-red necrotic tissue was passed per anus the following day. One month later, complete scarring of the site was confirmed colonoscopically. This is the first report of curative endoscopic treatment of an intussusception due to a giant colonic lipoma with detachable snares after the reduction with a wedged balloon of colonoscope tip.

Role of chemotherapy in dedifferentiated liposarcoma of the retroperitoneum: defining the benefit and challenges of the standard

Benefit from chemotherapy for well-differentiated/de-differentiated (WD/DD) liposarcomas has been reported to be minimal, however traditional response criteria may not adequately capture positive treatment effect. In this study, we evaluate benefit from first-line chemotherapy and characterize imaging response characteristics in patients with retroperitoneal (RP) WD/DD liposarcoma treated at The University of Texas MD Anderson Cancer Center. Response was assessed using RECIST (Response Evaluation Criteria in Solid Tumors) and an exploratory analysis of vascular response was characterized. Among 82 patients evaluable for response to first-line therapy, 31 patients received neoadjuvant chemotherapy for localized/locally advanced disease; 51 received chemotherapy for unresectable recurrent/metastatic disease. Median overall survival from the start of chemotherapy was 29 months (95% CI 24-40 months). Response rates by RECIST: partial response (PR) 21% (17/82), stable disease (SD) 40%, and progression (PD) 39%. All RECIST responses were in patients receiving combination chemotherapy. A qualitative vascular response was seen in 24 patients (31%). Combination chemotherapy yields a response rate of 24% and a clinical benefit rate (CR/PR/SD > 6 months) of 44%, higher than previously reported in DD liposarcoma. A higher percentage of patients experience a vascular response with chemotherapy that is not adequately captured by RECIST in these large heterogeneous tumors.