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[Quantitative evaluation of the effectiveness of radiotherapy].
The paper proposes a procedure for processing computed tomograms, which records changes in the density and size of the tissue portion exposed to radiation within the preset cross section of layers. Examples of management of 4 patients with various tumorous processes on radiation therapy are presented. The procedure of computed diagnostic processing of computed tomograms gives rather new quantitative information on the changes occurring in the pathological focus and its adjacent healthy tissues, which may lead to the efficiency of radiation therapy.
Fine-needle aspiration in liposarcoma: cytohistologic correlative study including well-differentiated, myxoid, and pleomorphic variants.
We have reviewed cytopathology and the corresponding histopathology material of 86 liposarcomas (55 patients) seen at Institut Curie. The liposarcomas (LS) were well differentiated in 14 cases (9 pure, 2 dedifferentiated, 3 sclerosing), 64 myxoid, and 8 pleomorphic. Twenty-four tumors were primary, 34 recurrent, and 28 secondary. Smears in LS were composed in different proportions of round, spindle cells, lipoblasts, and myxoid and vascular arborizing structures. Pure well-differentiated LS were frequently composed of lipoblasts, and round or spindle cells were occasionally seen. Dedifferentiated and sclerosing liposarcomas were composed of spindle or round cells, but lipoblasts were also occasionally present. Myxoid or vascular arborizing structures were absent. Myxoid LS (including round and spindle cell LS) frequently showed a myxoid background and less frequently vascular arborizing structures. Tumor cells were round or spindle. Lipoblasts were also seen. Pleomorphic LS were composed of an admixture of all cellular and stromal elements. Well-differentiated LS should be distinguished from hibernoma and spindle cell lipoma, and myxoid LS from myxoma, myxoid chondrosarcoma, chordoma, myxoid leiomyosarcoma, and myxoid malignant fibrous histiocytoma. The demonstration of the specific translocation t(12;16)(q13;p11) of myxoid LS is very helpful to establish the diagnosis. Pleomorphic LS should be differentiated from other high-grade sarcomas, whenever possible.
[Methodology, technical prerequisites and postoperative morbidity of intraoperative radiotherapy (IORT) of soft tissue sarcomas. Heidelberg Krankengut 6/91-9/92].
Since June 1991 the IORT facility has operated a dedicated linear accelerator, which was installed within the central operating theater of the Department of Surgery. As of 9/92 a total of 28 patients suffering from peripheral (n = 20) or centrally (n = 8) located soft tissue sarcomas had been were treated. Thirteen patients revealed a primary and 15 patients a recurrent tumor. Tumor resection with negative margins was performed in 20 patients, positive margins remained in 5 patients, and gross macroscopic residual disease in 3 patients. Combined intraoperative and external beam radiotherapy was applied in 22 patients, using IORT doses of 10-20 Gy and an external beam dose of 26-50 Gy. Three patients were irradiated intraoperatively twice with a time interval of 24 h. After a median follow-up of 9.9 months, 20 patients are disease free. Two patients died 4 and 5 months after the end of therapy with rapidly progressive distant metastases. An infield failure within the external beam target volume was seen in 1 patient and local failure at the field margin of the external field in 3 patients. So far, there have been no IORT infield failures. Follow-up is performed with magnetic resonance imaging. In 3 patients a second operation was necessary because of a severe wound infection, including one patient suffering from osteomyelitis of a neighboring bone. Mild sensory neuropathy occurred in 1 patient 7 months after treatment. Overall only mild and reversible postoperative and posttherapeutic complications were seen.(ABSTRACT TRUNCATED AT 250 WORDS)
Histocompatibility antigens and solid malignant neoplasms.
To evaluate the relation between histocompatibility antigen phenotypes and solid malignant neoplasms, HL-A type was determined in 633 cancer patients and compared with those of 489 normal controls. HL-A8 was elevated in patients with squamous cancer, melanoma, and adenocarcinoma. The highest incidence occurred in patients with salivary gland adenocarcinoma (67% vs only 17% in normal controls). A threefold increase in HL-A5 was detected in patients with connective tissue sarcomas (28% incidence vs 9% in normal controls). Antigen frequencies did not vary when analyzed by time of diagnosis or interval after treatment. The finding that certain malignant neoplasms have associations with increased frequency of individual HL-A antigens may give clues to cause and genesis for these tumors.
Complications of combined radiotherapy and isolated limb perfusion with tumor necrosis factor alpha +/- interferon gamma and melphalan in patients with irresectable soft tissue tumors.
BACKGROUND: Isolated limb perfusion (ILP) with tumor necrosis factor alpha (TNF alpha) +/-interferon gamma (IFN gamma) and melphalan in patients with primarily irresectable soft tissue sarcoma is promising in terms of tumor regression and limb salvage. However, the feasibility of radiotherapy in combination with this treatment modality has not been established. METHODS: Fifteen patients with irresectable soft tissue tumors of the limb underwent ILP with TNF alpha, +/-IFN gamma, and melphalan. Three groups could be distinguished with respect to the role of radiotherapy. In nine patients, the residual tumor could be resected after ILP, and this was followed by radiotherapy with a total dose of 50-70 Gy (2 Gy/day). In one patient with aggressive fibromatosis, ILP was followed by radiotherapy without tumor resection (Group I). In two patients who underwent ILP for recurrent sarcoma, the primary tumor had been treated before by resection and radiotherapy (60 Gy) (Group II). In three patients whose tumors remained irresectable after ILP, radiotherapy was applied later in the course of disease for local palliation (Group III). RESULTS: In Group I, healing of the resection wound was markedly delayed in four patients, with soft tissue necrosis and infection necessitating amputation in two of them. Following completion of radiotherapy, persistent lymphoceles were encountered in two patients. Radiotherapy-induced fibrosis was encountered in five patients, resulting in a mild limb malfunction in two. Three-patients developed mild edema during radiotherapy. Tumor-associated neuropathy was aggravated by ILP in three patients causing severely disabling motor deficits and limb contractures in two of them. In Group II, ILP did not cause any local problem in the heavily irradiated areas. In Group III, pre-existing limb edema was increased after a total palliative dose of 20 Gy in one patient. Another patient, who had been re-operated for arterial thrombosis immediately after ILP, developed occlusion of the brachial artery 4 months after completion of palliative radiotherapy (36 Gy in 6 Gy fractions). CONCLUSIONS: In patients with irresectable soft tissue tumors, multimodality treatment using ILP with TNF alpha +/- IFN gamma and melphalan, tumor resection, and postoperative high-dose radiotherapy is associated with a considerable risk of tissue necrosis and impaired healing. This risk should be weighed against a possible benefit from radiotherapy in local tumor control.
Combination of pegylated liposomal doxorubicin (PLD) and paclitaxel in patients with advanced soft tissue sarcoma: a phase II study of the Hellenic Cooperative Oncology Group.
Patients with soft tissue sarcoma (STS), even after complete local disease control, often relapse locally or with distant metastases. This multicenter phase II study was conducted to evaluate the safety and efficacy of the combination of pegylated liposomal doxorubicin (PLD) and paclitaxel, as first-line treatment in patients with advanced STS. In all, 42 patients with locally advanced or metastatic STS, median age 54 years and median Eastern Cooperative Oncology Group performance status (PS) 1 were treated with PLD 45 mg m(-2) and paclitaxel 150 mg m(-2), every 28 days for a total of six cycles. Histological types included mainly leiomyosarcomas (43%), malignant fibrous histiocytomas (14%) and liposarcomas (12%). At study entry, 69% of patients had distant metastases. Overall response rate was 16%, including one complete (CR 2%) and six partial responses (PRs 14%), while an additional 14 patients had disease stabilization (SD 33%). At median follow-up 41.5 months, median time to progression (TTP) was 5.7 months with median overall survival (OS) 13.2 months. Grade 3-4 toxicities included neutropenia (17%), anaemia (15%), neurotoxicity (5%) and palmar-plantar erythrodysesthesia (9%). There were no treatment-related deaths. The combination of PLD and paclitaxel is a safe and well-tolerated regimen demonstrating modest efficacy as first-line treatment in patients with advanced STS.
Soft tissue sarcomas in childhood.
The authors discuss the epidemiology, pathology, clinical presentation, and treatment of rhabdomyosarcoma as well as some of the less common sarcomas of childhood and adolescence. Special focus is placed on making careful histopathologic distinction between entities and on clearly recognizing distinct clinical syndromes.
[Interscapular-thoracic amputation].
An analysis of results of treatment and prostheses of 89 patients with malignant tumors of the upper extremities and shoulder girdle has shown that among the tumors there were osteogenous sarcomas, chondroid sarcomas, nonclassified sarcomas, reticulosarcomas, angiosarcoma, fibrohistocytic sarcoma, Euring's sarcoma, solitary myeloma, giant cells tumors. Interscapular-thoracic amputations were performed in all the patients. The overall survival rate was (28.6 +/- 8.3)%. An orthosis and a modified prosthesis developed at the research institute of prostheses named after prof. G. Albrekht are recommended for rehabilitation of invalids.
Soft-tissue sarcoma: a cause of increased interstitial pressure.
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Soft-tissue sarcoma. Imaged with technetium-99m pyrophosphate.
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Subdural sarcoma associated with chronic subdural hematoma. Report of two cases and review of the literature.
The authors report the cases of two children who presented in the first months of life with progressive macrocrania related to chronic pericerebral fluid collection. This condition resolved spontaneously without treatment after a few months in the first case, whereas it required several aspirations of blood-stained fluid via the fontanel in the second case. Both patients developed normally without evidence of disease in the earliest years of life and presented at the ages of 3 1/2 and 4 1/2 years, respectively, with symptoms and signs of rapidly progressing intracranial hypertension. In both cases contrast-enhanced computerized tomography and magnetic resonance imaging revealed masses in the subdural space of the skull base and the cranial vault associated with significant subdural fluid collections. In the first case the lesion was misdiagnosed in the initial phase and treated, by means of multiple craniotomies, as an organized subdural hematoma. After a diagnosis of liposarcoma had been made, the patient was treated with chemotherapy, which resulted in a good resolution of the lesions at 3-month follow-up review. In the second case a biopsy allowed the diagnosis of fibrohistiocytic sarcoma and the patient was treated with chemotherapy. The authors review the literature of the few reported cases and discuss the possible pathophysiological association between pericerebral fluid collection and the subsequent development of a subdural sarcoma.
[Therapeutic strategies in malignant soft tissue tumors. Results of the soft tissue tumor register study of the Surgical Oncology Working Group].
INTRODUCTION: This study, carried out by the Surgical Oncology Working Group (CAO) of the German Society for Surgery, was performed to analyse the strategies in the treatment of soft tissue sarcomas in adults. METHODS: In a period of 19 months the data on 292 patients suffering from soft tissue sarcomas, treated in 99 surgical departments in Germany, were analysed prospectively. A special questionnaire was developed including pretherapeutic biopsy, previous treatment, definitive surgical treatment, combined modality approach and histopathological results. RESULTS: Thirty-nine per cent of the tumours were treated in university hospitals, 36% in medical centres, 24% in regional hospitals. During the observation period two patients were treated on average (median) by each hospital. Limb-sparing treatment was performed in 96% of the extremity tumours. There was no significant difference in the frequency of R0 resections between the different hospitals. At the university hospitals local extended operations and additive measures were used more often. The indication for adjuvant radiotherapy differed: after compartmental resection, adjuvant radiotherapy was performed in 39% of cases (19/49); after wide-excision of high-grade tumours, in 45% of cases (20/44) no adjuvant radiotherapy was necessary. In spite of less radical treatment in tumours of the trunk, additional radiotherapy was not more frequently performed. CONCLUSION: To improve the quality in the treatment of soft tissue sarcomas it seems to be of great importance to avoid inadequate initial treatment (18%), to respect the rules of oncological surgery (tumour rupture in 7% of cases), to improve the histopathological examination (no R classification in 5-12%) and to develop guidelines for multimodality treatment.
Influence of local recurrence on the prognosis of soft-tissue sarcomas.
We have investigated the significance of local recurrence on survival in 173 patients with localised soft-tissue sarcomas of the limbs and of the trunk. The overall survival rates at five and ten years were 75.2% and 68.0%, respectively. After definitive surgery at our hospitals, there was local recurrence in 25 patients (14.5%). After inadequate operations elsewhere, there was a higher incidence of late local recurrence (28.3%), in comparison with those with primary tumours treated by us (9.0%), or patients referred to us immediately after inadequate surgery elsewhere (10.2%). Because of small numbers these differences in the survival rates were not statistically significantly different. Univariate survival analysis showed that local recurrence after definitive surgery (p = 0.006) together with the histological grade (p = 0.0002), the size of the tumour (p = 0.002), its depth in relation to deep fascia (p = 0.003), and the surgical margin (p = 0.0001) were the significant prognostic factors. Local recurrence at the initial presentation did not affect survival. Multivariate analysis showed that local recurrence after definitive surgery also lost its apparent prognostic significance.
Application of markers in the diagnosis of soft tissue tumours.
In this review we describe the application of markers which are useful for the diagnosis of soft tissue tumours in paraffin sections. Detection of intermediate filament proteins appears to be most useful for first screening of these neoplasms because all, except neuroblastomas, express vimentin; cytokeratin is expressed in synovial sarcomas, epithelioid sarcomas and mesotheliomas; desmin in myogenic tumours and glial fibrillary acidic protein in astrocytomas and gliomas. Tissue-specific markers are: factor VIII--related antigen-endothelial cells; myoglobulin and skeletal muscle myosin--skeletal muscle cells; neuron specific enolase--neurons and cells of the APUD systems; and leukocyte-associated antigen--leukocytes. Markers which are present in a variety of cell types and therefore do not serve as tissue-specific markers are; S-100 proteins, alpha-1-antichymotrypsin, creatine kinase M and actin. The S-100 antigens have been detected in melanomas, granular cell tumours, chondrosarcomas and in some schwannomas and liposarcomas. Alpha-1-antichymotrypsin has been found in fibrohistiocytic and 'true' histiocytic tumours and creatine kinase M and actin in myogenic tumours. No specific markers have, as yet, been described for fibrosarcomas, Ewing's sarcomas and hemangiopericytomas.
Gastric leiomyosarcoma with massive myxoid degeneration. A histochemical and ultrastructural study.
Histochemical and ultrastructural features of a gastric myxoid leiomyosarcoma from a 55-year-old man were examined. At autopsy, the tumor was located mainly in the greater omentum and was directly connected to a coinsized gastric tumor. Multiple hepatic metastases and peritoneal disseminations were noted. Light-microscopically, the tumor was composed of a prominent myxoid stroma and ovoid or rounded tumor cells. The myxoid stroma was stained weakly basophilic with hematoxylin and eosin, and was mainly composed of hyaluronic acid. Tumor cells in the stomach were spindle-shaped and apparently myogenic. Ultrastructurally, the gastric tumor cells showed a loose cohesion with junctional apparatuses, pinocytotic vesicles, basal laminae, and cytoplasmic filaments with focal densities. Tumor cells in the omentum and the liver, however, were poorly differentiated and showed an epithelioid nature in part. This unique leiomyosarcoma is reported with some differential diagnoses from other myxoid sarcomas.
[Liposarcoma of the spermatic cord].
Liposarcoma of the spermatic cord is rare. It usually presents as a painless slowly-growing scrotal mass of consistency like lipoma. Inguinal orchiectomy is an adequate surgical approach. Retroperitoneal lymphadenectomy is not indicated owing to the low malignancy potential of the sarcomas. Value of adjuvant radiotherapy/chemotherapy remains uncertain. Recurrences are frequent, owing to incomplete surgical removal of the tumor. We report on a 62 year old male who presented with a half a year history of a soft painless mass in the left scrotum extending from the groin up to the testis. Clinical examination suggested inguinal hernia. Radical orchiectomy was performed. Histological examination revealed a well-differentiated liposarcoma of sclerosing subtype. No evidence of recurrence or metastases has been noted during the 6-month and one year follow-up without any postoperative adjuvant therapy.
Salvage surgical resection after high-dose ifosfamide (HDIF) based regimens in advanced soft tissue sarcoma (ASTS): a potential positive selection bias--a study of the Spanish group for research on sarcomas (GEIS).
PURPOSE: To assess the impact of different factors on response rate (RR), time to tumor progression (TTP), and overall survival time (OS) in patients with locally advanced or metastatic soft tissue sarcoma (ASTS), included in three protocols with high-dose ifosfamide (HDIF). PATIENTS AND METHODS: One hundred fifty six ASTS patients included in three consecutive phase II trials with HDIF (>10 g/m(2)), alone or in combination with doxorubicin (DX), were analyzed. Cofactors were institution, trial, gender, age, performance status, histologic type, grade of malignancy, prior radiotherapy, presence of locoregional disease, metastatic site, salvage surgery, number of organs involved, and disease-free interval. RESULTS: By multivariate analysis performance status >0 and lack of salvage surgery correlated with a poorer survival. A good-risk and a poor-risk group were identified, with median survival time (OS) of 29, 5, and 10 months, respectively (P = 0.00001). The 1-, 2-, and 3-year OS for 83 good-risk patients (either with PS = 0 or receiving salvage surgery) was 83, 44, and 29%, respectively, those figures being 37, 7, and 3% for 73 poor-risk patients. CONCLUSION: The design of randomized trials in ASTS including HDIF should consider those prognostic factors as stratification variables.