Soft-tissue and bone sarcoma histopathology peer review: the frequency of disagreement in diagnosis and the need for second pathology opinions. The Southeastern Cancer Study Group experience

Histological diagnostic discrepancy and its clinical impact in bone and soft tissue tumors referred to a sarcoma center

Histological diagnosis of sarcomas (malignant bone and soft tissue tumors) is challenging due to their rarity, morphological diversity, and constantly evolving diagnostic criteria. In this study, we aimed to assess the concordance in histological diagnosis of bone and soft tissue tumors between referring hospitals and a tertiary sarcoma center and analyzed the clinical impact of the diagnostic alteration. We analyzed 628 consecutively accessioned specimens from 624 patients who visited a specialized sarcoma center for treatment. The diagnoses at referring hospitals and those at the sarcoma center were compared and classified into four categories: agreed, disagreed, specified, and de-specified. Of the 628 specimens, the diagnoses agreed in 403 (64.2%) specimens, whereas some changes were made in 225 (35.8%) specimens: disagreed in 153 (24.3%), specified in 52 (8.3%), and de-specified in 20 (3.2%) cases. The benign/intermediate/malignant judgment changed for 92 cases (14.6%). The diagnostic change resulted in patient management modification in 91 cases (14.5%), including surgical and medical treatment changes. The main inferred reason for the diagnostic discrepancies was a different interpretation of morphological findings of the tumor, which accounted for 48.9% of the cases. This was followed by the unavailability of specialized immunohistochemical antibodies and the unavailability of genetic analysis. In summary, our study clarified the actual clinical impact of diagnostic discrepancy in bone and soft tissue tumors. This may underscore the value of pathology consultation, facilitating access to specialized diagnostic tools, and continued education. These measures are expected to improve diagnostic precision and ultimately benefit patients.

The Impact of Expert Pathology Review and Molecular Diagnostics on the Management of Sarcoma Patients: A Prospective Study of the Hellenic Group of Sarcomas and Rare Cancers

Precise classification of sarcomas is crucial to optimal clinical management. In this prospective, multicenter, observational study within the Hellenic Group of Sarcoma and Rare Cancers (HGSRC), we assessed the effect of expert pathology review, coupled with the application of molecular diagnostics, on the diagnosis and management of sarcoma patients. Newly diagnosed sarcoma patients were addressed by their physicians to one of the two sarcoma pathologists of HGSRC for histopathological diagnostic assessment. RNA next-generation sequencing was performed on all samples using a platform targeting 86 sarcoma gene fusions. Additional molecular methods were performed in the opinion of the expert pathologist. Therefore, the expert pathologist provided a final diagnosis based on the histopathological findings and, when necessary, molecular tests. In total, 128 specimens from 122 patients were assessed. Among the 119 cases in which there was a preliminary diagnosis by a non-sarcoma pathologist, there were 37 modifications in diagnosis (31.1%) by the sarcoma pathologist, resulting in 17 (14.2%) modifications in management. Among the 110 cases in which molecular tests were performed, there were 29 modifications in diagnosis (26.4%) through the genomic results, resulting in 12 (10.9%) modifications in management. Our study confirms that expert pathology review is of utmost importance for optimal sarcoma diagnosis and management and should be assisted by molecular methods in selected cases.

Breast Sarcomas-How Different Are They from Breast Carcinomas? Clinical, Pathological, Imaging and Treatment Insights

Breast sarcoma (BS) is a very rare and poorly studied condition. This has led to a lack of studies with a high level of evidence and to low efficacy of current clinical management protocols. Here we present our experience in treating this disease in the form of a retrospective case series study including discussion of clinical, imaging, and pathological features and treatment. We also compare the main clinical and biological features of six cases of BS (phyllodes tumors were excluded) with a cohort of 184 patients with unilateral breast carcinoma (BC) from a previous study performed at our institution. Patients with BS were diagnosed at a younger age, presented no evidence of lymph node invasion or distant metastases, had no multiple or bilateral lesions, and underwent a shorter length of hospital stay versus the breast carcinoma group. Where recommended, adjuvant chemotherapy consisted of an anthracycline-containing regimen, and adjuvant external radiotherapy was delivered in doses of 50 Gy. The comparison data obtained from our BS cases and the ones with BC revealed differences in diagnosis and treatment. A correct pathological diagnosis of breast sarcoma is essential for the right therapeutic approach. We still have more to learn about this entity, but our case series could add value to existing knowledge in a meta-analysis study.

Treatment for local control of retroperitoneal and pelvis sarcomas: A review of the literature

Retroperitoneal and pelvis sarcomas are uncommon tumors for which complete surgical resection is the mainstay of treatment. However, achieving complete gross resection with microscopically negative margins is challenging, and local recurrence rates can be high. Patients often succumb to uncontrolled local disease. Radiation therapy offers a potential means for sterilizing microscopic residual disease, although its use continues to be controversial. Chemotherapy alone or in combination with radiation continues to be investigated as an adjunct to surgery, along with immunotherapy and targeted therapies. In this review, we discuss the current management of retroperitoneal and pelvis sarcomas, focusing on studies of surgery and radiation therapy to maximize local control.

Time and Accuracy to Establish the Diagnosis of Soft Tissue Tumors: A Comparative Analysis from the Swiss Sarcoma Network

Soft tissue tumors are rare tumors, and their histological examination remains a challenge. The establishment of the correct initial histopathologic diagnosis is critical. However, due to the rarity of soft tissue and bone tumors and the inherent difficulty of their classification and diagnostics, discrepancies may occur in up to one third of cases. For these reasons, several studies recommend the involvement of experienced pathologists frequently performing sarcoma diagnostics. Until now, there is only scarce information about how long it takes to establish a correct sarcoma diagnosis. We thus analyzed all consecutive patients presented to the Swiss Sarcoma Network Tumor Board (SSN-MDT/SB) with a primary diagnosis of a soft tissue tumor over a 2-year period (01/2019 to 12/2020) based on a tumor biopsy. We then compared the final histopathological diagnosis of two comparable institutions with similar case load, but different workflows: (i) institution A, with an initial diagnosis performed by a local pathologist, and reviewed by a reference pathologist, and (ii) institution B, with the final diagnosis performed directly by a reference pathologist. In addition, we analyzed the time from biopsy to establishment of the diagnosis. A total of 347 cases were analyzed, 196 from institution A, and 149 from institution B. In 77.6% of the cases, the diagnosis from the local pathologist was concordant with the expert review. Minor discrepancies were found in 10.2% of the cases without any consecutive changes in treatment strategy. In the remaining 12.2% of the cases, there were major discrepancies which influenced the treatment strategy directly. Establishing the final report took significantly longer in institution A (4.7 working days) than in institution B (3.3 working days; p < 0.01). Our results confirm the importance of a pathological second review by a reference pathologist. We recommend direct analysis by experts, as diagnoses can be made more accurately and quickly. Within the SSN, establishing the sarcoma diagnosis is overall accurate and quick but still can be improved.

EWS-FLI1-targeting peptide identifies Ewing sarcoma tumor boundaries and lymph node metastasis via near-infrared imaging

Ewing sarcoma (ES) is one of the most aggressive types of pediatric tumors. The lack of tools for the identification of ES has largely hindered clinical diagnosis and the improvement of treatment. To address this challenge, we synthesized a near‐infrared (NIR) fluorescent probe (CS2‐N‐E9R) that targets the ES‐specific fusion protein EWS–FLI1 (E/F). This probe exhibited specific and high binding affinity to E/F. Further studies in animal models showed that CS2‐N‐E9R can be used to identify the boundaries of ES and lymph node metastases under a complex biological environment. These results demonstrate that CS2‐N‐E9R is a promising probe for early diagnosis and surgical guidance of ES through molecularly targeted NIR imaging.

Radiologists and Clinical Trials: Part 2: Practical Statistical Methods for Understanding and Monitoring Independent Reader Performance

Though many clinical trials rely on medical image evaluations for primary or key secondary endpoints, the methods to monitor reader performance are all too often mired in the legacy use of adjudication rates. If misused, this simple metric can be misleading and sometimes entirely contradictory. Furthermore, attempts to overcome the limitations of adjudication rates using de novo or ad hoc methods often ignore well-established research conducted over the last half-century and can lead to inaccurate conclusions or variable interpretations. Underperforming readers can be missed, expert readers retrained, or worse, replaced. This paper aims to standardize reader performance evaluations using proven statistical methods. Additionally, these methods will describe how to discriminate between scenarios of concern and normal medical interpretation variability. Statistical methods are provided for inter-reader and intra-reader variability and bias, including the adjudicator's bias. Finally, we have compiled guidelines for calculating correct sample sizes, considerations for intra-reader memory recall, and applying alternative designs for independent readers.

Radiologists and Clinical Trials: Part 1 The Truth About Reader Disagreements

The debate over human visual perception and how medical images should be interpreted have persisted since X-rays were the only imaging technique available. Concerns over rates of disagreement between expert image readers are associated with much of the clinical research and at times driven by the belief that any image endpoint variability is problematic. The deeper understanding of the reasons, value, and risk of disagreement are somewhat siloed, leading, at times, to costly and risky approaches, especially in clinical trials. Although artificial intelligence promises some relief from mistakes, its routine application for assessing tumors within cancer trials is still an aspiration. Our consortium of international experts in medical imaging for drug development research, the Pharma Imaging Network for Therapeutics and Diagnostics (PINTAD), tapped the collective knowledge of its members to ground expectations, summarize common reasons for reader discordance, identify what factors can be controlled and which actions are likely to be effective in reducing discordance. Reinforced by an exhaustive literature review, our work defines the forces that shape reader variability. This review article aims to produce a singular authoritative resource outlining reader performance's practical realities within cancer trials, whether they occur within a clinical or an independent central review.

Elbow flexion reconstruction after arm-sparing excision for high-grade triton sarcoma: a case report

Background

Soft tissue sarcomas affecting the root of an upper extremity raise the question of limb amputation depending on their location, size, and malignancy. Malignant triton tumors are a rare subtype of neurofibrosarcomas that have been poorly reported in the literature. We report the case of a challenging reconstruction of the upper extremity using a pedicled latissimus dorsal flap.

Case presentation

A 25-year-old Occidental man was referred to our sarcoma unit for the management of a large, high-grade malignant peripheral nerve sheath tumor with no regional or distant extension and very fast progression. He was treated first by concomitant neoadjuvant radiotherapy and chemotherapy. Carcinologic excision was performed “en bloc” including the skin, the tumor, and the flexor muscles of our patient’s elbow. Coverage of the skin defect and elbow flexion restoration were achieved by using a homolateral pedicled musculocutaneous latissimus dorsi flap. Histological analysis showed an R0 resection. The reconstruction process recovered a complete bending of his elbow. He is still in remission at 26 months follow-up.

Conclusions

A malignant triton tumor is a rare, aggressive, and high-grade sarcoma. It was successfully treated and this case report describes an effective treatment modality. Reconstructive surgery, allowing large, complete tumor removal, is indispensable after neoadjuvant chemotherapy and radiotherapy.

Management of localized extremity and retroperitoneal soft tissue sarcoma

The optimal management of localized soft tissue sarcomas of the extremities and retroperitoneum involves a high volume multidisciplinary team with expertise in sarcoma. In this review, we will highlight the importance of the sarcoma pathologist and imaging techniques prior to surgery and radiation. In addition, the data on neoadjuvant and adjuvant chemotherapy will be discussed. Finally, consideration is given to the importance of identifying genetic cancer predispositions, multidisciplinary management, long-term survivorship, and the current clinical trials for patients undergoing curative intent management.

Histopathologic challenges: The second OPINION issue

Classification and definition criteria for rare cancer is still an open issue in clinical practice due to several factors, which include the limited available molecular data to better defining specific tumor groups or "families" of interest. An important issue related to the proper management of these entities is the correct diagnosis and subtyping of a given entity. The high complexity associated with the histopathologic diagnosis and eventual molecular analysis may suggest the use of a histopathologic second opinion from a specialized pathologist. Diagnostic inaccuracies and difference between primary diagnosis and second opinion are expected at the population level: however, the magnitude of this difference is remarkably high and calls for implementation of second opinion in routine practice outside reference centers.

Leiomyosarcoma of the infratemporal fossa with perineurial spread along the right mandibular nerve: a case report

Leiomyosarcomas are malignant tumors displaying strong smooth muscle differentiation. They can often develop within the GI tract and myometrium, but are particularly rare in the head and neck. Perineurial spread of head and neck cancer is observed in patients with neoplasms of the skin (squamous cell carcinoma, melanoma) or skin appendages (adenoid cystic carcinoma). We report the case of a woman who presented with diplopia and headaches. MRI showed an infratemporal mass lesion and faint enhancement tracking along the mandibular nerve into the wall of the right cavernous sinus. A nerve biopsy revealed leiomyosarcoma. We review the medical literature to provide further insight into the diagnosis and management of this tumor and its peculiar pattern of spread. A similar case was unidentifiable in the literature.

Care in Specialized Centers and Data Sharing Increase Agreement in Hypertrophic Cardiomyopathy Genetic Test Interpretation

Background—

Clinically impactful differences in the interpretation of genetic test results occur between laboratories and clinicians. To improve the classification of variants, a better understanding of why discrepancies occur and how they can be reduced is needed.

Methods and Results—

We examined the frequency, causes, and resolution of discordant variant classifications in the Sarcomeric Human Cardiomyopathy Registry (SHaRe), a consortium of international centers with expertise in the clinical management and genetic architecture of hypertrophic cardiomyopathy. Of the 112 variants present in patients at >1 center, 23 had discordant classifications among centers (20.5%; Fleiss κ, 0.54). Discordance was more than twice as frequent among clinical laboratories in ClinVar, a public archive of variant classifications (315/695 variants; 45.2%; Fleiss κ, 0.30; P <0.001). Discordance in SHaRe most frequently occurred because hypertrophic cardiomyopathy centers had access to different privately held data when making their classifications (75.0%). Centers reassessed their classifications based on a comprehensive and current data summary, leading to reclassifications that reduced the discordance rate from 20.5% to 10.7%. Different interpretations of rarity and co-occurrence with pathogenic variants contributed to residual discordance.

Conclusions—

Discordance in variant classification among hypertrophic cardiomyopathy centers is largely attributable to privately held data. Some discrepancies are caused by differences in expert assessment of conflicting data. Discordance was markedly lower among centers specialized in hypertrophic cardiomyopathy than among clinical laboratories, suggesting that optimal genetic test interpretation occurs in the context of clinical care delivered by specialized centers with both clinical and genetics expertise.

Treatment challenges in and outside a network setting: Soft tissue sarcomas

Patients with soft tissue sarcoma (STS) experienced better outcomes when treated according to existing clinical practice guidelines either at reference institution or dedicated treatment networks. Despite increasing evidence supporting referral to sarcoma specialised units, up to half of patients are not managed according to guidelines, particularly those in the early stage of their disease requiring surgery. Also, criteria to certify expertise of institutions, such as the treatment volume, are debated and health authorities have only recently started identification of these centres and creation of treatment networks in Europe as well as in several countries. This process have important implications for both patient outcomes and innovation of existing treatment strategies through clinical research, making improvement of clinical pathways a priority for health care authorities. This article will discuss issues with management of patients with STS, such as pathological diagnosis and adherence to guidelines, and the definition of referral centres and networks will be illustrated along with existing experiences and population-based data.

Predictive and prognostic factors associated with soft tissue sarcoma response to chemotherapy: a subgroup analysis of the European Organisation for Research and Treatment of Cancer 62012 study

BACKGROUND

The European Organization for Research and Treatment of Cancer (EORTC) 62012 study was a Phase III trial of doxorubicin versus doxorubicin-ifosfamide chemotherapy in 455 patients with advanced soft tissue sarcoma (STS). Analysis of the main study showed that combination chemotherapy improved tumor response and progression-free survival, but differences in overall survival (OS) were not statistically significant. We analyzed factors prognostic for tumor response and OS, and assessed histological subgroup and tumor grade as predictive factors to identify patients more likely to benefit from combination chemotherapy.

METHODS

Central pathology review was performed by six reference pathologists. Gender, age, performance status, time from first presentation with sarcoma to starting palliative chemotherapy, tumor grade, histological subgroup, primary tumor site involvement, and sites of metastases were assessed as prognostic factors.

RESULTS

Three hundred and ten patients were included in this study. Discordance between local and central pathology opinion of tumor histology and tumor grade was observed in 98 (32%) and 122 (39%) cases, respectively. In multivariate analysis, liposarcoma patients had improved tumor response compared to other histological subgroups, whilst patients with metastases other than lung, liver or bone had a poorer response [odds ratio (OR) 0.42, 95% confidence interval (CI) 0.23-0.78; p = 0.006]. Patients with bone metastases had reduced OS [hazard ratio (HR) 1.56, 95% CI 1.16-2.09; p = 0.003]. By central pathology review, patients with undifferentiated pleomorphic sarcoma (UPS) had improved tumor response and OS with doxorubicin-ifosfamide compared to single-agent doxorubicin (OR 9.90, 95% CI 1.93-50.7 and HR 0.44, 95% CI 0.26-0.79, respectively). Grade III tumors had improved response with combination chemotherapy but there was no interaction between chemotherapy and grade on OS.

CONCLUSIONS

Prospective central pathology review of tumor histology should be integrated into future STS clinical trials. Doxorubicin-ifosfamide may be most appropriate for young, fit patients with poorly differentiated Grade III tumors including UPS.

Radiomic analysis of soft tissues sarcomas can distinguish intermediate from high-grade lesions

PURPOSE

To assess the feasibility of grading soft tissue sarcomas (STSs) using MRI features (radiomics).

MATERIALS AND METHODS

MRI (echo planar SE, 1.5T) from 19 patients with STSs and a known histological grading, were retrospectively analyzed. The apparent diffusion coefficient (ADC) maps, obtained by diffusion-weighted imaging acquisitions, were analyzed through 65 radiomic features, intensity-based (first order statistics, FOS) and texture (gray level co-occurrence matrix, GLCM; and gray level run length matrix, GLRLM) features. Feature selection (sequential forward floating search) and classification (k-nearest neighbor classifier) were performed to distinguish intermediate- from high-grade STSs. Classification was performed using the three different sub-groups of features separately as well as all the features together. The entire dataset was divided in three subsets: the training, validation and test set, containing, respectively, 60, 30, and 10% of the data.

RESULTS

Intermediate-grade lesions had a higher and less disperse ADC values compared with high-grade ones: most of FOS related to intensity are higher for the intermediate-grade STSs, while FOS related to signal variability were higher in the high grade (e.g., the feature variance is 2.6*10⁵  ± 0.9*10⁵ versus 3.3*10⁵  ± 1.6*10⁵ , P = 0.3). The GLCM features related to entropy and dissimilarity were higher in the high-grade. When performing classification, the best accuracy is obtained with a maximum of three features for each subgroup, FOS features being those leading to the best classification (validation set: FOS accuracy 0.90 ± 0.11, area under the curve [AUC] 0.85 ± 0.16; test set: FOS accuracy 0.88 ± 0.25, AUC 0.87 ± 0.34).

CONCLUSION

Good accuracy and AUC could be obtained using only few Radiomic features, belonging to the FOS class.

LEVEL OF EVIDENCE

4 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018;47:829-840.

Prognostic role of elevated preoperative systemic inflammatory markers in localized soft tissue sarcoma

BACKGROUND

Systemic inflammation has been implicated in cancer development and progression. The aim of the present study was to evaluate whether pre-operative systemic inflammatory markers can predict outcomes in bone and soft tissue sarcomas.

METHODS

Relevant literature was mainly identified using Pubmed, EMBASE and CNKI. Patients' clinical characteristics, overall survival (OS), disease/relapse free survival (DFS/RFS) with high-level CRP or neutrophils to lymphocytes ratio (NLR) were extracted. The statistics extracted from Kaplan-Meier survival curves with log-rank p value were calculated with methods developed by Parmar, Williamson, and Tierney; multivariate Cox hazard regression analysis data were used directly in STATA 10.0. Pooled hazard ratio (HR) and 95% CI were calculated to evaluate the prognostic role of these systemic inflammatory markers (CRP/NLR).

RESULTS

After full text review, 11 articles containing 1809 patients were identified as eligible articles. The meta-analysis for survival outcome showed significant prognostic value of systemic inflammatory markers including CRP and NLR in pre-operative blood. The combined HRs (95% CI) for five year overall survival (OS) and disease/recurrence free survival (DFS/RFS) were 2.54 [2.04, 3.16] and 2.28 [1.72, 3.04]. Specifically, higher NLR was associated with decreased 5-year OS (HR 3.75, 95% CI 1.24 to 11.37) and 3 year RFS/DFS (HR 2.43, 95% CI 0.84 to 7.05). Besides, the pooled HR showed a higher risk of 5-year disease progression (HR 2.55, 95% CI 1.60 to 4.08, I2 = 52%) and lower 5-year OS (HR 2.50, 95% CI 2.00 to 3.12, I2 = 0%) in sarcoma patients with high CRP level. We then grouped the meta-analysis by patient source (Asian and non-Asian), tumor stage (I/II or III/IV) and grade (high or low), respectively. All the subgroup analysis showed significant prognostic role in survival condition. The CRP/NLR levels are also found closely related with patient age, tumor stage and size.

CONCLUSION

Higher level of pre-operative CRP and NLR demonstrated a significantly higher risk of recurrence and overall decreased survival rates in sarcomas.

Voluntary Second Opinions in Pediatric Bone and Soft Tissue Pathology: A Retrospective Review of 1601 Cases From a Single Mesenchymal Tumor Consultation Service

The diagnosis of bone and soft tissue tumors in children is challenging. These lesions are especially difficult for general pathologists. We reviewed our experience with pediatric mesenchymal tumors sent in consultation to our service, with the goal of identifying issues that most often prompted second-opinion referral. Roughly 16 000 cases were seen in toto, of which 1601 occurred in children. These included 491 bone cases and 1110 soft tissue cases. The cases were referred by private practices/nonacademic medical centers (85%), academic medical centers (8%), and pediatric hospitals (7%). Reasons for referral were (a) self-perceived lack of experience with pediatric mesenchymal tumors (n = 930), (b) second opinion requested by the clinician or patient (n = 132), and (c) perceived or real need for ancillary studies not available at the referring institution (n = 116). The referring pathologists suggested a diagnosis for 670 cases; of these, 476 (71%) were in essential agreement with our final diagnosis. Of the remaining, 139 (21%) were considered "minor disagreements" and 55 (8%) "major disagreements." The "major disagreement" cases could be divided into (a) malignant tumors submitted with benign diagnoses (58%), (b) benign tumors submitted with malignant diagnoses (25%), (c) nonneoplastic conditions submitted as representing neoplasms (11%), and (d) neoplasm submitted as representing nonneoplastic conditions (6%). Pediatric mesenchymal tumors comprised 10% of cases sent to our mesenchymal tumor consultation practice. The rates of diagnostic disagreement found in this study are roughly in accordance with prior studies of mandatory and voluntary second opinion in adult soft tissue tumors. Given the rarity of these tumors, expert second opinion may be of value.

Biopsy and the diagnostic evaluation of musculoskeletal tumours: critical but often missed in the 21st century

Bone and soft-tissue sarcomas are rare and heterogeneous malignancies arising from tissues of mesenchymal origin. Treatment planning is informed by accurate diagnosis for which biopsy is the diagnostic standard. Biopsy in the setting of suspected malignancy is a technically challenging procedure that should only be performed at specialist institutions. Without the requisite expertise, they can compromise the viability of reconstructive procedures and may make necessary amputation to achieve adequate surgical margins. The risk of complications arising from the procedure must be minimized and therefore biopsy should always be preceded by imaging. There must be no attempt at biopsy or excision prior to referral if there is any suspicion of malignancy. Patients with suspected bone and soft-tissue tumours are best evaluated and treated at specialist sarcoma centres under the care of expert multidisciplinary teams. Prompt referral to a specialist sarcoma centre should always be made prior to biopsy for any suspicious mass that is painful, progressively increasing in size, greater than 5 cm in diameter, deep to deep fascia or recurs following inadvertent excision.

Down-regulated E-cadherin expression is associated with poor five-year overall survival in bone and soft tissue sarcoma: results of a meta-analysis

Purpose

To conduct a meta-analysis to evaluate the prognostic role of E-cadherin expression in bone and soft tissue sarcomas.

Methods

The PubMed, EMBASE, and Web of Science databases were searched using terms related to E-cadherin, sarcoma, and prognosis for all articles published in English before March 2014. Pooled effect was calculated from the available data to evaluate the association between negative E-cadherin expression and 5-year overall survival and tumor clinicopathological features in sarcoma patients. Pooled odds ratios (OR) and risk ratios (RR) with 95% confidence intervals (CI) were calculated using a fixed-effects model.

Result

Eight studies met the selection criteria and reported on 812 subjects. A total of 496 subjects showed positive E-cadherin expression (59.9%). Negative E-cadherin expression in bone and soft tissue sarcomas was correlated with lower 5-year overall survival (OR = 3.831; 95% CI: 2.246–6.534), and was associated with higher clinical stage (RR = 1.446; 95% CI: 1.030–2.028) and with male sex (RR = 0.678; 95% CI: 0.493–0.933).

Conclusion

In the E-cadherin negative group, 5-year overall survival was significantly worse than in the E-cadherin positive group. However, further studies are required to confirm these results.

Surgical management of retroperitoneal and pelvic sarcomas

Management of retroperitoneal sarcomas presents technical and oncological challenges. Imaging is crucial for diagnosis and to define local tumor extent. Complete gross resection at initial presentation is the best chance for cure, but there is controversy as to how this can be best achieved. There is a long-term risk of local recurrence, which is best treated with repeat resection if feasible. The roles of radiation and chemotherapy remain undefined.

Etiologic, environmental and inherited risk factors in sarcomas

Sarcomas are a rare group of mesenchymal tumors affecting a younger population. The etiology remains unknown in most cases. Environmental factors that increase sarcoma risk include radiation exposure and chemical carcinogens. Several familial cancer syndromes confer sarcoma predisposition, such as the Li-Fraumeni Syndrome (LFS). In this increasingly genomic focussed era of medicine, it will be clinically important to understand the genetic basis of sarcoma risk.

Histopathological diagnostic discrepancies in soft tissue tumours referred to a specialist centre: reassessment in the era of ancillary molecular diagnosis

Introduction. Soft tissue tumour pathology is a highly specialised area of surgical pathology, but soft tissue neoplasms can occur at virtually all sites and are therefore encountered by a wide population of surgical pathologists. Potential sarcomas require referral to specialist centres for review by pathologists who see a large number of soft tissue lesions and where appropriate ancillary investigations can be performed. We have previously assessed the types of diagnostic discrepancies between referring and final diagnosis for soft tissue lesions referred to our tertiary centre. We now reaudit this 6 years later, assessing changes in discrepancy patterns, particularly in relation to the now widespread use of ancillary molecular diagnostic techniques which were not prevalent in our original study. Materials and Methods. We compared the sarcoma unit's histopathology reports with referring reports on 348 specimens from 286 patients with suspected or proven soft tissue tumours in a one-year period. Results. Diagnostic agreement was seen in 250 cases (71.8%), with 57 (16.4%) major and 41 (11.8%) minor discrepancies. There were 23 cases of benign/malignant discrepancies (23.5% of all discrepancies). 50 ancillary molecular tests were performed, 33 for aiding diagnosis and 17 mutational analyses for gastrointestinal stromal tumour to guide therapy. Findings from ancillary techniques contributed to 3 major and 4 minor discrepancies. While the results were broadly similar to those of the previous study, there was an increase in frequency of major discrepancies. Conclusion. Six years following our previous study and notably now in an era of widespread ancillary molecular diagnosis, the overall discrepancy rate between referral and tertiary centre diagnosis remains similar, but there is an increase in frequency of major discrepancies likely to alter patient management. A possible reason for the increase in major discrepancies is the increasing lack of exposure to soft tissue cases in nonspecialist centres in a time of subspecialisation. The findings support the national guidelines in which all suspected soft tissue tumour pathology specimens should be referred to a specialist sarcoma unit.

Myxofibrosarcoma: prevalence and diagnostic value of the "tail sign" on magnetic resonance imaging

OBJECTIVE

Myxofibrosarcoma frequently shows curvilinear extensions of high T2 signal that also enhance on magnetic resonance imaging; these "tails" represent fascial extension of tumor at histopathological examination. This study was performed to determine whether the tail sign is helpful in distinguishing myxofibrosarcoma from other myxoid-containing neoplasms.

MATERIALS AND METHODS

The study group consisted of 44 patients with pathologically proven myxofibrosarcoma; the control group consisted of 52 patients with a variety of other myxoid-predominant tumors. Three musculoskeletal radiologists independently evaluated T2-weighted (and/or short-tau inversion recovery) and post-contrast MR images for the presence of one or more enhancing, high-signal intensity, curvilinear projections from the primary mass. Sensitivity and specificity for the diagnosis of myxofibrosarcoma were calculated for each reader. Interobserver variability was assessed with kappa statistic and percentage agreement.

RESULTS

A tail sign was deemed present in 28, 30, and 34 cases of myxofibrosarcoma and in 11, 9, and 5 of the controls for the three readers respectively, yielding a sensitivity of 64-77 % and a specificity of 79-90 %. The interobserver agreement was moderate-to-substantial (kappa=0.626).

CONCLUSION

The tail sign at MRI is a moderately specific and sensitive sign for the diagnosis of myxofibrosarcoma relative to other myxoid-containing tumors.

Sarcoma: concordance between initial diagnosis and centralized expert review in a population-based study within three European regions

BACKGROUND

Sarcomas represent a heterogeneous group of tumors. Accurate determination of histological diagnosis and prognostic factors is critical for the delineation of treatment strategies. The contribution of second opinion (SO) to improve diagnostic accuracy has been suggested for sarcoma but has never been established in population-based studies.

METHODS

Histological data of patients diagnosed with sarcoma in Rhone-Alpes (France), Veneto (Italy) and Aquitaine (France) over a 2-year period were collected. Initial diagnoses were systematically compared with SO from regional and national experts.

RESULTS

Of 2016 selected patients, 1463 (73%) matched the inclusion criteria and were analyzed. Full concordance between primary diagnosis and SO (the first pathologist and the expert reached identical conclusions) was observed in 824 (56%) cases, partial concordance (identical diagnosis of connective tumor but different grade or histological subtype) in 518 (35%) cases and complete discordance (benign versus malignant, different histological type or invalidation of the diagnosis of sarcoma) in 121 (8%) cases. The major discrepancies were related to histological grade (n = 274, 43%), histological type (n = 144, 24%), subtype (n = 18, 3%) and grade plus subtype or grade plus histological type (n = 178, 29%).

CONCLUSION

More than 40% of first histological diagnoses were modified at second reading, possibly resulting in different treatment decisions.

Correlating metabolic activity on 18F-FDG PET/CT with histopathologic characteristics of osseous and soft-tissue sarcomas: a retrospective review of 136 patients

OBJECTIVE

The objective of our study was to determine whether there is a statistically significant correlation between metabolic activity of osseous and soft-tissue sarcomas as measured by the maximum standardized uptake value (SUV(max)) on (18)F-FDG PET/CT and histopathologic characteristics such as mitotic counts, the presence of necrosis, and the presence of a myxoid component.

MATERIALS AND METHODS

We retrospectively evaluated 238 consecutive patients with known soft-tissue or osseous sarcoma who underwent (18)F-FDG PET/CT for initial staging or assessment for recurrence of disease. The SUV(max) of each primary or of the most intense metastatic lesion was measured and was compared with the histologic data provided in the final pathology reports.

RESULTS

Histopathologic data were available for 136 sarcomas. The median SUV(max) values of sarcomas with mitotic counts of less than 2.00 (per 10 high-power fields [HPF]), 2.00-6.99, 7.00-16.24, and 16.25 or greater were 5.0, 6.6, 10.3, and 13.0, respectively (p = 0.0003). The median SUV(max) for the sarcomas with necrosis (90 patients) was 8.6 and for those without necrosis (43 patients), 6.0 (p = 0.026). The median SUV(max) for the sarcomas without a myxoid component (118 patients) was 7.7 and with a myxoid component (16 patients) was 6.2 (p = 0.28).

CONCLUSION

There was a statistically significant correlation between the mitotic count and the SUV(max) as well as between the presence of tumor necrosis and the SUV(max). Although a correlation between the presence of a myxoid component and SUV(max) was shown, it was not found to be statistically significant. These findings improve on the current information in the literature regarding the use of PET/CT for guidance in sarcoma biopsy. Correlating the SUV(max) with histologic markers that also feature prominently in major sarcoma grading systems may help improve the accuracy of grading and of prognostication by allowing the SUV(max) to potentially serve as a surrogate marker in these grading systems, particularly in cases in which there is interobserver disagreement in the pathologic diagnosis or in cases in which the sarcoma cannot be properly classified on the basis of histopathologic evaluation alone.

Soft tissue sarcoma across the age spectrum: a population-based study from the Surveillance Epidemiology and End Results database

BACKGROUND

Soft tissue sarcomas (STS) are a heterogeneous group of mesenchymal malignancies that occur throughout the lifespan. The impact of age on disease features and outcome is unclear.

METHODS

We analyzed the clinical features and outcome of all STS cases registered between 1973 and 2006 in the SEER database.

RESULTS

There were 48,012 cases that met the selection criteria. Individuals less than 20 years of age represented 5.6%, with rhabdomyosarcoma being the most common subtype. In adults, the most common types were Kaposi sarcoma, fibrohistiocytic tumors, and leiomyosarcoma. Rhabdomyosarcoma was the only entity with a median age <20 years. Male predominance (male/female of 1.5:1) was noticed for almost all types of STS, except for alveolar soft part sarcoma and leiomyosarcoma. Tumor stage was similar across different age groups. Younger patients (<50 years) had significantly better survival than older patients (88.8 ± 0.2% vs. 40 ± 0.3%, P < 0.001), but for most histologies the survival decline with advancing age was gradual and did not occur abruptly at the onset of adulthood. The decline in survival with advancing age was particularly significant for rhabdomyosarcoma.

CONCLUSION

With few exceptions, the clinical features of STS are similar in children and adults. However, individuals over 50 years of age have an inferior survival.

Diagnosing musculoskeletal tumours

In 1993 we became aware of a worrying increase in apparent errors in the histopathological diagnosis of musculoskeletal tumours in our Unit. As a result all cases seen over the past 8 years were reviewed by an independent panel. Of the 1996 cases reviewed there was an error in 87. In 54 cases (2.7%) this had led to some significant change in the active management of the patient. The main areas where errors arose were in those very cases where clinical and radiological features were not helpful in confirming or refuting the diagnosis. The incidence of errors rose with the passage of time, possibly related to a deterioration in the pathologist's health. The error rate in diagnosing bone tumours in previously published series ranges from 9 to 40%. To ensure as accurate a rate of diagnosis as possible multidisciplinary working and regular audit are essential.

Should Soft Tissue Sarcomas be Treated at a Specialist Centre?

Objective. We have investigated whether there is evidence that patients with soft tissue sarcomas do better if treated in a specialist centre compared with district general hospitals.

Patients. All patients diagnosed with soft tissue sarcomas who were residents of WMRHA between 1994 and 1996, with minimum follow up of 5 years, excluding head and neck or retroperitoneal tumors.

Methods. We reviewed data from the Royal Orthopaedic Hospital Oncology Service (ROHOS) database and the Cancer Intelligence Unit (CIU) Database, with medial record review where necessary. Main outcome measures were local recurrence and overall survival.

Results. A total of 260 patients were diagnosed as having STS over the 3-year period (incidence=1.62per 100000 per year): 37% of patients had the majority of treatment at the specialist centre under the care of three surgeons, whilst the other 63% were treated at a total of 38 different hospitals. The rate of local recurrence was 39% at the district general hospitals compared with 19% at the specialist centre despite the fact that tumours treated at the district hospitals were smaller and of lower grade. The most significant factors affecting survival were grade (high versus low) and depth of the tumour. Patients treated at the specialist centre had a small survival advantage after multivariate testing.

Conclusion. Soft tissue sarcomas are rare. Centralization of treatment improves local control in all patients and survival in some. Appropriate mechanisms for ensuring that patients with soft tissue sarcomas are seen and treated at specialist centres should be developed.

Added Value of Molecular Biological Analysis in Diagnosis and Clinical Management of Liposarcoma: A 30-Year Single-Institution Experience

Background

Treatment decisions and prognosis assessment for liposarcoma is based on a classification that depends on morphological and genetic features. Revisions by experienced referral pathologists are often advocated.

Methods

The process of histopathological classification in referring hospitals and subsequently in a referral center in relation to molecular biological information is evaluated. A total of 331 consecutive liposarcoma patients were evaluated for the added value of histological review at time of referral. Subsequently, cases were reclassified with implementation of present-day molecular information. For all patients, complete data on staging, treatment, and follow-up were available.

Results

Upon histological revision, 15/54 (28%) diagnoses were reclassified in the first decade, 14/65 (22%) in the second, and 14/53 (26%) in the last decade. Molecular biological analysis enabled well-differentiated liposarcoma with or without dedifferentiated component to be better recognized as such and distinguished from myxoid liposarcoma and pleomorphic liposarcoma. Inclusion of cytogenetic information resulted in reclassification after revision in 4/18 (22%) cases in the first decade, 10/38 (26%) cases in the second decade, and 19/75 (25%) cases in the last decade.

Conclusions

This study indicates that liposarcomas are heterogeneous tumors. Expert assessment and implementation of molecular biological analysis are valuable for adequate classification as a basis for treatment decisions.

Epidemiological evaluation of concordance between initial diagnosis and central pathology review in a comprehensive and prospective series of sarcoma patients in the Rhone-Alpes region

Background

Sarcomas are rare malignant tumors. Accurate initial histological diagnosis is essential for adequate management. We prospectively assessed the medical management of all patients diagnosed with sarcoma in a European region over a one-year period to identify the quantity of first diagnosis compared to central expert review (CER).

Methods

Histological data of all patients diagnosed with sarcoma in Rhone-Alpes between March 2005 and Feb 2006 were collected. Primary diagnoses were systematically compared with second opinion from regional and national experts.

Results

Of 448 patients included, 366 (82%) matched the inclusion criteria and were analyzed. Of these, 199 (54%) had full concordance between primary diagnosis and second opinion (the first pathologist and the expert reached identical conclusions), 97 (27%) had partial concordance (identical diagnosis of conjonctive tumor but different grade or subtype), and 70 (19%) had complete discordance (different histological type or invalidation of the diagnosis of sarcoma). The major discrepancies were related to histological grade (n = 68, 19%), histological type (n = 39, 11%), subtype (n = 17, 5%), and grade plus subtype or grade plus histological type (n = 43, 12%).

Conclusions

Over 45% of first histological diagnoses were modified at second reading, possibly resulting in different treatment decisions. Systematic second expert opinion improves the quality of diagnosis and possibly the management of patients.

Histopathological diagnostic discrepancies in soft tissue tumours referred to a specialist centre

Aims. A study was performed to determine areas of diagnostic discrepancy in the reporting of cases of soft tissue tumours referred to a specialist sarcoma unit. This was to pinpoint common discrepancies and to determine their causes. Methods and Results. We compared the sarcoma unit's histopathology reports with referring reports on 349 specimens from 277 patients with suspected or proven soft tissue tumours in a one-year period. Conclusions. Diagnostic agreement was found in 256 of 349 cases (73.4%), with minor diagnostic discrepancy in 55 cases (15.7%) and major discrepancy in 38 cases (10.9%). Benign/malignant discordances accounted for only 5% of all discrepancies (5 cases). The most common discrepancies occurred in tumour classification, including diagnosis of gastrointestinal stromal tumour and leiomyosarcoma and the subtyping of spindle cell sarcomas, as well as in tumour grading that could conceivably lead to changes in clinical management. Major diagnostic discrepancies leading to management change occurred in a relatively select range of tumour groups, and almost all discrepancies occurred due to differences in tumour interpretation between general or nonsoft tissue pathologists, and pathologists at the specialist unit. The findings support guidelines by the National Institute for Health and Clinical Excellence that diagnostic review of soft tissue tumours should be performed by specialist soft tissue pathologists.

[Impact of pathological review by an expert on the diagnosis and management of patients with cancer in Aquitania]

AIMS

The goal of this work was to evaluate the impact of expert pathological second opinion on the diagnosis and management of patients with cancer, in a French region (Aquitaine) and with an economic point of view.

MATERIAL AND METHODS

The study was first quantitative, performed retrospectively on all cases of cancer, voluntary sent for a second opinion to an expert pathologist of two centers. Secondly, we restricted the study to lymphoid, melanocytic and soft tissue tumors sent for second opinion. We considered that the expert review had an important diagnostic impact either when the initial pathologist sent the specimen to identify or classify malignant tumor or hesitated between benign and malignant tumor or had no hypothesis, or if there were discordant diagnoses (malignant/benign) between the two pathologists. We considered that the expert review had a high therapeutic impact if the disagreement between initial and expert diagnoses induced a complete modification in therapy. We evaluated the cost of second opinion for the expert centers and the cost of care management.

RESULTS

Over the year 2006, the expert centers received 5077 lesions for consultation: 3769 specimens were sent by a pathologist for a second review, 1324 by pathologists of Aquitania and of these, 751 samples were submitted for lymphoid (55%), soft tissues (30%) or melanocytic tumors (15%). There was an important diagnostic impact for 75% of the samples; the impact of the expert review on patient management was considered high for 46% of specimens and the expert pathological diagnosis modified the clinical prognosis for 40% of the specimens. We estimated that for 53 discordant diagnoses (malignant/benign), second opinion allowed an economy of 500,000 euro.

CONCLUSION

Expert second opinion is very important not only for diagnosis and management for patient with cancer but also for economic reasons.

Results of diagnostic review in pediatric bone tumors and tumorlike lesions

BACKGROUND

Histological examination of bone tumors is one of the most difficult subjects in pathology. In this manuscript, correctness of initial histological diagnosis in pediatric bone tumors and tumorlike lesions was investigated.

PROCEDURE

All 262 bone tumor specimens of children up to the age of 19 years reviewed from 1999 to 2003 by the Netherlands Committee on Bone Tumors were included. Initial diagnosis and diagnosis after review were compared.

RESULTS

Only 60% of original diagnoses proved to be correct. After classification according to the main categories of the World Health Organization classification, only 75% of tumors were correctly categorized. Thirteen of the 60 malignant tumors were not recognized as malignant. Seven of 198 benign lesions were reclassified as malignant. Kappa values were indicative for good agreement in the (by the Ministry of Health designated) bone tumor centers. For nondesignated hospital kappa values, a substantial lower level of agreement was noted. Agreement was almost perfect in Ewing/primitive neuroectodermal tumors. For cartilaginous, osteogenic, and fibrous tumors, agreement was lower. Adamantinomas were not recognized in non-bone tumor centers. For the remaining group composed of miscellaneous tumors, poor levels of agreement were noted.

CONCLUSIONS

We conclude that correct diagnosis of childhood bone tumors requires review by a multidisciplinary team of experts. Specifically in non-bone tumor centers, the correctness of the initial diagnosis can be questioned.

Incidence of biopsy-proven bone tumors in children: a report based on the Dutch pathology registration "PALGA"

INTRODUCTION

Data on childhood bone tumors are mainly confined to reports on malignant tumors or on institutional registries. Incidence figures on both benign and malignant bone tumors in childhood are lacking.

METHODS

From January 1999 to December 2003, 1474 newly diagnosed bone tumors in children up to 18 years were registered in Pathologisch Anatomisch Landelijk Geautomatiseerd Archief (the nationwide network and registry of histopathology and cytopathology in The Netherlands). Data provided were diagnosis, date of birth, age at diagnosis, and localization. For incidence calculations, data on age and sex in each year of investigation were obtained from the StatLine database of Statistics Netherlands (www.cbs.nl).

RESULTS/CONCLUSIONS

Incidence of pathology-proven bone tumors in children is low. Incidence of pathology-proven bone tumors in The Netherlands is 79.3 per 1,000,000. From the very first year of life, incidence increases from 3.9 per 1,000,000 to a peak at 13 to 15 years of 142.9 per 1,000,000. Osteochondromas are the most prevalent tumors, followed by aneurysmal bone cysts. The overall incidence is higher for male compared with female patients, mainly due to different frequencies found in aneurysmal bone cysts, Ewing sarcoma, and osteochondroma. Shifts in incidence differ among the various tumors. In infants, bone tumors are mainly chondromas and fibrous dysplasia, which both show a steady increase at older ages. Tumors most prevalent at older ages are osteochondromas, osteosarcomas, osteoid osteomas, and chondromas. A peak incidence at approximately the age of 10 is noted for solitary bone cysts, nonossifying fibromas, and osteoblastomas. Small children more often have localizations in the skull and facial bones. Comparison with literature data showed significant differences due to referral-based institutionally bias, whereas tumor registries only give data for specific tumor types.

The value of expert second opinion in diagnosis of soft tissue sarcomas

INTRODUCTION

Soft tissue sarcomas represent a heterogeneous group of tumours with a wide range of clinical behaviour. Exact determination of diagnosis and prognosis is critical in order to guide surgical decisions and provide systemic therapy or radiation for patients. The value of consultative second opinions has been proven for general surgical pathology; some studies suggest an even higher value for the soft tissue tumour specimens in particular.

METHODS

We reviewed 603 patients who were operated on at our institution with the diagnosis of soft tissue sarcoma and aggressive fibromatosis; we focused on mismatches in primary and definite tumour-entity and -grading with respect to the diagnosing institution and the primary surgical procedure.

RESULTS

We found concordant primary diagnosis in 28.3% for pathologists in private clinics, 29.6% for hospital pathologists, 36.8% for academic medical centres (university hospitals) and 70.5% for the Department of Pathology at our institution. An improvement in diagnosis or confirmation of the correct primary diagnosis by the second opinion was seen in 73.1% of the patients; in 2.5%, the second opinion was false.

DISCUSSION

For accurate determination of prognosis and to provide optimal therapeutic decisions we consider expert second opinion essential for optimal treatment of soft tissue sarcomas.

Agreement among surgical pathologists evaluating routine histologic sections of digits amputated from cats and dogs

Agreement among pathologists interpreting histologic specimens is an area of interest within human pathology, but little work in this area has been reported in the veterinary literature. Agreement among pathologists evaluating routine histologic sections of amputated digits from cats and dogs submitted to multiple diagnostic centers was examined. Histologic sections from surgical specimens were reviewed in a blinded fashion by two pathologists, and a comparison to the original diagnosis, as stated in the diagnostic report, was recorded. A total of 513 cases were reviewed, and complete agreement was reached in 409 (79.7%). Of the 104 instances of disagreement, 77 (74.0%) were considered to be of clinical significance. The diagnosis of keratoacanthoma was disagreed with in 19 of 21 diagnoses (90.4%). No other individual diagnosis was similarly disputed. The overall level of disagreement is large and is similar to that reported in human pathology and suggests that further study of this issue would be useful in veterinary pathology.

Diagnostic ‘errors’ in anatomical pathology: relevance to Australian laboratories

Failure to recognise that anatomical pathology diagnosis is a process of cognitive interpretation of the morphological features present in a small tissue sample has led to the public misperception that the process is infallible. The absence of a universally accepted definition of diagnostic error makes comparison of error rates impossible and one large study of laboratories in the United States shows a significant error rate of about 5%, most of which have no major impact on patient management. A recent review of the work of one pathologist in New South Wales confirms a lack of appreciation in medical administration that variable diagnostic thresholds result in an inherent fallibility of anatomical pathology diagnoses. The outcome of the review emphasises the need to educate both public and non-pathology colleagues of the nature of our work and brings into consideration the requirement to establish baseline error rates for Australian laboratories and the role of the Royal College of Pathologists of Australasia (RCPA) in developing fair and unbiased protocols for review of diagnostic errors. The responsibility of ensuring that diagnostic error rates are kept to the minimum is a shared one. Area health services must play their part by seeking to ensure that pathologists in any laboratory are not overworked and have adequate support and back-up from pathologists with expertise in specialised areas. It has been clearly enunciated by the Royal College of Pathologists in the United Kingdom that it is not safe for any histopathology service to be operated single-handedly by one histopathologist. Service managers and clinicians have to understand that country pathologists cannot provide the full range and depth of pathology expertise in the many clinical subspecialty areas that are often practised in non-metropolitan areas. Attending clinicians share the responsibility of accepting proffered pathology diagnoses only if it conforms to the clinical context. Pathology laboratories must continue to develop and maintain best-practice protocols and conduct periodic reviews of diagnosis, cytology-histology concordance, frozen section/permanent section correlations, conference reviews, intra and interdepartmental consultations, participate in external quality assurance programs and maintain ongoing education for all laboratory staff.