Prognostic and survival factors in myxofibrosarcomas

Giant Myxofibrosarcoma in the Lower Limb: An Overview of Diagnostic and Clinical Management

Myxofibrosarcoma (MFS), an aggressive soft tissue sarcoma, is one of the undifferentiated pleomorphic sarcomas; it has a low incidence, affecting people in the sixth to eighth decades of life. It usually involves the extremities and is painless with a slow-growing pattern. Based on the case of a 52-year-old female patient who presented with a painful, massive, rapid-growing, ulcerated tumor of the anterior surface of the left thigh, we performed a literature review regarding the current standard of care for patients with MFS. Computed tomography examination, followed by magnetic resonance imaging and surgical biopsy with histopathological examination, confirmed the diagnosis and the presence of lung and inguinal lymph node metastases. Due to the rapid-growing pattern and the local aggressiveness, our tumor board team recommended emergency excisional surgery, with subsequent reconstructive procedures followed by referral to an oncological center. This review emphasizes the importance of proper and rapid diagnosis, followed by multidisciplinary management, for MFS cases with atypical presentation and distal metastases to improve overall outcomes.

Clear surgical margins as a prognostic indicator for disease recurrence, with no impact on survival rates in patients with myxofibrosarcoma

Myxofibrosarcoma presents an infiltrating growth pattern that results in a high tendency for local recurrence. Clear margin resection is challenging because of microscopic infiltration. The purpose of the present study was to analyze the overall and disease-free survival rates of patients with myxofibrosarcoma and the prognostic factors that determine both survival and disease recurrence. Among the 111 patients included in our study, the 5-year overall survival rate was 65.5%. An age of more than 65 years (hazard ratio [HR] 1.9 [95% confidence interval (CI) 1.4-5.6]; p < 0.001), a tumor size of more than 5 cm (HR 2.8 [95% CI 0.9-8.1]; p = 0.049) and the G3 tumor grade (HR 14.1 [95% CI 2.1-105.0]; p < 0.001) negatively affected overall survival. The 5-year recurrence-free survival rate was 49.4%. R1/R2-type resection (HR 2.4 [95% CI 1.0-5.6]; p = 0.048) had a detrimental effect on tumor recurrence. Clear margins had a positive impact on recurrence-free survival, but did not significantly affect overall patient survival, suggesting that other factors may play a more significant role in determining patient outcomes. A surgical margin of 2 mm was not sufficient to significantly influence the incidence of recurrence. Consequently, a wider surgical margin may be necessary to reduce the risk of myxofibrosarcoma recurrence.

Myxofibrosarcoma of Head and Neck Region - A Rare Case Report

Myxofibrosarcoma (MFS) is a rare subtype of soft tissue sarcoma that usually occurs in the extremities of the body. Its location in the head and neck region is unique. Surgery is the primary treatment for all non-metastatic MFS. It has high rates of local recurrence and metastasis. Like other soft tissue sarcomas, the aim of adjuvant treatment is to decrease the chances of local recurrence or metastasis in MFS. Due to its rarity, there is a lack of data showing the benefit of adjuvant treatment in MFS of the head and neck region. We are presenting a case report and literature review on MFS in the head and neck.

Is Perioperative Radiotherapy Effective in Preventing Local Recurrence in Myxofibrosarcoma?

Background

Myxofibrosarcoma (MFS) is a rare type of soft tissue sarcoma that is locally aggressive and has a high risk of recurrence. The effectiveness of perioperative radiotherapy (RT) in preventing local recurrence (LR) of MFS remains uncertain. This retrospective study aimed to evaluate the impact of perioperative radiotherapy on local recurrence in patients with MFS.

Methods

A total of 75 patients diagnosed with MFS and treated at a single institution were included in the study. Patient data, including demographics, tumor characteristics, and treatment variables, were collected from electronic medical records. The primary endpoint was the occurrence of local recurrence.

Results

Among the patients, 25/75 (33.3%) received radiation therapy, while 50/75 (66.7%) did not. Local recurrence in the radiated group was 28% (7/25) compared to 36% (18/50) in the non-irradiated group (p = 0.20). The LR rate trended higher in patients who received RT postoperatively (adjuvant) (6/12, 50%) than preoperatively (neoadjuvant) (1/13, 7.6%) (p = 0.124). Of the 54 patients with negative margins, the local recurrence rate was lower in the radiated group (1/12, 8.33) than the non-irradiated group (9/36, 25%) (p = 0.034). A subgroup analysis based on tumor grade did not reveal any significant differences in recurrence rates between the radiated and non-irradiated groups. Furthermore, there was no significant difference in recurrence rates between the irradiated and non-irradiated groups at the one-year (p = 0.32), two-year (p = 0.24), and five-year (p = 0.32) follow-up marks.

Conclusion

Although radiotherapy demonstrated a trend toward reduction in recurrence rates in patients with MFS in this study, the observed difference did not reach statistical significance. Neoadjuvant radiation appears to be more effective than adjuvant radiation. However, there was a significant reduction in recurrence in patients with negative margins who received radiation demonstrating that effective surgical resection continues to be the most important intervention in patients with myxofibrosarcoma. Level of Evidence: III.

Myxofibrosarcoma in adolescents and young adults: a clinicopathologic study of 17 cases

Myxofibrosarcoma is a locally aggressive sarcoma that characteristically arises in the extremities of older patients. Cases arising at a younger age are rare, leading to diagnostic challenges. Our aim was to study the clinicopathologic features of myxofibrosarcoma in patients aged ≤40 years. Cases of myxofibrosarcoma and myxoid malignant fibrous histiocytoma arising in patients aged ≤40 years with clinical follow-up were collected from multiple institutions. Hematoxylin and eosin slides were evaluated for mitoses, necrosis, and epithelioid areas. Seventeen cases were identified (13 females, 4 males; 16-39 years; median 32 years), tumors ranged from 2.2 to 34 cm (median 4.1 cm). Anatomic sites included proximal extremity (9), distal extremity (4), trunk (1), and head/neck (3). Ten were superficial, and 6 were deep-seated. Three cases were predominantly epithelioid. In untreated resection specimens, 6 were FNCLCC grade 1, 4 grade 2, and 2 grade 3. Follow-up (6-204 months, median 36 months) revealed that 2 patients experienced local recurrences, 1 distant metastasis, and 2 patients both. The 5-year overall survival (OS) and event-free survival (EFS) were 84% and 55.9%, respectively. Tumor depth and necrosis were correlated with inferior OS (P = .025, P = .005), while tumor depth was also associated with worse EFS (P = <.001). We conclude that myxofibrosarcomas arising in adolescents and young adults show similar behavior compared to their older adult counterparts. Tumor depth and necrosis are poor prognostic factors in myxofibrosarcoma in this age group. Awareness that myxofibrosarcoma can rarely present in this population is important for accurate diagnosis.

Biology and Management of High-Grade Myxofibrosarcoma: State of the Art and Future Perspectives

Myxofibrosarcoma (MFS) is one of the most common adult soft tissue sarcomas, typically arising in the extremities. Histologically, MFS is classified into three grades: low, intermediate, and high. Histological grades correlate with distant metastases and tumor-associated mortality. The diagnosis of MFS is challenging due to a lack of well-characterized immunohistochemical markers. High-grade MFS displays highly complex karyotypes with multiple copy number alterations. Recent integrated genomic studies have shown the predominance of somatic copy number aberrations. However, the molecular pathogenesis of high-grade MFS remains poorly understood. The standard treatment for localized MFS is surgical resection. The systemic treatment options for advanced disease are limited. This review provides an updated overview of the clinical and imaging features, pathogenesis, histopathology, and treatment of high-grade MFS.

Histological markers, sickle-shaped blood vessels, myxoid area, and infiltrating growth pattern help stratify the prognosis of patients with myxofibrosarcoma/undifferentiated sarcoma

Myxofibrosarcoma (MFS) and undifferentiated sarcoma (US) have been considered as tumors of the same lineage based on genetic/epigenetic profiling. Although MFS shows a notably better prognosis than US, there are no clear criteria for distinguishing between them. Here, we examined 85 patients with MFS/US and found that tumors with infiltrative growth patterns tended to have more myxoid areas and higher local recurrence rates but fewer distant metastases and better overall survival. Morphologically characteristic sickle-shaped blood vessels, which tended to have fewer αSMA-positive cells, were also observed in these tumors, compared with normal vessels. Based on the incidence of these sickle-shaped blood vessels, we subdivided conventionally diagnosed US into two groups. This stratification was significantly correlated with metastasis and prognosis. RNA sequencing of 24 tumors (9 MFS and 15 US tumors) demonstrated that the proteasome, NF-kB, and VEGF pathways were differentially regulated among these tumors. Expression levels of KDR and NFATC4, which encode a transcription factor responsible for the neuritin-insulin receptor angiogenic signaling, were elevated in the sickle-shaped blood vessel-rich US tumors. These findings indicate that further analyses may help elucidate the malignant potential of MFS/US tumors as well as the development of therapeutic strategies for such tumors.

Oncologic outcomes in myxofibrosarcomas: the role of a multidisciplinary approach and surgical resection margins

BACKGROUNDS

Myxofibrosarcomas (MFS) are malignant soft tissue sarcomas with an infiltrative growth pattern and propensity for local recurrence(LR).We aimed to assess our management of MFS and make recommendations about the role of a multidisciplinary team approach and margin widths.

METHODS

Fifty-seven patients were identified with MFS treated at a single sarcoma centre between 1998 and 2020. Patients were stratified based on whether they presented for a planned resection (59.6%) or after an unplanned resection (40.4%) performed at a non-specialized facility. All patients underwent radiotherapy before definitive surgery.

RESULTS

73.7% underwent a combined onco-plastic approach. The 5 year LRFS rate was 78.2% (84.4%, planned, versus 70.1%, unplanned, P = 0.194) and found comparable oncological outcomes between the planned and unplanned groups for the 5 year metastasis free survival (74.5% versus 86.1%, P = 0.257), disease free survival (70.1% versus 72.4%, P = 0.677), and Overall Survival (64.5% versus 75.9%, P = 0.950). Margin width ≥ 2 cm was obtained in 84.2% of cases and improved local control (HR = 0.22; 95% CI 0.06-0.81; P = 0.023), metastasis (HR = 0.24; 95% CI 0.07-0.80; P = 0.019) and mortality rates (HR = 0.23; 95% CI 0.09, 0.61; P = 0.003) compared to <2 cm. Margin width > 3 cm did not further affect oncological outcomes.

CONCLUSION

Our study shows that a multidisciplinary team approach allows the achievement of low local recurrence rate and good oncological outcomes of myxofibrosarcomas, regardless of presentation status. We recommend a minimum of 2 cm margin width.

Immunohistochemical expression and clinicopathological assessment of PD-1, PD-L1, NY-ESO-1, and MAGE-A4 expression in highly aggressive soft tissue sarcomas

Immunotherapy has altered the treatment paradigm for soft tissue sarcomas (STSs). Considering the limited information regarding the clinical significance of immunohistochemical markers in STS, the purpose of this study was to determine the clinical significance of programmed cell death-1 (PD-1), PD ligand-1(PD-L1), New York esophageal squamous cell carcinoma-1 (NY-ESO-1), and melanoma-associated antigen-A4 (MAGE-A4) expression in STSs. Twenty-two patients (median age, 72.5 years) with STSs treated at our hospital were included in this study. The specimens obtained at the time of biopsy were used to perform immunostaining for PD-1, PD-L1, NY-ESO, and MAGE-A4. The rates of PD-1-, PD-L1-, NY-ESO-, and MAGE-A4-positive cells and cases were calculated. The correlations among the positive cell rates of the immunohistochemical markers as well as their correlations with the histological grade, tumor size, or maximum standardized uptake (SUVmax) value were also determined. The average rates of PD-1-, PD-L1-, NY-ESO-, and MAGE-A4-positive cells were 4.39%, 28.0%, 18.2%, and 39.4%, respectively. PD-1-, PD-L1-, NY-ESO-1-, and MAGE-A4- positive cell rates showed weak to strong correlations with the SUVmax value. Thus, PD-1, PD-L1, NY-ESO, and MAGE-A4 expressions might be involved in the aggressive elements of STSs.

Clinicopathological Assessment of Cancer/Testis Antigens NY-ESO-1 and MAGE-A4 in Highly Aggressive Soft Tissue Sarcomas

We aimed to investigate the clinical significance of the expression of NY-ESO-1 and MAGE-A4 in soft tissue sarcoma (STS). Immunostaining for NY-ESO-1, MAGE-A4, and Ki67 was performed using pathological specimens harvested from 10 undifferentiated pleomorphic sarcoma (UPS), nine myxofibrosarcoma (MFS), and three malignant peripheral nerve sheath tumor (MPNST) patients treated at our hospital. We examined the correlation of NY-ESO-1 and MAGE-A4 expression levels with tumor size, histological grade, and SUVmax values. Positive cell rates of various markers were also compared between patients in remission and those who were not in remission. The rates of cases positive for NY-ESO, MAGE-A4, and Ki67 were 50%, 63.6%, and 90.9%, respectively. The average rates of cells positive for NY-ESO, MAGE-A4, and Ki67 in all STS types were 18.2%, 39.4%, and 16.8%, respectively. A positive correlation was observed between rates of cells positive for NY-ESO-1 and MAGE-A4 and between NY-ESO-1 and MAGE-A4 expression levels and clinical features. There was no significant difference in the positive cell rate of NY-ESO-1 or MAGE-A4 between remission and non-remission cases. Our results suggest that NY-ESO-1 and MAGE-A4 expression may be useful for the diagnosis and prognostication of UPS, MFS, and MPNST.

Overall Survival of Patients with Myxofibrosarcomas: An Epidemiological Study

Myxofibrosarcoma (MFS) is a rare mesenchymal soft tissue sarcoma type, with a high local recurrence (LR) rate. Robust epidemiological data on MFS are lacking. We, therefore, aimed to identify prognostic factors and describe real-life outcomes of a large cohort of 908 MFS patients obtained from the nationwide database of the Netherlands Cancer Registry and diagnosed between 2002 and 2019. Median Overall survival (OS) was 155 (range 0.1-215) months, with a five-year OS of 67.7%. No improvement of OS was found over time. Multivariable Cox regression survival analysis demonstrated known prognostic factors for OS, such as older age, tumour size, and histological grade with the addition of sex. Surgery at sarcoma expertise centres, instead of general hospitals, was associated with better OS outcomes. In a subcohort of 177 patients, 39% developed LR with a median time to recurrence of 20 months. From LR on, the median OS was 64.0 months (CI 95% 38.5-89.5). In 28%, distant metastases were diagnosed with a median OS of 34.3 months (CI 95% 28.8-39.8) after diagnosis of the primary tumour. In this largest nationwide cohort so far, survival outcomes and recurrence rates for MFS patients did not improve over time, emphasizing the need to improve treatment strategies and suggesting a role for sarcoma expertise centres.

Idiopathic and radiation-induced myxofibrosarcoma in the head and neck-case report and literature review

BACKGROUND

Myxofibrosarcoma (MFS), especially radiation-Induced MFS (RIMFS) in the head and neck, is an extremely rare malignant fibroblastic tumor. The diagnosis and treatment of MFS remain great challenges. In the present study, we presented one case of RIMFS. Combined with previous literature, the clinical features, essentials of diagnosis, and treatment modalities of MFS in the head and neck were reviewed to better understand this rare entity.

CASE PRESENTATION

We reported a case of RIMFS under the left occipital scalp in a 20-year-old girl with a history of medulloblastoma surgery and radiotherapy in 2006. A total tumor resection was performed with preservation of the overlying scalp the underlying bone, and no adjuvant therapy was administered after the first operation. The postoperative pathological diagnosis was high-grade MFS. The tumor relapsed 6 months later, and then, a planned extensive resection with negative surgical margins was carried out, followed by radiotherapy. No relapse occurred in a 12-month postoperative follow-up.

CONCLUSIONS

Planned gross total resection (GTR) with negative margins is the reasonable choice and footstone of other treatments for MFS. Ill-defined infiltrated borders and the complicated structures make it a great trouble to achieve total resection of MFS in the head and neck, so adjuvant radiotherapy and chemotherapy seem more necessary for these lesions.

Analysis of prognostic factors in 171 patients with myxofibrosarcoma of the trunk and extremities: a cohort study

Background

Myxofibrosarcoma (MFS) of the trunk and extremities has unique clinical features. However, it is not clear which indicators are the influencing factors of recurrence, metastasis, and survival of trunk and limb MFS. The aim of the present study was to analyze clinical features and prognosis of trunk and limb MFS.

Methods

The data of 171 patients with MFS of the trunk and extremities and a median follow-up period of 67 months from January 1999 to July 2018 were retrospectively analyzed. Risk factors for survival, recurrence and metastasis following resection of MFS of trunk and extremities were analyzed. The Kaplan-Meier method (log-rank test) was used for the univariate analysis and a Cox regression model was used for the multivariate analysis.

Results

The median age of the patients was 53 years; there were 111 males and 60 females. A total of 132 cases had French Federation of Cancer Centers grade 1, 24 cases had grade 2, and 15 cases had grade 3 MFS. The 3-year recurrence, 3-year metastasis, and 5-year survival rates were 29.2%, 19.3%, and 93.6%, respectively. Kaplan-Meier survival analysis showed that the surgical margin (χ²=22.228, P<0.001) and tumor size (χ²=6.697, P=0.010) were associated with recurrence. The surgical margin (χ²=12.353, P<0.001) and CD44 expression (χ²=5.227, P=0.022) were associated with metastasis. The multivariate analysis showed that the surgical margin [hazard ratio (HR) =3.635, 95% confidence interval (CI): 1.883-7.016, P<0.001] and tumor size (HR =1.889, 95% CI: 1.039-3.435, P=0.037) were risk factors for local recurrence. In addition, the surgical margin (HR =4.475, 95% CI: 1.918-10.438, P=0.001) and presence of CD44 (HR =3.406, 95% CI: 1.462-8.405, P=0.005) were risk factors for distant metastasis.

Conclusions

A negative surgical margin can be reduced effectively the rate of recurrence and metastasis in patients with MFS of the trunk and limbs. In addition, CD44 may be used to assess the metastatic risk of patients with MFS.

Establishment and characterization of NCC-MFS4-C1: a novel patient-derived cell line of myxofibrosarcoma

Myxofibrosarcoma (MFS) is an aggressive sarcoma with a highly complex karyotype. Complete resection is the only curative treatment for MFS because it is refractory to chemotherapy. To improve clinical outcomes, it is critical to develop novel treatments for MFS. Although patient-derived cell lines play a key role in cancer research, only 12 MFS cell lines have been reported to date, and considering the diversity of the disease, more cell lines need to be established. Hence, in the present study, we established a novel MFS cell line, NCC-MFS4-C1, using a surgically resected tumor tissue from a patient with MFS. NCC-MFS4-C1 cells exhibited copy number alterations similar to those of the original tumors and showed constant proliferation, spheroid formation, and aggressive invasion. By screening a drug library, we found that actinomycin D, bortezomib, docetaxel, eribulin, and romidepsin significantly reduced the proliferation of NCC-MFS4-C1 cells. Therefore, the NCC-MFS4-C1 cell line may be a useful resource for researching MFS.

Prognostic value of CD34 expression status in patients with myxofibrosarcomas and undifferentiated pleomorphic sarcomas

It is controversial whether patients with myxofibrosarcomas (MFSs) have better prognoses than those with undifferentiated pleomorphic sarcomas (UPSs). No useful prognostic factors have been established to date. We therefore aimed to evaluate the prognostic value of CD34 expression status in 192 patients with MFSs and UPSs. Using the log-rank test, we showed that patients with MFSs had a significantly better overall survival than did those with UPSs when defining the former as having a > 10% myxoid component (p = 0.03), but not when defining it as having a > 50% myxoid component (p = 0.1). Under the definition of MFSs as > 10% myxoid component, the log-rank test revealed that the diagnosis of the UPS and the CD34 loss (p < 0.001) were significant adverse predictors of overall survival. As per the Cox model, the CD34 loss remained an independent prognostic factor (hazard ratio = 3.327; 95% confidence interval 1.334-8.295), while the diagnosis of the UPS was a nonsignificant confounding factor (hazard ratio = 1.084; 95% confidence interval 0.679-1.727). In conclusion, CD34 expression status is a useful prognostic factor in patients with MFS and UPS, and it should be incorporated into grading systems that are used to predict outcomes.

Establishment and characterization of NCC-MFS3-C1: a novel patient-derived cell line of myxofibrosarcoma

Myxofibrosarcoma (MFS) is one of the most aggressive sarcomas with highly complex karyotypes and genomic profiles. Although a complete resection is required in the treatment of MFS, it is often not achieved due to its strong invasive nature. Additionally, MFS is refractory to conventional chemotherapy, leading to poor prognosis. Therefore, it is necessary to develop novel treatment modalities for MFS. Patient-derived cell lines are important tools in basic research and preclinical studies. However, only 10 MFS cell lines have been reported to date. Furthermore, among these cell lines, merely two MFS cell lines are publicly available. Hence, we established a novel MFS cell line named NCC-MFS3-C1, using a surgically resected tumor specimen from a patient with MFS. NCC-MFS3-C1 cells had copy number alterations corresponding to the original tumor. NCC-MFS3-C1 cells demonstrate constant proliferation, spheroid formation, and aggressive invasion. In drug screening tests, the proteasome inhibitor bortezomib and the histone deacetylase inhibitor romidepsin demonstrated significant antiproliferative effects on NCC-MFS3-C1 cells. Thus, the NCC-MFS3-C1 cell line is a useful tool in both basic and preclinical studies for MFS.

Myxofibrosarcoma: Clinical and Prognostic Value of MRI Features

Myxofibrosarcoma is one of the most common soft tissue sarcomas in the elderly. It is characterized by an extremely high rate of local recurrence, higher than other soft tissue tumors, and a relatively low risk of distant metastases.Magnetic resonance imaging (MRI) is the imaging modality of choice for the assessment of myxofibrosarcoma, which plays a key role in the preoperative setting of these patients. MRI features associated with the high risk of local recurrence are: high myxoid matrix content (water-like appearance of the lesions), high grade of contrast enhancement and presence of an infiltrative pattern ("tail sign"). On the other hand, MRI features associated with worse sarcoma specific survival are: large size of the lesion, deep location, high grade of contrast enhancement. Recognizing the above-mentioned imaging features of myxofibrosarcoma may be helpful in stratifying the risk for local recurrence and disease-specific survival. Moreover, the surgical planning should be adjusted according to the MRI features.

Tumor-associated mortality and prognostic factors in myxofibrosarcoma - A retrospective review of 109 patients

BACKGROUND

Myxofibrosarcoma (MFS) is one of the most common sarcoma subtype in elderly patients. They are reported to recur locally independently of the tumour grade in 30-40% of cases and metastases are reported to develop in high-grade tumours in 20-35% cases. As MFS is a rare diagnosis, data investigating specific survival and independent risk factors are lacking and have mostly been limited to single orthopaedic oncology centre studies so far. Thus we set up a pathology-based retrospective study and analyzed all MFS diagnosed in our institution with the following aims: (1) analysis of independent risk factors for overall survival, disease specific survival, local recurrence-free survival and distant metastasis free survival following resection of MFS; (2) analysis of resection margin status.

HYPOTHESIS

High-grade MFS have a low survival distant metastasis free survival and local recurrence free survival is dependent on surgical margin status.

PATIENTS AND METHODS

We retrospectively analysed 109 patients (median 66 years [range, 21-96]) diagnosed with MFS and a median follow-up of 42 months at one centre between 1990 and 2014. Tumor-associated survival, including competing risk analysis, and prognostic factors for local recurrence, metastatic disease and death from disease were investigated and included in a multivariate analysis.

RESULTS

Overall survival was 79% [95%CI: 71.9-87.5] at 3 years and 76% [95%CI: 67.4-84.6] at 5 years. Disease specific survival was 85% [95%CI: 78.4-92.2] at 3 years and 80% [95%CI: 72.2-88.2] at 5 years. There were local recurrences in 11/109 patients (10%). Local recurrence free survival (LRFS) was 95% [95%CI: 92.0-99.8] at 3 and 88% [95%CI: 84.3-96.4] at 5 years. Metastatic disease (n=25; 23%) occurred after a median follow-up of 10 months. Distant metastasis free survival was 78% [95%CI: 69.9-85.9] at 3 and 77% [95%CI: 68.4-84.8] at 5 years. R1 status at primary resection was an independent risk factor for decreased Local Recurrence-free survival (OR: 8.5, 95%CI: 1.59-49.79 [p=0.01]). Grading was an independent risk factor for decreased Disease specific survival (OR 13.4, 95%CI: 1.65-1734.84 [p=0.01]) and Distant metastasis free survival (OR 16.2, 95%CI: 2.0-2110.5 [p=0.004]). Primary resection achieved R0 margins in 63 (58%) of 109 patients. Margins were adequate significantly more often (p<0.001) in patients treated primarily at a sarcoma centre (R0=58/68, 85%) than in those treated primarily at non-sarcoma centres (R0= 5/41, 12%), whereby the latter significantly more often treated superficial tumours (p=0.001) with a size of less than 5cm (p<0.001).

DISCUSSION

Patients with high-grade MFS had a poorer prognosis with respect to Disease specific survival/Distant metastasis free survival than low-grade MFS. Local recurrence did not significantly affect disease specific survival.

LEVEL OF EVIDENCE

IV.

Complete remission of a case of high-grade myxofibrosarcoma with lung metastases after modified MAID regimen chemotherapy

The role of chemotherapy in the treatment of myxofibrosarcoma is unclear. There are no randomized clinical trials evaluating the therapeutic effect of chemotherapy on myxofibrosarcoma. We report, to the best of our knowledge, the first case of myxofibrosarcoma successfully treated with mesna, pirarubicin, ifosfamide and dacarbazine (modified MAID) regimen. The patient achieved complete remission evaluated according to Response Evaluation Criteria in Solid Tumours (RECIST).

Comparative Study of Myxofibrosarcoma With Undifferentiated Pleomorphic Sarcoma: Histopathologic and Clinicopathologic Review

Myxofibrosarcoma (MFS) is a malignant fibroblastic/myofibroblastic neoplasm with the prominent myxoid area. It has the clinical features of frequent local recurrence and occasional distant metastasis. Morphologically, MFS is occasionally difficult to distinguish from undifferentiated pleomorphic sarcoma (UPS), especially in the case of high-grade MFS. Here, we reviewed clinical and histologic data of 162 MFS cases and 43 UPS cases. MFS was distinguished from UPS with the criterion of 10% myxoid area as a cutoff value. Overall, 52 MFS (34.4%) and 9 UPS (20.9%) cases showed local recurrence, 18 MFS (12.2%) and 19 UPS (44.2%) cases developed distant metastasis, and 13 MFS (9.5%) and 14 UPS (32.6%) cases resulted in tumor-related death. Statistically, MFS had a better prognosis than UPS. Moreover, MFS with less myxoid area had a tendency to present a poorer prognosis. FNCLCC grade was a statistically significant prognostic factor (distant metastasis: P=0.0021, tumor-related death: P=0.0021). Cellularity and nuclear atypia had only a statistical tendency for associations with a poorer prognosis. The overall survival rate of MFS after transformation into a UPS-like condition (<10% myxoid area) was close to that of UPS. It was suggested that MFS is a biologically distinct tumor from UPS, and MFS with less myxoid area had a tendency to present a poorer prognosis. We considered that evaluation of the amount of myxoid area, cellularity, and nuclear atypia may be important as prognostic predictors. MFS may become similar to histologic malignancy of UPS in terms of morphology and biology via local recurrence.

Prognostic Impact of CD44 Expression in Patients With Myxofibrosarcoma

BACKGROUND/AIM

Abnormal expression of CD44 may promote cancer invasion. However, a limited number of studies have investigated the expression of CD44 in soft tissue sarcoma such as myxofibrosarcoma. We evaluated the relationship between expression of the standard form of CD44 (CD44s) and the clinical course of myxofibrosarcoma.

MATERIALS AND METHODS

Forty-four myxofibrosarcoma patients were retrospectively enrolled. Patient information including the proportion of CD44s-positive cells was collected, and multivariate analyses were conducted to determine the relationship between CD44s expression and clinicopathological factors.

RESULTS

Although CD44s did not affect prognosis, multivariate analysis indicated that high expression of CD44s predicted poor event-free survival (p=0.004) and local recurrence (p=0.049). CD44s expression was not associated with the occurrence of distant metastasis but was significantly higher in those with lung metastasis (p=0.044).

CONCLUSION

Increased expression of CD44s predicted poor event-free survival and local recurrence and was observed in myxofibrosarcoma patients with lung metastasis.

Soft tissue tumours of the elbow: current concepts

Soft tissue tumours of the elbow are mostly benign. Malignant tumours in this area, although uncommon, often present unique clinical and histopathological characteristics that are helpful for diagnosis.Management of soft tissue tumours around the elbow may be challenging because of their rarity and the proximity to neurovascular structures. Careful staging, histological diagnosis and treatment are essential to optimize clinical outcome. A missed or delayed diagnosis or an improperly executed biopsy may have devastating consequences for the patient.This article reviews the most common benign and malignant soft tissue tumours of the elbow and discusses the clinicopathological findings, imaging features and current therapeutic concepts. Cite this article: EFORT Open Rev 2019;4:668-677. DOI: 10.1302/2058-5241.4.190002.

De-Differentiated Myxofibrosarcoma Metastasis in the Right Atrium: An Invasive But Diagnostic Approach

Solitary cardiac metastasis remains an uncommon diagnosis. Herein, the authors report describes a rare case of a 53-year-old woman with cardiac metastasis of a peripheral de-differentiated myxofibrosarcoma. This case demonstrates the complexity of pairing multimodality imaging and invasive techniques to achieve tissue characterization and diagnosis. (Level of Difficulty: Beginner.).

Spontaneous Regression of Myxofibrosarcoma of the Thigh after Open Biopsy

Spontaneous regression of sarcoma is exceedingly rare. A 62-year-old male presented with myxofibrosarcoma of the thigh which regressed after open biopsy. Treatment strategy for this condition is not well-documented in the literature. In this report, we describe the case of a spontaneously regressed myxofibrosarcoma successfully treated by resection where the extent of the tumor was determined from the initial MRI. This case demonstrates that myxofibrosarcoma has the potential to regress spontaneously, and astute awareness of this phenomenon is necessary for appropriate management of this condition.

Soft-Tissue Sarcoma Masquerading as a Haematoma

Sarcomas commonly occur in the buttock and thigh, although the clinical presentation varies with no specific symptoms other than a painless lump. This case study reports on a soft-tissue sarcoma that was initially thought to be a haematoma on ultrasound, despite being rescanned 6 weeks later. The patient presented back to their general practitioner 8 months later with the subsequent ultrasound showing an irregular and hypervascular soft-tissue mass. Further imaging and ultrasound-guided biopsy led to a surgical excision of a myxofibrosarcoma. This case demonstrates the difficulty of differentiating between a haematoma and sarcoma, especially in patients presenting with a history of trauma.

Myxofibrosarcoma in Head and Neck: Case Report of Unusually Aggressive Presentation

Myxofibrosarcoma (MFS) is a malignant fibroblastic tumor that primarily affects the lower and upper extremities. It is usually described as a slow-growing tumor with high recurrence rates but low metastatic potential. The reported incidence of head and neck MFS is 2 to 4% and rarely presents with distant metastases. This report describes a case of maxillary MFS in a 72-year-old woman whose disease progression followed an atypical course with an extremely rapid rate of growth and early pulmonary and central nervous system lesions. The pulmonary symptoms at initial presentation made a final diagnosis a challenge. Various diagnostic modalities and multidisciplinary collaboration were required. The disease course and management are outlined. To the authors' knowledge, this is the first case of MFS originating in the maxillary alveolus with multiple metastases, including the brain and lungs, in the early course of the disease.

Distant metastasis in patients with myxofibrosarcoma

PURPOSE

A clinical feature of myxofibrosarcoma is local recurrence, but knowledge about distant metastasis is sparse. We evaluated the tendency of clinical and histological features of metastasis in myxofibrosarcoma patients.

METHODS

Fifty-eight patients with myxofibrosarcoma were treated in our hospitals, and a total of 16 consecutive patients with distant metastases were included in this retrospective study (9 males and 7 females, with a mean age of 77 years). Because there was no patient complicated by both lung and lymph node metastases, we compared the age, sex, tumor size and location, French Federation of Cancer Centers Sarcoma Group (FNCLCC) grade, American Joint Committee on Cancer (AJCC) stage, and times of the first metastasis from the initial examination between the lung and lymph node groups. In addition, we examined factors affecting the prognosis.

RESULTS

The median follow-up period was 42.9 months (range 8-142). Eleven of 16 patients developed pulmonary metastases. The sites of extra pulmonary metastases were the lymph nodes in 5 patients, bone in 1, subcutaneous in 1, intramuscular in 1, and peritoneum in 1. The median time for patients to develop distant metastases was 17.4 months (range 0-59). The time until the onset of the first metastasis in the lung metastasis group was significantly shorter than in the lymph node group (p < 0.05). Also, the survival rate in the lymph node metastasis group was better than in the lung metastasis group (p < 0.05).

CONCLUSIONS

Not only lung metastasis but also lymph node metastasis occurs frequently in myxofibrosarcoma patients. Myxofibrosarcoma with lung metastasis is more aggressive than the type with lymph node metastasis.

Myxofibrosarcoma of the extremity and trunk

Aims

Myxofibrosarcomas (MFSs) are malignant soft-tissue sarcomas characteristically presenting as painless slowly growing masses in the extremities. Locally infiltrative growth means that the risk of local recurrence is high. We reviewed our experience to make recommendations about resection strategies and the role of the multidisciplinary team in the management of these tumours.

Patients and Methods

Patients with a primary or recurrent MFS who were treated surgically in our unit between 1997 and 2012 were included in the study. Clinical records and imaging were reviewed. A total of 50 patients with a median age of 68.4 years (interquartile range 61.6 to 81.8) were included. There were 35 men; 49 underwent surgery in our unit.

Results

The lower limb was the most common site (32/50, 64%). The mean size of the tumours was 8.95 cm (1.5 to 27.0); 26 (52%) were French Fédération Nationale des Centres de Lutte Contre le Cancer grade III. A total of 21 (43%) had positive margins after the initial excision; 11 underwent further excision. Histology showed microscopic spread of up to 29 mm beyond macroscopic tumour. Local recurrence occurred in seven patients (14%) at a mean of 21 months (3 to 33) and 15 (30%) developed metastases at a mean of 17 months (3 to 30) post-operatively.

Conclusion

High rates of positive margins and the need for further excision makes this tumour particularly suited to management by multidisciplinary surgical teams. Microscopic tumour can be present up to 29 mm from the macroscopic tumour in fascially-based tumours. Cite this article: Bone Joint J 2016;98-B:1682–8.

Integrin-α10 Dependency Identifies RAC and RICTOR as Therapeutic Targets in High-Grade Myxofibrosarcoma

Myxofibrosarcoma is a common mesenchymal malignancy with complex genomics and heterogeneous clinical outcomes. Through gene-expression profiling of 64 primary high-grade myxofibrosarcomas, we defined an expression signature associated with clinical outcome. The gene most significantly associated with disease-specific death and distant metastasis was ITGA10 (integrin-α10). Functional studies revealed that myxofibrosarcoma cells strongly depended on integrin-α10, whereas normal mesenchymal cells did not. Integrin-α10 transmitted its tumor-specific signal via TRIO and RICTOR, two oncoproteins that are frequently co-overexpressed through gene amplification on chromosome 5p. TRIO and RICTOR activated RAC/PAK and AKT/mTOR to promote sarcoma cell survival. Inhibition of these proteins with EHop-016 (RAC inhibitor) and INK128 (mTOR inhibitor) had antitumor effects in tumor-derived cell lines and mouse xenografts, and combining the drugs enhanced the effects. Our results demonstrate the importance of integrin-α10/TRIO/RICTOR signaling for driving myxofibrosarcoma progression and provide the basis for promising targeted treatment strategies for patients with high-risk disease.

SIGNIFICANCE

Identifying the molecular pathogenesis for myxofibrosarcoma progression has proven challenging given the highly complex genomic alterations in this tumor type. We found that integrin-α10 promotes tumor cell survival through activation of TRIO-RAC-RICTOR-mTOR signaling, and that inhibitors of RAC and mTOR have antitumor effects in vivo, thus identifying a potential treatment strategy for patients with high-risk myxofibrosarcoma. Cancer Discov; 6(10); 1148-65. ©2016 AACR.This article is highlighted in the In This Issue feature, p. 1069.

Giant myxofibrosarcoma of the orbit: a rare case and a review of the literature

A 65-year-old man presented with giant orbital myxofibrosarcoma with no extraorbital extension. Imaging was suggestive of mesenchymal malignancy with significant vascularity. Incisional biopsy was suggestive of low-grade fibromyxoid sarcoma. The clinical and imaging features did not support the pathological diagnosis. Histopathology of the exenterated sample revealed features of high-grade myxofibrosarcoma. To the best of our knowledge, this is the largest reported myxofibrosarcoma of the orbit. Adjuvant radiotherapy was advised. Correlating the case history, imaging and histopathology, this case can best be summarised as a natural history of conversion from a low to high-grade myxoid malignancy. We emphasise that the overlapping features of myxoid malignancy (fibromyxosarcoma vs myxofibrosarcoma) and regional variation in tumour morphology in biopsy specimen may mislead the clinician. Therefore, knowledge about the key differentiating features as well as incisional biopsy of each radiologically different area can increase the possibility of correct diagnosis and management of each case.

Optimal Percent Myxoid Component to Predict Outcome in High-Grade Myxofibrosarcoma and Undifferentiated Pleomorphic Sarcoma

BACKGROUND

Myxofibrosarcoma and undifferentiated pleomorphic sarcoma (UPS) are aggressive, genetically complex sarcomas. The minimum myxoid component used as a criterion for myxofibrosarcoma varies widely, so we determined the optimal myxoid component cutpoints for stratifying outcomes of UPS and myxofibrosarcoma. We also analyzed clinicopathologic factors associated with outcome.

METHODS

Review of a prospective, single-institution database identified 197 patients with primary, high-grade extremity/truncal myxofibrosarcoma or UPS resected during 1992-2013. Histology was reviewed and percent myxoid component determined for each tumor. Disease-specific survival (DSS) and distant recurrence-free survival (DRFS) were analyzed using the Kaplan-Meier method, log-rank test, and Cox regression.

RESULTS

Median follow-up for survivors was 6.4 years. In minimum p value analysis of myxoid component, the best cutpoint for both DSS and DRFS was 5% (adjusted p ≤ 0.001), followed by 70%. Therefore, sarcomas with <5% myxoid component (n = 69) were classified as UPS and those with ≥5% myxoid component (n = 128) as myxofibrosarcoma. Five-year DRFS was 24% for UPS, 51% for 5-69% myxoid component myxofibrosarcoma, and 65% for ≥70% myxoid component myxofibrosarcoma. Myxoid component, tumor size, and age were independently associated with DSS; myxoid component and tumor size were associated with DRFS. Only tumor site was associated with local recurrence.

CONCLUSIONS

Percent myxoid component and tumor size are the two most important predictors of DSS and DRFS in high-grade myxofibrosarcoma and UPS. A 5% myxoid component cutpoint is an improved criterion for classifying myxofibrosarcoma. Myxoid component-based classification improves stratification of patient outcome and will aid in selection of patients for systemic therapy and clinical trials.

Immunohistochemical Analysis of Expressions of RB1, CDK4, HSP90, cPLA2G4A, and CHMP2B Is Helpful in Distinction between Myxofibrosarcoma and Myxoid Liposarcoma

The role and diagnostic efficacy of gene and protein products RB1, CDK4, CHMP2B, HSP90, and cPLA2G4A, all previously shown to be involved in tumor genesis and cell proliferation, were examined by immunohistochemical techniques in 32 cases of myxofibrosarcomas and 29 myxoid liposarcomas (all diagnosis had been confirmed by fluorescence in situ hybridization). HSP90 demonstrated strong nuclear and cytoplasmic positivity in all myxoid liposarcoma cases, while only 4 myxofibrosarcomas showed scattered HSP90 positivity. All but 4 cases of myxofibrosarcoma displayed strong positivity for cPLA2G4A, while only 2 myxoid liposarcoma cases were cPLA2G4A positive and both were CHMP2B negative. Overexpression of both cPLA2G4A and CHMP2B also suggested higher tumor grade. In conclusion, HSP90 and cPLA2G4A immunohistochemical stains are useful markers to distinguish myxofibrosarcoma from myxoid liposarcoma.