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Howitt BE, Folpe AL. Update on SWI/SNF-related gynecologic mesenchymal neoplasms: SMARCA4-deficient uterine sarcoma and SMARCB1-deficient vulvar neoplasms. Genes Chromosomes Cancer 2020; 60:190-209. [PMID: 33252159 DOI: 10.1002/gcc.22922] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 11/23/2020] [Accepted: 11/24/2020] [Indexed: 01/22/2023] Open
Abstract
Our knowledge regarding the role of genes encoding the chromatin remodeling switch/sucrose non-fermenting (SWI/SNF) complex in the initiation and progression of gynecologic malignancies continues to evolve. This review focuses on gynecologic tumors in which the sole or primary genetic alteration is in SMARCA4 or SMARCB1, two members of the SWI/SNF chromatin remodeling complex. In this review, we present a brief overview of the classical example of such tumors, ovarian small cell carcinoma of hypercalcemic type, and then a detailed review and update of SMARCB1-deficient and SMARCA4-deficient tumors of the uterus and vulva.
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Affiliation(s)
- Brooke E Howitt
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
| | - Andrew L Folpe
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
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Di Donato V, Casorelli A, Bardhi E, Vena F, Marchetti C, Muzii L, Benedetti Panici P. Bartholin gland cancer. Crit Rev Oncol Hematol 2017; 117:1-11. [PMID: 28807231 DOI: 10.1016/j.critrevonc.2017.06.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 06/12/2017] [Indexed: 10/19/2022] Open
Abstract
INTRODUCTION Bartholin gland carcinoma is an extremely rare condition. Because of its, phase III trials have not been carried out, there exists no unanimous consensus on treatment and guidelines are missing. METHODS All studies reporting cases of Bartholin cancer were collected and screened for the evaluations. Baseline characteristics of studies were extracted and were queried in a database. RESULTS A total number of 133 manuscripts collected were available for the review process, representing a total number of 275 reported cases. The histological type of Bartholin gland cancer was specified in 90.4% cases: 30.7% cases were squamous cell carcinoma, 29.6% adenoid cystic carcinoma, 25% adenocarcinomas. At multivariate analysis adenocarcinoma histotype and positive lymph node were statistical correlated with worse prognosis. CONCLUSION Bartholin gland cancer remains a challenge for gynecologic oncologists. To better understand and treat this disease, centralization to referral centers and design of multi institutional trials is crucial.
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Affiliation(s)
- Violante Di Donato
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, Italy.
| | - Assunta Casorelli
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, Italy
| | - Erlisa Bardhi
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, Italy
| | - Flaminia Vena
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, Italy
| | - Claudia Marchetti
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, Italy
| | - Ludovico Muzii
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, Italy
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Lee MY, Dalpiaz A, Schwamb R, Miao Y, Waltzer W, Khan A. Clinical Pathology of Bartholin's Glands: A Review of the Literature. Curr Urol 2015. [PMID: 26195958 DOI: 10.1159/000365683] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The Bartholin's glands are located symmetrically at the posterior region of the vaginal opening and play an important role in the female reproductive system. These two pea-sized glands are involved in mucus secretion and vaginal lubrication. Cyst formation in the glands is common and results from mucus build-up in gland ducts. It is important to monitor such cysts because they may occur in the form of carcinomas. Larger cysts and abscesses are found in the lower vestibular region and typically present with erythema and edema. Biopsy is an effective method for distinguishing between Bartholin's gland cysts and differential diagnosis. While smaller cysts may be asymptomatic and may be left untreated, larger cysts require medical attention. Several treatment options are available, including marsupialization and CO2 laser. Healing and recovery depend on the severity of infection and course of treatment.
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Affiliation(s)
- Min Y Lee
- Department of Physiology and Biophysics, Stony Brook University, Stony Brook, NY., USA
| | - Amanda Dalpiaz
- Department of Physiology and Biophysics, Stony Brook University, Stony Brook, NY., USA
| | - Richard Schwamb
- Department of Physiology and Biophysics, Stony Brook University, Stony Brook, NY., USA
| | - Yimei Miao
- Department of Urology, SUNY School of Medicine, Stony Brook University, Stony Brook, NY., USA
| | - Wayne Waltzer
- Department of Urology, SUNY School of Medicine, Stony Brook University, Stony Brook, NY., USA
| | - Ali Khan
- Department of Urology, SUNY School of Medicine, Stony Brook University, Stony Brook, NY., USA
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Iavazzo C, Gkegkes ID, Vrachnis N. Dilemmas in the management of patients with vulval epithelioid sarcoma: a literature review. Eur J Obstet Gynecol Reprod Biol 2014; 176:1-4. [PMID: 24636595 DOI: 10.1016/j.ejogrb.2014.02.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2013] [Revised: 01/21/2014] [Accepted: 02/09/2014] [Indexed: 10/25/2022]
Abstract
Vulval sarcomas are an extremely rare type of soft tissue tumor, the principal properties of which are unpredictable symptoms and frequent recurrences. This review discusses the management options specific for cases of vulval epithelioid sarcoma. The PubMed, Scopus and Cochrane databases were systematically searched and 28 studies met the inclusion criteria for our narrative review. The mean age of the 31 included patients was 31 years (range: 17-84). Local excision (19 out of 31, 61.3%), radical vulvectomy (8 out of 31, 25.8%) and hemivulvectomy (4 out of 31, 12.9%) were the principal surgical treatments. Radiotherapy and chemotherapy were performed in 8 and 5 patients, respectively. Recurrence of the disease was present in 13 out of 31 (42%). The interval to recurrence ranged from 1 to 48 months. The main location of recurrences was the local tissues, the lymph nodes and the lung. The mean period of follow-up was 38.5 months (range: 2-146 months). Cure was considered to have taken place in 19 out of 31 (61.3%) patients; 10 out of 31 (32.6%) died, and 2 out of 31 (6.4%) at the end of follow-up were alive but not considered cured. The first and principal step for the proper treatment of vulval epithelioid sarcomas is awareness of their existence by the specialist involved. Extensive imaging is proposed for staging, while the creation of a national or international register of patients with this malignancy would enable a more consistent approach to its management.
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Affiliation(s)
| | - Ioannis D Gkegkes
- 1st Department of Surgery, General Hospital of Attica "KAT", Athens, Greece.
| | - Nikolaos Vrachnis
- 2nd Department of Obstetrics and Gynecology, University of Athens Medical School, Aretaieio Hospital, Athens, Greece
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Patrizi L, Corrado G, Saltari M, Perracchio L, Scelzo C, Piccione E, Vizza E. Vulvar "proximal-type" epithelioid sarcoma: report of a case and review of the literature. Diagn Pathol 2013; 8:122. [PMID: 23886403 PMCID: PMC3751136 DOI: 10.1186/1746-1596-8-122] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 06/21/2013] [Indexed: 12/27/2022] Open
Abstract
Background The “proximal-type” epithelioid sarcoma is a very rare kind of mesenchimal tumor characterized by the difficulty in histological diagnosis and the very aggressive biological behavior. Case We report of a case of a 63 years old woman with a vulvar “proximal-type” epithelioid sarcoma that underwent a radical surgical staging followed by an adjuvant radiotherapy. She is on follow-up care for 14 months and there is no clinical evidence of disease. Conclusion Even if quite rare the proximal type epithelioid sarcoma should be regarded as a separate entity of particularly aggressive biologic behaviour. Its diagnosis attracts controversies and criticism related to the surgical approach and the choice of an adjuvant therapy. Virtual slides The virtual slide(s) for this article can be found here:
http://www.diagnosticpathology.diagnomx.eu/vs/1508554852942125
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Affiliation(s)
- Lodovico Patrizi
- Surgery Department, Gynecology Section and Obstetrics, Tor Vergata University, Rome, Italy
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Abstract
Epithelioid sarcoma of the vulva is an extremely rare neoplasm with aggressive behavior and poor outcome. Herein, we report a case of vulvar epithelioid sarcoma presenting in a 17-year-old very early in her pregnancy. The patient presented with an asymptomatic nodule of the right labia majora of 1-year duration. Computerized tomographic scans showed enlarged inguinal lymph nodes and numerous lung nodules. Positron emission tomography was performed and revealed no suspicious lesions for metastatic disease. The patient underwent local excision of her vulvar lesion. On the basis of morphology and extensive immunohistochemistry, the lesion was classified as epithelioid sarcoma. The patient was referred to radiation therapy and upon evaluation, she was found to be in her sixth week of gestation. The patient continued with her pregnancy and underwent a lymph node dissection, which was positive. We review the literature of only the well-documented cases extensively studied by immunohistochemical analysis. We summarize the clinical presentation, clinical impression, treatment modalities, and outcomes of these cases. On account of the rarity of this disease in the vulva, there is no clear consensus on treatment modalities, but it seems that early aggressive surgical resection is the treatment of choice, with the role of adjuvant therapy to be determined.
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de Visscher SAHJ, van Ginkel RJ, Wobbes T, Veth RPH, Ten Heuvel SE, Suurmeijer AJH, Hoekstra HJ. Epithelioid sarcoma: Still an only surgically curable disease. Cancer 2006; 107:606-12. [PMID: 16804932 DOI: 10.1002/cncr.22037] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Epithelioid sarcoma is a rare soft tissue sarcoma with a known high propensity for locoregional recurrence and distant metastases. The clinical behavior and prognostic factors that influence the survival of patients with epithelioid sarcoma were studied. METHODS Twenty-three patients, including 16 men (70%) and 7 women (30%), who were treated for epithelioid sarcoma between 1979-2003 at the University Medical Center Groningen and Radboud University Nijmegen Medical Center, were reviewed retrospectively. The median age at diagnosis was 22 years (range, 1-54 years). At the time of diagnosis, 11 patients (48%) had metastases. Six patients with distant metastasis and 1 patient with an unresectable tumor received palliative treatment (30%). The remaining 16 patients underwent surgical treatment of local disease (11 patients) or locoregional disease (5 patients). Five patients in that group received isolated limb perfusion with tumor necrosis factor and melphalan. RESULTS The 5-year and 10-year disease-free survival rates for all patients were 34% and 17%, respectively; for the 16 patients who received curative treatment, both rates were 56%. In the latter group, 8 patients developed local recurrence (50%) after a median follow-up of 4 months (range, 1-14 months). Nine patients were disease free after a median follow-up of 50 months (range, 6-290 months). Tumor size >5 cm (P < .0026) at diagnosis and local recurrence (P < .0008) were significant predictors of survival. CONCLUSIONS The prognosis for patients with epithelioid sarcoma is poor, because a substantial number of patients present with extensive disease, lymph node metastases, and/or distant metastases. Treatment consists of radical surgical excision of the tumor and, if indicated, therapeutic lymph node dissection. In patients who have large tumors, isolated limb perfusion may be useful.
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Affiliation(s)
- Sebastiaan A H J de Visscher
- Department of Surgical Oncology, University Medical Center Groningen and University of Groningen, Groningen, the Netherlands
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Abstract
Bartholin gland cysts account for 2% of all gynecologic visits per year. The treatment of Bartholin gland cysts has evolved from a complicated, bloody procedure requiring general anesthesia to, most recently, a simple puncture of the cyst and placement of a drain performed in the office. Although treatments for Bartholin gland cysts seem simple on the surface, recurrent cysts as well as diagnosing simple cysts versus abscesses versus malignant tumors can complicate treatment for this common problem. This article exams a history of the treatment of Bartholin gland cysts, including the use of the traditional treatments of excision, fistulization, marsupialization, as well as cauterization with carbon dioxide laser and silver nitrate. Modern variations are discussed, including the use of hydrodissection for excision, as well as the application of magnetic resonance imaging use in devising treatment for recurrent cysts.
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Affiliation(s)
- David A Marzano
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
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Finan MA, Barre G. Bartholin's gland carcinoma, malignant melanoma and other rare tumours of the vulva. Best Pract Res Clin Obstet Gynaecol 2003; 17:609-33. [PMID: 12965135 DOI: 10.1016/s1521-6934(03)00039-7] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Non-squamous cancers of the vulva encompass an exciting and broad group of tumours, including Bartholin's gland carcinoma, malignant melanoma, Paget's disease, sarcomas and lymphoma. These tumours range from innocuous lesions treatable with simple local excision, such as basal-cell carcinoma, to cancers with very poor prognosis, such as Merkel-cell tumours. All of these tumours are thoroughly reviewed, with emphasis on presenting symptoms, pathological diagnosis and optimal management approaches. The literature supporting these recommendations is reviewed. Of the utmost importance in the management of these tumours is a thorough review of the pathological diagnosis by a specialist pathologist and a gynaecological oncologist. Establishing the correct diagnosis is essential to reaching appropriate treatment decisions. Frequently this will necessitate a second opinion by a referral centre.
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Affiliation(s)
- Michael A Finan
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Ochsner Clinic Foundation, New Orleans, LA 70121, USA.
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Abstract
BACKGROUND Epithelioid sarcoma is a rare, yet aggressive soft tissue neoplasm that has not previously been reported to originate in the cervix. CASE A 29-year-old woman was seen in consultation at our institution after having been diagnosed with a poorly differentiated carcinoma of the cervix, which was treated with radiation and chemotherapy. Examination of the original biopsy material with additional studies led to a diagnosis of epithelioid sarcoma of the cervix. CONCLUSION Epithelioid sarcoma can occur in the cervix and should be included in the differential diagnosis of cervical neoplasms. Additional cases are needed to develop optimum treatment strategies and predict prognosis.
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Affiliation(s)
- Heather Jeney
- New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, NJ 07101, USA
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Abstract
BACKGROUND Epithelioid sarcoma is a soft tissue tumor rarely found centrally and even less commonly on the vulva. Vulvar sarcoma in pregnancy is also exceedingly rare with only five cases reported to date, none of which have been an epithelioid sarcoma. CASE We report a case of a 29-year-old woman presenting with a vulvar epithelioid sarcoma at 36 weeks of gestation. The patient underwent a radical resection 6 weeks postpartum followed by chemotherapy. Despite a radical hemivulvectomy and doxorubicin and ifosfamide chemotherapy, she developed pulmonary metastasis and died of tumor-related pulmonary failure secondary to her disease 612 months after diagnosis. To our knowledge this is the first case of a vulvar epithelioid sarcoma presenting during pregnancy. The English literature is reviewed and a total of 18 previous cases of vulvar epithelioid sarcoma have been reported outside of pregnancy. Insight into the biological behavior and therapeutic management of this disease is discussed. CONCLUSION The optimal management of vulvar epithelioid sarcoma remains to be determined. However, it would seem that early and aggressive surgical resection provides the best possibility for cure. The role of radiation and/or chemotherapy remains to be determined.
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Affiliation(s)
- Richard G Moore
- Department of Obstetrics and Gynecology, Program in Women's Oncology, Brown University, Providence, Rhode Island 02905, USA.
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Kasamatsu T, Hasegawa T, Tsuda H, Okada S, Sawada M, Yamada T, Tsunematsu R, Ohmi K, Mizuguchi K, Kawana T. Primary epithelioid sarcoma of the vulva. Int J Gynecol Cancer 2001; 11:316-20. [PMID: 11520372 DOI: 10.1046/j.1525-1438.2001.011004316.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A case of a 31-year-old woman with epithelioid sarcoma of the vulva which metastasized to the regional lymph node 8 years after onset of the disease is reported here. The patient first noticed a painless subcutaneous mass of 5 mm in diameter in the right labium majus at age of 21. This was excised locally at age 23, but recurred 17 months later. Although local excision was again performed, the tumor recurred and continued to enlarge very slowly. At this stage, based on the pathology of both the initial and second tumors, the diagnosis was of a benign inflammatory process. However, local recurrence and inguinal lymph node swelling occurred at age 29, and biopsy was taken. The pathology report indicated benign granulomatous changes. The slides were reconsidered and re-interpreted as epithelioid sarcoma, whereupon radical vulvectomy was performed at age 31. Vulvar epithelioid sarcoma with inguinal lymph node metastasis was first diagnosed at that time. Epithelioid sarcoma of the vulva is an exceedingly rare tumor, and only 15 cases have been reported thus far in the literature. Early diagnosis and curative treatment of this tumor may be problematic for gynecologists because of its rarity and therefore little-known characteristic clinical behavior and histology. Radical vulvectomy or extensive local excision with inguinal lymphadenectomy at the time of diagnosis is recommended as the treatment of choice.
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Affiliation(s)
- T Kasamatsu
- Division of Gynecology, National Cancer Center Hospital, Tokyo, Japan
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Bajaj P, Aiyer H, Sinha BK, Jain M, Ashok S. Pitfalls in the diagnosis of epithelioid sarcoma presenting in an unusual site: a case report. Diagn Cytopathol 2001; 24:36-8. [PMID: 11135466 DOI: 10.1002/1097-0339(200101)24:1<36::aid-dc1005>3.0.co;2-i] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The cytologic appearance of epithelioid sarcoma in fine-needle aspiration biopsy cytology (FNABC) smears has not been extensively described. We report a case of epithelioid sarcoma in a 55-year-old male who presented with nodular swellings in the abdominal wall and scrotum. The scrotal swelling was subsequently demonstrated to arise from the vas deferens. We highlight the cytomorphologic, immunocytochemical, and histopathologic features of this rare lesion in an unusual site, with particular emphasis on the dilemma encountered in the cytodiagnosis of this lesion.
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Affiliation(s)
- P Bajaj
- Department of Pathology, Lady Hardinge Medical College and S.K. Hospital, New Delhi, India
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Reinecke P, Knopf C, Schmitz M, Schneider EM, Gabbert HE, Gerharz CD. Growth inhibitory effects of paclitaxel on human epithelioid sarcoma in vitro: heterogeneity of response and the multidrug resistance phenotype. Cancer 2000; 88:1614-22. [PMID: 10738220 DOI: 10.1002/(sici)1097-0142(20000401)88:7<1614::aid-cncr16>3.0.co;2-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Epithelioid sarcoma is a highly malignant soft tissue tumor that is largely resistant to conventional chemotherapy and radiotherapy. Because paclitaxel has been proven to be effective in other human malignancies refractory to conventional chemotherapy, the authors analyzed the in vitro growth inhibitory effects of paclitaxel on the human epithelioid-sarcoma cell line GRU-1 and its clonal subpopulations GRU-1A, GRU-1B, and GRU-1C. METHODS Paclitaxel-induced morphologic alterations were visualized using light microscopy, immunofluorescence microscopy, and transmission electron microscopy. The antiproliferative effects of paclitaxel on the cell lines were determined by 3-[4,5-dimethylthiazol-2-yl]-2, 5-diphenyltetrazolium' bromide (MTT) assay. The extent of paclitaxel-induced apoptosis was determined by light microscopy. The expression and function of P-glycoprotein and the multidrug resistance-associated protein (MRP) were defined by reverse transcriptase-polymerase chain reaction and fluorescence-activated cell sorter analysis. RESULTS Paclitaxel-induced morphologic alterations such as micronucleus formation and microtubule bundles showed no significant differences between the parental cell line and its clonal subpopulations. A significant (P < 0.05) dose-dependent growth inhibition was observed in GRU-1 and its clonal subpopulations, with the IC(50) (concentration that inhibits 50%) values ranging from 0.04-0.49 microM in the different subpopulations. Paclitaxel-induced growth inhibition was accompanied by a slight increase in apoptosis. All cell lines showed an expression of and an effective function of P-glycoprotein and MRP. CONCLUSIONS The differential response of GRU-1 and its clonal subpopulations to paclitaxel could not be predicted by the expression and function of P-glycoprotein and MRP, suggesting that other drug resistance mechanisms might be relevant in the heterogenous response observed in the epithelioid sarcoma cell lines in the current study.
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Affiliation(s)
- P Reinecke
- Institute of Pathology, University Hospital of Düsseldorf, Germany
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Ross HM, Lewis JJ, Woodruff JM, Brennan MF. Epithelioid sarcoma: clinical behavior and prognostic factors of survival. Ann Surg Oncol 1997; 4:491-5. [PMID: 9309338 DOI: 10.1007/bf02303673] [Citation(s) in RCA: 96] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Epithelioid sarcoma is a rare histologic subtype of sarcoma. The clinical behavior and prognostic factors influencing survival in this disease are examined. METHODS A review of clinicopathologic features of patients with epithelioid sarcoma prospectively followed between July 1982 and July 1995 at Memorial Sloan-Kettering Cancer Center was performed. Kaplan-Meier and log-rank analysis were used. RESULTS Eleven men (69%) and five women (31%) were treated during this period. Mean age at diagnosis was 33 years, and length of symptoms before diagnosis was 18 months. Tumors presented in the trunk in 44% of patients, the lower extremity in 31%, and the upper extremity in 25%. Median follow-up time was 45 months. At least one local recurrence was experienced by 69% of patients. Metastases to regional lymph nodes during the course of the disease developed in 44% of patients and to the lungs in 44%. Median survival was 88.8 months, with a 66% 5-year survival rate. Pulmonary metastasis was correlated with decreased survival. CONCLUSIONS A delay in diagnosis of epithelioid sarcoma is common. Epithelioid sarcoma differs from other sarcoma subtypes in propensity for nodal spread and local recurrence. Careful follow-up evaluating local recurrence, nodal spread, and pulmonary metastases is warranted.
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Affiliation(s)
- H M Ross
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
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