UK guidelines for the management of soft tissue sarcomas

Soft tissue sarcomas (STS) are rare tumours arising in mesenchymal tissues and can occur almost anywhere in the body. Their rarity, and the heterogeneity of subtype and location, means that developing evidence-based guidelines is complicated by the limitations of the data available. This makes it more important that STS are managed by expert multidisciplinary teams, to ensure consistent and optimal treatment, recruitment to clinical trials, and the ongoing accumulation of further data and knowledge. The development of appropriate guidance, by an experienced panel referring to the evidence available, is therefore a useful foundation on which to build progress in the field. These guidelines are an update of the previous versions published in 2010 and 2016 [1, 2]. The original guidelines were drawn up by a panel of UK sarcoma specialists convened under the auspices of the British Sarcoma Group (BSG) and were intended to provide a framework for the multidisciplinary care of patients with soft tissue sarcomas. This iteration of the guidance, as well as updating the general multidisciplinary management of soft tissue sarcoma, includes specific sections relating to the management of sarcomas at defined anatomical sites: gynaecological sarcomas, retroperitoneal sarcomas, breast sarcomas, and skin sarcomas. These are generally managed collaboratively by site specific multidisciplinary teams linked to the regional sarcoma specialist team, as stipulated in the recently published sarcoma service specification [3]. In the UK, any patient with a suspected soft tissue sarcoma should be referred to a specialist regional soft tissues sarcoma service, to be managed by a specialist sarcoma multidisciplinary team. Once the diagnosis has been confirmed using appropriate imaging and a tissue biopsy, the main modality of management is usually surgical excision performed by a specialist surgeon, combined with pre- or post-operative radiotherapy for tumours at higher risk for local recurrence. Systemic anti-cancer therapy (SACT) may be utilised in cases where the histological subtype is considered more sensitive to systemic treatment. Regular follow-up is recommended to assess local control, development of metastatic disease, and any late effects of treatment.

Progress in histology specific treatments in soft tissue sarcoma

INTRODUCTION

Soft tissue sarcomas (STS) represent a heterogenous group of rare tumors, primarily treated with surgery. Preoperative radiotherapy is often recommended for extremity high-risk STS. Neoadjuvant chemotherapy, typically based on doxorubicin with ifosfamide, has shown efficacy in limbs and trunk wall STS. Second-line chemotherapy, commonly utilized in the metastatic setting, is mostly histology-driven. Molecular targeted agents are used across various histologies, and although the use of immunotherapy in STS is still in its early stages, there is increasing interest in exploring its potential.

AREAS COVERED

This article involved an extensive recent search on PubMed. It explored the current treatment landscape for localized and metastatic STS, focusing on the combined use of radiotherapy and chemotherapy for both extremity and retroperitoneal tumors, and with a particular emphasis on the most innovative histopathology driven therapeutic approaches. Additionally, ongoing clinical trials identified via clinicaltrials.gov are included.

EXPERT OPINION

Recently there have been advancements in the treatment of STS, largely driven by the outcomes of clinical trials. However further research is imperative to comprehend the effect of chemotherapy, targeted therapy and immunotherapy in various STS, as well as to identify biomarkers able to predict which patients are most likely to benefit from these treatments.

Canadian consensus on TRK-inhibitor therapy for NTRK fusion-positive sarcoma

Malignant sarcomas are rare accounting for <1% of all adult solid malignancies and approximately 11% to 13% of all pediatric malignancies. TRK-inhibitors have demonstrated robust and long-lasting responses in patients with NTRK fusion-positive solid tumors, including sarcoma. Access to these agents in many jurisdictions such as Canada remains limited. We undertook a modified Delphi consensus to articulate and convey the clinical importance of these agents for the Canadian sarcoma community. A systematic search of published and presented literature was conducted to identify clinical trials reporting outcomes on the use of TRK-inhibitors in relapsed/refractory NTRK fusion-positive sarcoma. Three main consensus questions were identified: (a) is there currently an unmet clinical need for systemic therapy options in relapsed/refractory sarcoma? (b) do TRK-inhibitors confer a clinical benefit to patients with NTRK fusion-positive sarcoma? (c) do phase I/II basket trials provide sufficient evidence to justify funding of TRK-inhibitors in NTRK fusion-positive sarcoma? Response rates to the first and second surveys were 57% (n = 30) and 42% (n = 22), respectively. There was strong agreement among the Canadian sarcoma community that there was unmet clinical need for effective systemic therapy options in relapsed/refractory sarcoma, that TRK-inhibitors are a safe and effective treatment option for patients with NTRK fusion-positive sarcoma, and that available phase I/II basket trials provide sufficient evidence to support funding of these agents in relapsed/refractory NTRK fusion-positive sarcoma. TRK-inhibitors are a safe and effective systemic therapy option for patients with relapsed/refractory NTRK fusion-positive sarcoma.

Modern Management of High-risk Soft Tissue Sarcoma With Neoadjuvant Chemoradiation: A Single-center Experience

OBJECTIVE

Neoadjuvant chemoradiation (NA-CRT), followed by resection of high-risk soft tissue sarcoma (STS), may offer good disease control and toxicity outcomes. We report on a single institution's modern NA-CRT experience.

MATERIALS AND METHODS

Delay to surgical resection, resection margin status, extent of necrosis, tumor cell viability, presence of hyalinization, positron emission tomography (PET)/computed tomography data, and treatment toxicities were collected. Using the Kaplan-Meier survival analysis, 5-year overall survival, disease-free survival, distant metastasis-free survival, and local control (LC) were estimated. Clinicopathologic features and PET/computed tomography avidity changes were assessed for their potential predictive impact using the log-rank test.

RESULTS

From 2011 to 2018, 37 consecutive cases of localized high-risk STS were identified. Twenty-nine patients underwent ifosfamide-based NA-CRT to a median dose of 50 Gy before en bloc resection. At a median follow-up of 40.3 months, estimated 5-year overall survival was 86.1%, disease-free survival 70.2%, distant metastasis-free survival 75.2%, and LC 86.7%. Following NA-CRT, a median reduction of 54.7% was observed in tumor PET avidity; once resected, median tumor necrosis of 60.0% with no viable tumor cells was detected in 13.8% of the cases. Posttreatment resection margins were negative in all patients, with 27.6% having a margin of ≤1 mm. Delays of over 6 weeks following the end of radiation treatment to surgical resection occurred in 20.7% cases and was suggestive of inferior LC (92.8% vs. 68.6%, P=0.025).

CONCLUSIONS

This single-institution series of NA-CRT demonstrates favorable disease control. Delay in surgical resection was associated with inferior LC, a finding that deserves further evaluation in a larger cohort.

LEVEL OF EVIDENCE

Level III-retrospective cohort study.

Diagnostic Differences in Expert Second-Opinion Consultation Cases at a Tertiary Sarcoma Center

Soft tissue tumors are diagnostically challenging, and it is recommended that these are reported or reviewed by specialist soft tissue pathologists. We present our experience with second-opinion (consultation) cases in a specialist tertiary sarcoma center. The aim of this study was to determine areas of diagnostic difficulty in soft tissue pathology. We assessed 581 second-opinion cases which were reviewed by two experienced pathologists in a period of one year. There was 62% concordance between the original and the second-opinion diagnosis, with diagnostic discrepancy in 38%. The largest group of soft tissue neoplasms received for second opinion was fibroblastic/myofibroblastic tumors, and most major diagnostic problems were encountered in adipocytic and so-called “fibrohistiocytic” tumors. Major diagnostic errors impacting management were found in 148 cases (25%). Morphologic assessment of tumors, judicious use of molecular techniques, newer immunostains and their interpretation, along with importance of knowledge of rarer entities were found to be most useful in avoiding errors.

Cytologic grading of canine and feline spindle-cell sarcomas of soft tissues and its correlation with histologic grading

In humans, soft tissue spindle cell sarcomas (STSCS) grading is considered a useful parameter in determining prognosis and therapy, and it is recognized as an important prognostic factor in canine STSCS. The purpose of this study was to assess the utility and the accuracy of a cytologic grading system on fine needle aspiration cytology (FNAC) smears of canine and feline cutaneous and subcutaneous STSCS .Thirty-three cases of cytologically diagnosed STSCS were included. The smears and their tumour sections were cytologically and histologically graded, according to established methods in human oncology.Canine STSCS showed a cyto/histologic concordance in 12/20 cases (60%). Concordance was observed in 4/8 (50%) of grade 1, in 8/12 (67%) of grade 2, and in 0 cases of grade 3. Feline STSCS showed concordance in 11/13 cases (85%). Concordance was observed in 5/6 (83%) of grade 1, in 4/4 (100%) of grade 2, and in 2/3 (66.6%) of grade 3 cases. The overall concordance in the entire canine and feline population was 70%. The gradewise concordance was 65% in grade 1, 75% in grade 2, and 66% in grade 3 cases. The overall concordance is similar to that reported in humans. Although a wider population is required to strengthen our findings, these results suggest that cytologic grading of STSCSs may be a useful tool for therapeutic and prognostic evaluations in dogs and cats.

Mesenchymal neoplasms: Is it time for cytology? New perspectives for the pre-operative diagnosis of soft tissue tumors in the molecular era

Soft tissue tumors comprise a great variety of common and rare entities with overlapping features. Their diagnosis is based on the evaluation of several histological parameters which are difficult to assess on small incisional biopsies. Useful diagnostic markers in the field of soft tissue tumors include: 1) molecular biomarkers detecting pathogenetically relevant, distinctive alterations; 2) immunohistochemical surrogate biomarkers of pathogenetically relevant, distinctive molecular alterations; 3) highly specific immunohistochemical biomarkers indicating tumor differentiation. Their introduction in clinical practice has revolutionized the pre-operative diagnosis of soft tissue tumors. Cytology has long been considered inadequate as a first-line approach in this setting. However, since the implementation of new immunohistochemical and molecular tests with high diagnostic specificity, fine needle aspiration cytology (FNAC) is starting to gain acceptance for the pre-operative assessment of soft tissue tumors. FNAC represents a versatile, poorly expensive and well-tolerated diagnostic strategy with relevant advantages over histological biopsies. Moreover, evidences suggest that, in expert hands, FNAC can also aim at a definite diagnosis, especially if a cell block is prepared, allowing the application of multiple ancillary techniques.

Dedifferentiated liposarcoma: when eribulin can make the difference

We describe the case of a male subject affected by retroperitoneal advanced, anthracycline-pretreated liposarcoma, who experienced a long, beneficial clinical effect from eribulin treatment. In March 2013, a left, paraortic, retroperitoneal mass was surgically removed and diagnosed as Mdm2-positive dedifferentiated liposarcoma. In June 2015, a CT scan revealed disease progression and first-line epirubicin/ifosfamide treatment was started, followed by epirubicin in monotherapy. In January 2017, following a new disease progression, the patient started a second-line eribulin treatment that went on for about 1 year with no major adverse events. The CT scans performed every 3-4 months showed stable disease. After 13 months of treatment, a CT scan revealed disease progression and 10 days later, the patient died of bowel perforation and peritonitis.

Soft tissue head and neck sarcoma: experience of a tertiary referral centre over a 15-year period

BACKGROUND

Head and neck soft tissue sarcoma is uncommon. It is both histologically and clinically heterogeneous, ranging from an indolent, locally destructive tumour, to a locally aggressive neoplasm with metastatic potential.

METHODS

A retrospective review was conducted of all adult head and neck soft tissue sarcomas, including cases of malignant soft tissue sarcoma and all intermediate type tumours, diagnosed between 1997 and 2012.

RESULTS

Sixty-eight cases were identified in this series from the sarcoma multidisciplinary team. Seventeen different histological subtypes of sarcoma were identified. Neither age, gender nor tumour size were significant prognostic indicators for survival in this series.

CONCLUSION

Prognosis is dependent on histological subtype, underscoring the importance of histological classification. Some histological subtypes occur only once or twice in a decade, even within a large regional referral centre. An accumulation of evidence from relatively small case series is key in the long-term development of treatment strategies.

An automated method for segmentation and quantification of blood vessels in histology images

Alzheimer's disease (AD) is a chronic neuro-degenerative disease that adversely affect many people on a global scale. Despite different diagnostic and therapeutic treatment, there is no cure for AD. The brain is one of the most complex organ and researchers are still trying to understand so as to find a cure.

OBJECTIVE

To complement the efforts of clinical researchers engaged in research in alzheimer's disease, accurate segmentation and quantification of blood vessels in brain images is required.

METHOD

For robust segmentation of blood vessels even in the presence of colour variation, we introduce a fully automated morphological tool that can extract and quantify vessels from haematoxylin and diaminobenzidine stained histology brain image. The method, exploits saturation channel of stained image slides, ISODATA threshold method is applied to obtain a binary image. This helps in eliminating background and remaining with only blood vessels. A one-stage procedure that includes eliminating small artefacts is performed on the binary mask. The intensity of the image is transformed. Joining is performed to deal with fragmentation of intact blood vessels on the images, and artefactual appearance of the blood vessel structures. The artefactual fragments based on measured incoherence with neighbouring tissue are removed. The vessels are then labelled to facilitate quantification. Morphometric measurements are used during the vessel quantification assess both vessels with lumen and vessels without lumen. We have quantified the diameter of blood vessels.

RESULTS

The image processing technique is developed in close collaboration with neuroscientist experts to help clinician. We have evaluated our proposed approach qualitatively. The method was validated against their manual quantification results. Qualitative results show that the method can indeed segment the blood vessels in the presence of colour variations and artefacts. The quantitative method produces fairly better results.

Leiomyosarcoma: Clinicopathological study and retrospective analysis of prognostic factors in a series of 100 patients

The Authors reported a retrospective study of 100 Leiomyosarcoma (LMS), evaluating factors that may influence Overall Survival (OS), Local Recurrence Free Survival (LRFS), Metastasis Free Survival (MFS). Tumor Size (P = 0,0009), Local Recurrence (P = 0,0487), Distant relapse (P < 0,0001), Type of Presentation (P = 0,0213) were significant risk factors affecting overall survival (OS). Tumor Size (P = 0.024), age at diagnosis (P = 0,0086), type of presentation (P < 0,0001) and Local Recurrence (P = 0.0152) affected metastasis free survival (MFS). Type of presentation (P = 0,001) was an independent prognostic factor of local recurrence-free survival (LRFS).

Aldoxorubicin in soft tissue sarcomas

Aldoxorubicin is a prodrug formulation of doxorubicin currently under investigation for the treatment of soft tissue sarcomas. Early studies have demonstrated a promising reduction in the cardiotoxicity of aldoxorubicin compared with equivalent doses of doxorubicin leading to an increase in the equivalent cumulative dose of aldoxorubicin. The current clinical and pharmacological data available for aldoxorubicin are extremely promising for its use in the treatment of advanced and metastatic soft tissue sarcomas compared with equivalent doses of doxorubicin although Phase III data are lacking. We review aldoxorubicin for the treatment of advanced and metastatic soft tissue sarcomas and discuss the impact it may have in the future.

A phase 1 and randomized controlled phase 2 trial of the safety and efficacy of the combination of gemcitabine and docetaxel with ontuxizumab (MORAb-004) in metastatic soft-tissue sarcomas

Background

Ontuxizumab, a humanized monoclonal antibody, targets endosialin (tumor endothelial marker 1 [TEM‐1] or CD248), which is expressed on sarcoma cells and is believed to be involved in tumor angiogenesis. This is the first trial to evaluate ontuxizumab in patients with sarcoma.

Methods

Part 1 was an open‐label, dose‐finding, safety lead‐in: 4, 6, or 8 mg/kg with gemcitabine and docetaxel (G/D; 900 mg/m² gemcitabine on days 1 and 8 and 75 mg/m² docetaxel on day 8). In part 2, patients were randomized in a double‐blind fashion in 2:1 ratio to ontuxizumab (8 mg/kg) or a placebo with G/D. Randomization was stratified by 4 histological cohorts.

Results

In part 2 with 209 patients, no significant difference in progression‐free survival between ontuxizumab plus G/D (4.3 months; 95% confidence interval [CI], 2.7‐6.3 months) and the placebo plus G/D (5.6 months; 95% CI, 2.6‐8.3 months) was observed (P = .67; hazard ratio [HR], 1.07; 95% CI, 0.77‐1.49). Similarly, there was no significant difference in median overall survival between the 2 groups: 18.3 months for the ontuxizumab plus G/D group (95% CI, 16.2‐21.1 months) and 21.1 months for the placebo plus G/D group (95% CI, 14.2 months to not reached; P = .32; HR, 1.23; 95% CI, 0.82‐1.82). No significant differences between the treatment groups occurred for any efficacy parameter by sarcoma cohort. The combination of ontuxizumab plus G/D was generally well tolerated.

Conclusions

Ontuxizumab plus G/D showed no enhanced activity over chemotherapy alone in soft‐tissue sarcomas, whereas the safety profile of the combination was consistent with G/D alone.

Endosialin is involved in tumor blood vessel formation and is expressed on sarcoma tumor cells. This phase 1/2 randomized controlled trial shows that ontuxizumab, an endosialin‐directed monoclonal antibody, does not enhance efficacy in sarcomas when it is combined with chemotherapy (gemcitabine and docetaxel), although the combination is generally well tolerated.

IGF-I regulates HT1080 fibrosarcoma cell migration through a syndecan-2/Erk/ezrin signaling axis

Fibrosarcoma is a tumor of mesenchymal origin, originating from fibroblasts. IGF-I is an anabolic growth factor which exhibits significant involvement in cancer progression. In this study, we investigated the possible participation of syndecan-2 (SDC-2), a cell membrane heparan sulfate (HS) proteoglycan on IGF-I dependent fibrosarcoma cell motility. Our results demonstrate that SDC-2-deficient HT1080 cells exhibit attenuated IGF-I-dependent chemotactic migration (p < 0.001). SDC-2 was found to co-localize to IGF-I receptor (IGF-IR) in a manner dependent on IGF-I activity (P ≤ 0.01). In parallel, the downregulation of SDC-2 significantly inhibited both basal and due to IGF-I action ERK1/2 activation, (p < 0.001). The phosphorylation levels of ezrin (Thr567), which is suggested to act as a signaling bridge between the cellular membrane receptors and actin cytoskeleton, were strongly enhanced by IGF-I at both 1h and 24h (p < 0.05; p < 0.01). The formation of an immunoprecipitative complex revealed an association between SDC2 and ezrin which was enhanced through IGF-I action (p < 0.05). Immunoflourescence demonstrated a co-localization of IGF-IR, SDC2 and ezrin upregulated by IGF-I action. IGF-I enhanced actin polymerization and ezrin/actin specific localization to cell membranes. Finally, treatment with IGF-I strongly increased SDC2 expression at both the mRNA and protein level (p < 0.001). Therefore, we propose a novel SDC2-dependent mechanism, where SDC2 is co-localized with IGF-IR and enhances its' IGFI-dependent downstream signaling. SDC2 mediates directly IGFI-induced ERK1/2 activation, it recruits ezrin, contributes to actin polymerization and ezrin/actin specific localization to cell membranes, ultimately facilitating the progression of IGFI-dependent fibrosarcoma cell migration.

Eribulin in advanced liposarcoma and leiomyosarcoma

INTRODUCTION

The heterogeneity of soft tissue sarcomas (STS) presents a formidable management challenge. Consequently, one of the main research goals is to define specific tailored therapy for each histological subtype and to develop a more personalised approach to treatment. The standard first line chemotherapy for advanced STS is doxorubicin, with or without ifosfamide, however, a number of different drugs are emerging as active therapies beyond first-line. Areas covered: Eribulin has recently been approved for advanced liposarcoma, after an anthracycline-containing regimen, demonstrating an overall survival (OS) advantage in liposarcoma and leiomyosarcoma in a randomised Phase III clinical trial. In this manuscript, an overview of the efficacy and safety of eribulin in STS is presented, highlighting different clinical outcomes between histological subtypes and comparing data with other effective drugs used in the treatment of sarcomas. The potential mechanisms of action of eribulin are also described, including its activity as potent microtubule-destabilizing anticancer agent, which has other antitumor biological effects. Expert commentary: Eribulin is highly effective in some STS populations and also has an acceptable toxicity profile. Further studies are required to better understand the precise mechanism of action of this agent and potential role in combination schedules.

Soft tissue sarcomas in adolescents and young adults: a comparison with their paediatric and adult counterparts

Survival outcomes for adolescent and young adult patients with soft tissue sarcomas lag behind those of children diagnosed with histologically similar tumours. To help understand these differences in outcomes, we discuss the following issues with regard to the management of these patients with soft tissue sarcomas: delays in diagnosis, trial availability and participation, aspects of the organisation of care (with an emphasis on age-specific needs), national centralisation of sarcoma care, international consortia, and factors related to tumour biology. Improved understanding of the causes of the survival gap between adolescents and young adults with sarcomas will help drive new initiatives to improve final health outcomes in these populations. In this Review, we specifically focus on embryonal and alveolar rhabdomyosarcoma, synovial sarcoma, and adult soft tissue sarcomas diagnosed in adolescents and young adults, and discuss the age-specific needs of these patients.

SEOM Clinical Guideline of management of soft-tissue sarcoma (2016)

Soft-tissue sarcomas are uncommon and heterogeneous tumors of mesenchymal origin. A soft-tissue mass that is increasing in size, greater than 5 cm, or located under deep fascia are criteria for suspicion of sarcoma. Diagnosis, treatment, and management should preferably be performed by a multidisciplinary team in reference centers. MRI and lung CT scan are mandatory for local and distant assessment. A biopsy indicating histological type and grade is needed previous to the treatment. Wide surgical resection with tumor-free tissue margin is the primary treatment for localized disease. Radiotherapy is indicated in large, deep, high-grade tumors, or after marginal resection not likely of being improved with reexcision. Neoadjuvant and adjuvant chemotherapy improve survival in selected cases, usually in high-grade sarcomas of the extremities. In the case of metastatic disease, patients with exclusive lung metastasis could be considered for surgery. First-line treatment with anthracyclines (or in combination with ifosfamide) is the treatment of choice. New drugs have shown activity in second-line therapy and in specific histological subtypes.

Clinical applications of MALDI imaging technologies in cancer and neurodegenerative diseases

Matrix-assisted laser desorption/ionization (MALDI) time-of-flight (TOF) imaging mass spectrometry (IMS) enables localization of analytes of interest along with histology. More specifically, MALDI-IMS identifies the distributions of proteins, peptides, small molecules, lipids, and drugs and their metabolites in tissues, with high spatial resolution. This unique capacity to directly analyze tissue samples without the need for lengthy sample preparation reduces technical variability and renders MALDI-IMS ideal for the identification of potential diagnostic and prognostic biomarkers and disease gradation. MALDI-IMS has evolved rapidly over the last decade and has been successfully used in both medical and basic research by scientists worldwide. In this review, we explore the clinical applications of MALDI-IMS, focusing on the major cancer types and neurodegenerative diseases. In particular, we re-emphasize the diagnostic potential of IMS and the challenges that must be confronted when conducting MALDI-IMS in clinical settings. This article is part of a Special Issue entitled: MALDI Imaging, edited by Dr. Corinna Henkel and Prof. Peter Hoffmann.

UK guidelines for the management of soft tissue sarcomas

Soft tissue sarcomas (STS) are rare tumours arising in mesenchymal tissues, and can occur almost anywhere in the body. Their rarity, and the heterogeneity of subtype and location means that developing evidence-based guidelines is complicated by the limitations of the data available. However, this makes it more important that STS are managed by teams, expert in such cases, to ensure consistent and optimal treatment, as well as recruitment to clinical trials, and the ongoing accumulation of further data and knowledge. The development of appropriate guidance, by an experienced panel referring to the evidence available, is therefore a useful foundation on which to build progress in the field. These guidelines are an update of the previous version published in 2010 (Grimer et al. in Sarcoma 2010:506182, 2010). The original guidelines were drawn up following a consensus meeting of UK sarcoma specialists convened under the auspices of the British Sarcoma Group (BSG) and were intended to provide a framework for the multidisciplinary care of patients with soft tissue sarcomas. This current version has been updated and amended with reference to other European and US guidance. There are specific recommendations for the management of selected subtypes of disease including retroperitoneal and uterine sarcomas, as well as aggressive fibromatosis (desmoid tumours) and other borderline tumours commonly managed by sarcoma services. An important aim in sarcoma management is early diagnosis and prompt referral. In the UK, any patient with a suspected soft tissue sarcoma should be referred to one of the specialist regional soft tissues sarcoma services, to be managed by a specialist sarcoma multidisciplinary team. Once the diagnosis has been confirmed using appropriate imaging, plus a biopsy, the main modality of management is usually surgical excision performed by a specialist surgeon. In tumours at higher risk of recurrence or metastasis pre- or post-operative radiotherapy should be considered. Systemic anti-cancer therapy (SACT) may be utilized in some cases where the histological subtype is considered more sensitive to systemic treatment. Regular follow-up is recommended to assess local control, development of metastatic disease, and any late-effects of treatment. For local recurrence, and more rarely in selected cases of metastatic disease, surgical resection would be considered. Treatment for metastases may include radiotherapy, or systemic therapy guided by the sarcoma subtype. In some cases, symptom control and palliative care support alone will be appropriate.

Efficacy and safety of eribulin mesylate in advanced soft tissue sarcomas

Despite recent advances in the field, treatment options for metastatic soft tissue sarcoma patients are limited. Eribulin, an antimitotic derived from the natural marine sponge product halichondrin B, is currently approved for the treatment of metastatic breast cancer. Following the promising activity of eribulin in sarcoma in a Phase II trial, the drug was recently compared to dacarbazine in pretreated advanced leiomyosarcoma (LMS) and liposarcoma (LPS) patients in a Phase III trial. Eribulin was associated with a significant 2-month improvement in median overall survival compared to dacarbazine (13.5 vs. 11.5 months, heart rate: 0.768) despite no documented significant difference in progression-free survival. In a subgroup analysis, the survival advantage associated with eribulin was evident in the LPS subgroup but not in the LMS subgroup. Following these encouraging results, the Food and Drug Administration has approved eribulin for the treatment of advanced LPS for patients who received prior anthracycline chemotherapy. In this short review, we will evaluate the evidence for eribulin in soft tissue sarcoma, highlight its mechanisms of action, and summarize the results of the major preclinical and clinical studies with a particular focus on the results of the Phase III trial.

Heparin regulates B6FS cell motility through a FAK/actin cytoskeleton axis

Soft tissue sarcomas are rare, heterogeneous tumors of mesenchymal origin with an aggressive behavior. Heparin is a mixture of heavily sulfated, linear glycosaminoglycan (GAG) chains, which participate in the regulation of various cell biological functions. Heparin is considered to have significant anticancer capabilities, although the mechanisms involved have not been fully defined. In the present study, the effects of unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) on B6FS fibrosarcoma cell motility were examined. Both preparations of heparin were shown to both enhance B6FS cell adhesion (p<0.01 and p<0.05), and migration (p<0.05), the maximal effect being evident at the concentration of 10 µg/ml. The utilization of FAK-deficient cells demonstrated that the participation of FAK was obligatory for heparin-dependent fibrosarcoma cell adhesion (p<0.05). The results of confocal microscopy indicated that heparin was taken up by the B6FS cells, and that UFH and LMWH induced F-actin polymerization. Heparitinase digestion demonstrated that the endogenous heparan sulfate (HS) chains did not affect the motility of the B6FS cells (p>0.05, not significant). In conclusion, both UFH and LMWH, through a FAK/actin cytoskeleton axis, promoted the adhesion and migration of B6FS fibrosarcoma cells. Thus, our findings indicate that the responsiveness of fibrosarcoma cells to the exogenous heparin/HS content of the cancer microenvironment may play a role in their ability to become mobile and metastasize.

Phosphoproteomics in translational research: a sarcoma perspective

Phosphoproteomics has been extensively used as a preclinical research tool to characterize the phosphorylated components of the cancer proteome. Advances in the field have yielded insights into new drug targets, mechanisms of disease progression and drug resistance, and biomarker discovery. However, application of this technology to clinical research has been challenging because of practical issues relating to specimen integrity and tumour heterogeneity. Beyond these limitations, phosphoproteomics has the potential to play a pivotal role in translational studies and contribute to advances in different tumour groups, including rare disease sites like sarcoma. In this review, we propose that deploying phosphoproteomic technologies in translational research may facilitate the identification of better defined predictive biomarkers for patient stratification, inform drug selection in umbrella trials and identify new combinations to overcome drug resistance. We provide an overview of current phosphoproteomic technologies, such as affinity-based assays and mass spectrometry-based approaches, and discuss their advantages and limitations. We use sarcoma as an example to illustrate the current challenges in evaluating targeted kinase therapies in clinical trials. We then highlight useful lessons from preclinical studies in sarcoma biology to demonstrate how phosphoproteomics may address some of these challenges. Finally, we conclude by offering a perspective and list the key measures required to translate and benchmark a largely preclinical technology into a useful tool for translational research.

The Current Status of Solitary Fibrous Tumor: Diagnostic Features, Variants, and Genetics

Solitary fibrous tumor (SFT) is a fibroblastic mesenchymal tumor originally described in the pleura but now shown at almost every anatomic site. Histopathologically, SFT is characteristically a circumscribed neoplasm composed of variably cellular and patternless distributions of bland spindle and ovoid cells within prominent collagenous stroma and shows diffuse expression of CD34, but it has a broad spectrum of both morphology and of biologic behavior. Many different names (particularly hemangiopericytoma) were previously used in the course of our understanding of this neoplasm but are now subsumed under the term "SFT," and the putative cell of origin was debated. However, it is now recognized that SFT is a translocation-associated neoplasm, consistently associated with NAB2-STAT6 gene fusions arising from recurrent intrachromosomal rearrangements on chromosome 12q, and this translocation is a likely major contributor to its pathogenesis. While most SFT with classical morphologic features behave in an indolent manner and those with overtly malignant histologic features tend to be aggressive neoplasms that behave as high-grade sarcomas, the behavior of SFT is unpredictable, and it is important to be aware of the propensity for aggressive behavior in a minority of histologically classical SFT and to ensure adequate clinical follow-up. Surgical excision remains the treatment gold standard; while radiotherapy and conventional chemotherapeutic agents have only shown limited efficacy, further understanding of the molecular events underlying tumorigenesis may allow the development of novel targeted treatments. We review SFT, discussing the morphologic spectrum and variants, including malignant and dedifferentiated subtypes, clinicopathological aspects, recent molecular genetic findings, and the differential diagnosis.