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Arispe Angulo KR, Logan S, Bahrami A, John I, Billings SD, Agrawal S, Bena J, Mesko N, Folpe AL, Fritchie KJ. Myxofibrosarcoma in adolescents and young adults: a clinicopathologic study of 17 cases. Hum Pathol 2023; 142:90-95. [PMID: 37742946 DOI: 10.1016/j.humpath.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 09/18/2023] [Indexed: 09/26/2023]
Abstract
Myxofibrosarcoma is a locally aggressive sarcoma that characteristically arises in the extremities of older patients. Cases arising at a younger age are rare, leading to diagnostic challenges. Our aim was to study the clinicopathologic features of myxofibrosarcoma in patients aged ≤40 years. Cases of myxofibrosarcoma and myxoid malignant fibrous histiocytoma arising in patients aged ≤40 years with clinical follow-up were collected from multiple institutions. Hematoxylin and eosin slides were evaluated for mitoses, necrosis, and epithelioid areas. Seventeen cases were identified (13 females, 4 males; 16-39 years; median 32 years), tumors ranged from 2.2 to 34 cm (median 4.1 cm). Anatomic sites included proximal extremity (9), distal extremity (4), trunk (1), and head/neck (3). Ten were superficial, and 6 were deep-seated. Three cases were predominantly epithelioid. In untreated resection specimens, 6 were FNCLCC grade 1, 4 grade 2, and 2 grade 3. Follow-up (6-204 months, median 36 months) revealed that 2 patients experienced local recurrences, 1 distant metastasis, and 2 patients both. The 5-year overall survival (OS) and event-free survival (EFS) were 84% and 55.9%, respectively. Tumor depth and necrosis were correlated with inferior OS (P = .025, P = .005), while tumor depth was also associated with worse EFS (P = <.001). We conclude that myxofibrosarcomas arising in adolescents and young adults show similar behavior compared to their older adult counterparts. Tumor depth and necrosis are poor prognostic factors in myxofibrosarcoma in this age group. Awareness that myxofibrosarcoma can rarely present in this population is important for accurate diagnosis.
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Affiliation(s)
| | - Suzanna Logan
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Armita Bahrami
- Department of Pathology, Emory University, Atlanta, GA, USA
| | - Ivy John
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Steven D Billings
- Department of Anatomic Pathology, Cleveland Clinic, Cleveland, OH, USA
| | - Shruti Agrawal
- Department of Anatomic Pathology, Cleveland Clinic, Cleveland, OH, USA
| | - James Bena
- Section of Biostatistics, Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Nathan Mesko
- Orthopedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Andrew L Folpe
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Karen J Fritchie
- Department of Anatomic Pathology, Cleveland Clinic, Cleveland, OH, USA.
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Parker SM, Mayo ZS, Shah CS, Scott JG, Mesko N, Nystrom L, Campbell SR. Dosimetric Analysis of Major Wound Complications Following Preoperative Ultra-Hypofractionated Radiation Therapy for Soft Tissue Sarcoma. Int J Radiat Oncol Biol Phys 2023; 117:e331-e332. [PMID: 37785170 DOI: 10.1016/j.ijrobp.2023.06.2383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Preoperative radiation therapy (RT) for soft tissue sarcomas (STS), delivered with conventional fractionation, has been shown to reduce long-term toxicity at the expense of increased postoperative major wound complications (MWC). Ultra-hypofractionated RT has emerged as a potential alternative preoperative modality with early but comparable outcomes to conventional regimens. However, limited data are available evaluating dosimetric, patient, and treatment specific factors associated with development of MWC in this setting. MATERIALS/METHODS This IRB approved review included STS patients treated with preoperative 5 fraction daily RT followed by surgical resection within 7 days. Patients were evaluated for MWCs in association with patient and tumor characteristics, dosimetric parameters, and treatment techniques. MWCs were defined as a return to operating room, readmission for wound care or IV antibiotics, and persistent deep packing for >120 days. Prescription isodose line, PTV mean dose and the PTV volume exposed to 105% and 110% of prescribed dose were recorded. Dose to tissue likely to be involved in wound healing was assessed by creating a 1 cm thick superficial skin strip within 2 cm of the PTV which was then evaluated for volume, mean dose, V15, V21, V27, and V30. Secondary endpoints were locoregional control (LRC), metastasis free survival (MFS), and overall survival (OS). RESULTS A total of 31 patients with a median age of 66 years (range 28-87) and a median follow up of 21 months (IQR 8-43) were included. All patients received 30 Gy in 5 fractions using IMRT/VMAT. There were 11 upper limb (36%) and 20 lower limb (65%) tumors included. Median time to resection following RT was 1 day (IQR 0-3). Median tumor size was 8 cm (IQR 5-13). MWC occurred in 13 patients (42%) with 10 patients (32%) requiring additional surgery. Dehiscence and infection requiring IV antibiotics occurred in 12 (39%) and 6 patients (19%), respectively. RT plans were predominately prescribed to the PTV mean (87%) with a median prescription isodose of 97% (IQR 96-97) and PTV mean dose of 3110 cGy (IQR 3089-3142). Median PTV volume, mean dose, and volume of PTV receiving 105% and 110% of the prescribed dose were higher in the MWC cohort although none reached significance. Similarly, for the 1 cm skin strip the median volume, mean dose, V30, V27, V21, and V15 were all higher in the MWC cohort without significant difference. Among patient, treatment, and tumor factors: tumor size, location, grade, margin status, type of wound closure, and prior non-oncologic resection were not associated with MWC. LRC, MFS, and OS at 3-years were 96%, 67%, and 76%, respectively. CONCLUSION Although not reaching significance, increased plan homogeneity and reduced dose/volume relationships in proximity to the skin trended to reduced MWC in this limited cohort. Multi-institutional collaboration may be warranted to better identify factors associated with MWC in patients treated with preoperative ultra-hypofractionated RT.
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Affiliation(s)
- S M Parker
- Department of Radiation Oncology, Cleveland Clinic Foundation, Cleveland, OH
| | - Z S Mayo
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - C S Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | | | - N Mesko
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - L Nystrom
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - S R Campbell
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
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Mayo ZS, Mesko N, Nystrom L, Shah CS, Scott JG, Campbell SR. Radiotherapy Innovation in Rare Diseases- Focusing on the Value of Single Institutional Experiences for Hypofractionated Radiotherapy in Soft Tissue Sarcoma. Radiother Oncol 2023:109626. [PMID: 36963441 DOI: 10.1016/j.radonc.2023.109626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 03/13/2023] [Indexed: 03/26/2023]
Affiliation(s)
- Zachary S Mayo
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH
| | - Nathan Mesko
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Lukas Nystrom
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Chirag S Shah
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH
| | - Jacob G Scott
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH
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Ardakani AHG, Faimali M, Nystrom L, Mesko N, Mughal M, Ware H, Gikas P. Metastatic bone disease: Early referral for multidisciplinary care. Cleve Clin J Med 2022; 89:393-399. [PMID: 35777838 DOI: 10.3949/ccjm.89a.21062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
It is estimated that more than half of all cancers develop bony metastases, exacting a substantial cost in terms of patient quality of life and healthcare expenses. Prompt diagnosis and management have been shown to reduce morbidity and costs. When a patient with a history of cancer presents with musculoskeletal pain, heightened awareness of the risk of bone metastasis should prompt immediate referral to an orthopedic specialist. A multidisciplinary approach is needed to identify an appropriate treatment plan for the patient based on the prognosis, fracture status, and extent of skeletal disease.
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Affiliation(s)
| | - Martina Faimali
- Department of Orthopaedic Oncology, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Lukas Nystrom
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH; Associate Professor of Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Nathan Mesko
- Associate Professor of Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH; Center Director, Musculoskeletal Oncology, Department of Orthopaedic Surgery, and Co-Director of Sarcoma Care, Cleveland Clinic, Cleveland, OH
| | - Muntzer Mughal
- Director, Department of Surgical Oncology, Cleveland Clinic London, UK
| | - Howard Ware
- Director, Department of Orthopaedic Surgery, Cleveland Clinic London, UK
| | - Panagiotis Gikas
- Department of Orthopaedic Surgery, South West London Elective Orthopaedic Centre, London, UK; Department of Orthopaedic Surgery, Cleveland Clinic London, UK
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Somasundaram E, D Smile T, Halima A, Broughman JB, Reddy CA, Parsai S, Scott JG, Shah C, Chan T, Campbell S, Angelov L, Anderson PM, Zahler S, Trucco M, Thomas SM, Johnson S, Mesko N, Nystrom L, Shepard D, Budd GT, Qi P, Magnelli A, Murphy ES. Association between biologically effective dose and local control after stereotactic body radiotherapy for metastatic sarcoma. J Radiosurg SBRT 2022; 8:265-273. [PMID: 37416333 PMCID: PMC10322177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 02/28/2023] [Indexed: 07/08/2023]
Abstract
Introduction Stereotactic body radiation therapy (SBRT) is increasingly utilized for patients with recurrent and metastatic sarcoma. SBRT affords the potential to overcome the relative radioresistance of sarcomas through delivery of a focused high biological effective dose (BED) as an alternative to invasive surgery. We report local control outcomes after metastatic sarcoma SBRT based on radiation dose and histology. Methods From our IRB-approved single-institution registry, all patients treated with SBRT for metastatic sarcoma between 2014 and 2020 were identified. Kaplan-Meier analysis was used to estimate local control and overall survival at 1 and 2 years. A receiver operating characteristic (ROC) curve was generated to determine optimal BED using an α/β ratio of 3. Local control was compared by SBRT dose using the BED cut point and evaluated by histology. Results Forty-two patients with a total of 138 lesions met inclusion criteria. Median imaging follow up was 7.73 months (range 0.5-35.0). Patients were heavily pre-treated with systemic therapy. Median SBRT prescription was 116.70 Gy BED (range 66.70-419.30). Desmoplastic small round cell tumor, Ewing sarcoma, rhabdomyosarcoma, and small round blue cell sarcomas were classified as radiosensitive (n = 63), and all other histologies were classified as radioresistant (n = 75). Local control for all lesions was 66.7% (95% CI, 56.6-78.5) at 1 year and 50.2% (95% CI, 38.2-66.1) at 2 years. Stratifying by histology, 1- and 2-year local control rates were 65.3% and 55.0%, respectively, for radiosensitive, and 68.6% and 44.5%, respectively, for radioresistant histologies (p = 0.49). The ROC cut point for BED was 95 Gy. Local control rates at 1- and 2-years were 75% and 61.6%, respectively, for lesions receiving >95 Gy BED, and 46.2% and 0%, respectively, for lesions receiving <95 Gy BED (p = 0.01). On subgroup analysis, local control by BED > 95 Gy was significant for radiosensitive histologies (p = 0.013), and trended toward significance for radioresistant histologies (p = 0.25). Conclusion There is a significant local control benefit for sarcoma SBRT when a BED > 95 Gy is used. Further investigation into the dose-response relationship is warranted to maximize the therapeutic index.
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Affiliation(s)
| | - Timothy D Smile
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - Ahmed Halima
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - James B Broughman
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - Chandana A Reddy
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - Shireen Parsai
- Department of Radiation Oncology, Ohio Health Riverside Methodist Hospital, Columbus, OH, USA
| | - Jacob G Scott
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - Timothy Chan
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - Shauna Campbell
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - Lilyana Angelov
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
| | - Peter M Anderson
- Department of Pediatric Hematology Oncology and Blood and Marrow Transplantation, Cleveland Clinic, Cleveland, OH, USA
| | - Stacy Zahler
- Department of Pediatric Hematology Oncology and Blood and Marrow Transplantation, Cleveland Clinic, Cleveland, OH, USA
| | - Matteo Trucco
- Department of Pediatric Hematology Oncology and Blood and Marrow Transplantation, Cleveland Clinic, Cleveland, OH, USA
| | - Stefanie M Thomas
- Department of Pediatric Hematology Oncology and Blood and Marrow Transplantation, Cleveland Clinic, Cleveland, OH, USA
| | - Shavaughn Johnson
- Department of Pediatric Hematology Oncology and Blood and Marrow Transplantation, Cleveland Clinic, Cleveland, OH, USA
| | - Nathan Mesko
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Lukas Nystrom
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Dale Shepard
- Department of Hematology and Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - George Thomas Budd
- Department of Hematology and Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - Peng Qi
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - Anthony Magnelli
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - Erin S Murphy
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
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Parsai S, Lawrenz J, Mesko N, Nystrom L, Kilpatrick S, Campbell S, Billings S, Goldblum J, Rubin B, Shah C, Scott J. Early Outcomes of Preoperative 5-fraction Radiation Therapy for Soft Tissue Sarcoma with Immediate Resection. Int J Radiat Oncol Biol Phys 2019. [DOI: 10.1016/j.ijrobp.2019.06.2520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Karthik N, Ward M, Scott J, Mesko N, Shah C. Factors Associated With Acute and Chronic Wound Complications in Patients With Soft-Tissue Sarcoma With Long-Term Follow-Up. Int J Radiat Oncol Biol Phys 2017. [DOI: 10.1016/j.ijrobp.2017.06.188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Morrison J, Osrin D, Shrestha B, Tumbahangphe KM, Tamang S, Shrestha D, Thapa S, Mesko N, Manandhar DS, Costello A. How did formative research inform the development of a women's group intervention in rural Nepal? J Perinatol 2008; 28 Suppl 2:S14-22. [PMID: 19057563 PMCID: PMC3428870 DOI: 10.1038/jp.2008.171] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Inability to reduce neonatal and maternal mortality in poor countries is sometimes blamed on a lack of contextual knowledge about care practices and care-seeking behavior. There is a lack of knowledge about how to translate formative research into effective interventions to improve maternal and newborn health. We describe the findings of formative research and how they were used to inform the development of such an intervention in rural Nepal. Formative research was carried out in four parts. Part 1 involved familiarization with the study area and literature review, and parts 2, 3 and 4 involved community mapping, audit of health services, and qualitative and quantitative studies of perinatal care behaviors. Participatory approaches have been successful at reducing neonatal mortality and may be suitable in our context. Community mapping and profiling helped to describe the community context, and we found that community-based organizations often sought to involve the Female Community Health Volunteer in community mobilization. She was not routinely conducting monthly meetings and found them difficult to sustain without support and supervision. In health facilities, most primary care staff were in post, but doctors and staff nurses were absent from referral centers. Mortality estimates reflected under-reporting of deaths and hygiene and infection control strategies had low coverage. The majority of women give birth at home with their mother-in-law, friends and neighbors. Care during perinatal illness was usually sought from traditional healers. Cultural issues of shyness, fear and normalcy restricted women's behavior during pregnancy, birth and the postpartum period, and decisions about her health were usually made after communications with the family and community. The formative research indicated the type of intervention that could be successful. It should be community-based and should not be exclusively for pregnant women. It should address negotiations within families, and should tailor information to the needs of local groups and particular stakeholders such as mothers-in-law and traditional healers. The intervention should not only accept cultural constructs but also be a forum in which to discuss ideas of pollution, shame and seclusion. We used these guidelines to develop a participatory, community-based women's group intervention, facilitated through a community action cycle. The success of our intervention may be because of its acceptability at the community level and its sensitivity to the needs and beliefs of families and communities.
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Affiliation(s)
- J Morrison
- Centre for International Health and Development, Institute of Child Health, University College London, London, UK.
| | - D Osrin
- Centre for International Health and Development, Institute of Child Health, University College London, London, UK
| | - B Shrestha
- Mother Infant Research Activities (MIRA), Nepal
| | | | - S Tamang
- Mother Infant Research Activities (MIRA), Nepal
| | - D Shrestha
- Mother Infant Research Activities (MIRA), Nepal
| | - S Thapa
- Mother Infant Research Activities (MIRA), Nepal
| | - N Mesko
- Centre for International Health and Development, Institute of Child Health, University College London, London, UK
| | | | - A Costello
- Centre for International Health and Development, Institute of Child Health, University College London, London, UK
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Osrin D, Manandhar S, Shrestha A, Mesko N, Tumbahangphe KS, Shrestha D, Manandhar DS, Costello AM. DESIGN OF A SURVEILLANCE SYSTEM FOR PREGNANCY AND ITS OUTCOMES IN RURAL NEPAL. JNMA J Nepal Med Assoc 2003. [DOI: 10.31729/jnma.784] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
IntroductionCommunity trials in low-income countries require monitoring and evaluation systems.The requirements of a community surveillance system include coherent design, training,field supervision and reporting, as well as the need for a robust and flexible database.Materials and methodsThis paper describes a surveillance system for identification of pregnancy and itsoutcomes in a rural area of Nepal. Mother Infant Research Activities (MIRA), incollaboration with the Institute of Child Health, London, are presently conducting astudy on the impact of a community-based participatory intervention to improveessential newborn care (ENC) in rural Nepal. The study is a cluster randomisedcontrolled trial involving 12 pairs of Village Development Committees (VDCs) inMakwanpur District. The surveillance system covers approximately 28 000 householdsand 28 000 married women of reproductive age. It was designed to identify pregnancy,its outcome for mother and infant, and activities such as antenatal care and problem-related health care seeking behaviour.DiscussionThe paper describes the processes of mapping and enumeration, pregnancyidentification, conduct of interviews, quality control and data management.Key Words: data quality, database, rural Nepal.
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