Primary leiomyosarcoma of bone: clinicopathologic, immunohistochemical, and molecular biologic aspects

Rare bone sarcomas: A retrospective analysis of 145 adult patients from the French Sarcoma Group

The benefit of chemotherapy (CT) in rare bone sarcomas is not documented in prospective studies. Our retrospective study from the French sarcoma network for bone tumors ResOs was performed in adult patients (pts) from 1976 to 2014, with histologically verified diagnosis of leiomyosarcomas (LMS), undifferentiated pleomorphic sarcoma (UPS) or radiation-associated sarcomas of bone. The median follow-up was 4.7 years (95% CI: 3.7-6.5). Clinical features, treatment modalities and outcomes were recorded and analyzed from 145 pts (median age 53 years [range 20-87]). Site of disease was extremities (66%) or axial skeleton (34%), 111 (77%) presented with localized and potentially resectable disease. The most common histological subtypes were UPS (58%) and LMS (33%); 58% were high-grade tumors. Surgery was performed in 127 pts. In the 111 localized pts, 28 pts (25%) underwent upfront surgery or exclusive radiotherapy (RT; >50 Gy) without CT, whereas 83 pts (75%) received either neoadjuvant (n = 26) or adjuvant CT (n = 13) or both (n = 44). Neoadjuvant and adjuvant CT was mostly doxorubicin-based (95%/86%) and cisplatin-based (67%/63%). R0 resection was achieved in 59 pts, and a good histological response in 15 patients (25%). Adjuvant RT was performed in 24 (22%) pts. For the whole cohort (n = 145), the 5-year overall survival (OS) rate was 53% [42; 62]. In univariate analysis, age ≤ 60 was associated with a longer disease-free survival (DFS) (P = .0436). Neoadjuvant and adjuvant CT tended to be associated with better DFS (P = .056) with no significant impact on OS in this retrospective series.

Primary Leiomyosarcoma of Bone: Review and Update

Context.—

Leiomyosarcoma of bone is a rare primary osseous sarcoma characterized by smooth muscle differentiation and absence of malignant osteoid formation. Leiomyosarcoma of bone is diagnostically challenging; this can be improved with greater awareness of this entity and the ability to differentiate it from its histologic mimics. Because of its rarity, only a small number of studies are available in the literature. These factors contribute to our limited understanding of its pathology, prognosis, and treatment.

Objective.—

To review the clinicopathologic features of leiomyosarcoma of bone and present the most up-to-date understanding of its behavior and management in accordance with the current literature.

Data Sources.—

Review of pertinent literature on the major features, current knowledge thereof, and the authors' experience in the diagnosis and management of leiomyosarcoma of bone.

Conclusions.—

Leiomyosarcoma of bone is a rare but well-recognized primary osseous sarcoma that may arise de novo or in association with radiation. Although it is diagnostically challenging, awareness of this rare sarcoma and knowledge of its key histomorphologic and immunohistochemical features allow for accurate diagnosis.

A Spindle Cell Tumor of Unknown Origin and Diffuse Bone Marrow Involvement in a Patient with Hypercalcemia

Background

Metastasis of unknown origin in bone marrow is infrequent, although, when it occurs, adenocarcinoma is the most common histologic type. Involvement of bone marrow by a spindle cell tumor and presentation with hypercalcemia are very rare.

Method

This report describes a 21-year-old man with diffuse bone marrow involvement from a spindle cell tumor.

Results

The patient presented with low back pain, anemia, thrombocytopenia, azotemia, and hypercalcemia. Bone marrow biopsy revealed a spindle cell tumor that was positive for vimentin staining but whose primary site could not be identified. A bone marrow scan revealed absence of uptake, which suggested systemic disease. We treated this case as a type of sarcoma by giving combined chemotherapy consisting of vincristine, actinomycin-D and cyclophosphamide. The patient showed a clinical response for seven months, but the disease progressed despite chemotherapy and he died one year after diagnosis.

Conclusions

We have documented a rare case of spindle cell tumor involving bone marrow without evidence of the tumor's primary site.

Primary leiomyosarcoma of the bone: a case report and a review of the literature

RATIONALE

Leiomyosarcoma (LMS) is a malignant sarcoma that can occur in different anatomic sites, including the bone, showing similar histological characteristics but heterogeneous clinical behavior and prognosis. Primary bone LMS was first described in 1965. It is a very rare sarcoma, accounting for <0.7% of all primary malignant bone tumors.

PATIENT CONCERNS

We report the case of a 52-year-old male with primary bone LMS who presented with a solitary osteolytic lesion with focal cortical destruction in the left clavicle, seen on an x-ray and subsequent computed tomography (CT) scan.

DIAGNOSIS

The multidisciplinary Osteoncology team of our institute planned a biopsy that revealed the presence of spindle and pleomorphic cells with a positive reaction for smooth muscle actin and desmin at immunohistochemical analysis, without the presence of cartilage or bone matrix. These results were consistent with a high-grade malignant LMS arising from the bone.

INTERVENTIONS

Complete surgical resection of the tumor was performed and a decision was made with the patient not to proceed with adjuvant chemotherapy or radiotherapy.

OUTCOMES

After more than 1 year of surgery, the patient is well, with no evidence of recurrent or metastatic disease. Follow-up is ongoing.

LESSONS

Little is known about the biology and clinical behavior of bone LMS due to its extreme rarity. A multidisciplinary team in a specialized center is needed for the optimal management of the disease. Surgery with a curative intent is the cornerstone of treatment of localized disease. No data are available about chemotherapy in neoadjuvant, adjuvant, or advanced settings. Further research is needed to identify more effective therapies.

Leiomyosarcoma in the humerus with leukocytosis and elevation of serum G-CSF

Leukocytosis associated with secretion of granulocyte colony-stimulating factor (G-CSF) has been reported in various tumors, primarily poorly differentiated epithelial tumors, but is extremely rare in bone tumors. An 84-year-old woman experienced swelling and pain in the shoulder for 1 month. Leukocytosis and elevated serum G-CSF were observed, but resolved following tumor resection. A diagnosis of leiomyosarcoma of the bone with expression of G-CSF was confirmed immunohistochemically. Histological diagnosis of leiomyosarcoma showed it to be differentiated, which is unusual for G-CSF-secreting tumors.

The ‘other’ bone sarcomas

We aimed to identify the incidence, outcome and prognostic factors associated with spindle cell sarcomas of bone (SCSB). We studied 196 patients with a primary non-metastatic tumour treated with the intent to cure. The results were compared with those of osteosarcoma patients treated at our hospital during the same period. The overall incidence of SCSB was 7.8% of all patients with a primary bone sarcoma. The five- and ten-year survival rates were 67.0% and 60.0%, respectively, which were better than those of patients with osteosarcoma treated over the same period. All histological subtypes had similar outcomes. On univariate analysis, factors that were significantly associated with decreased survival were age > 40 years, size > 8 cm, the presence of a pathological fracture, amputation, involved margins and a poor response to pre-operative chemotherapy. Multivariate analyses showed that age > 65 years, amputation and involved margins were all statistically significant prognostic factors. Involved margins and poor response to pre-operative chemotherapy were associated with an increased risk of local recurrence. SCSB has a better prognosis than osteosarcoma when matched for age. Most prognostic factors for osteosarcoma also seem to apply to SCSB. Patients with SCSB should be treated in the same way as patients of the same age with osteosarcoma.

Leiomyosarcoma of bone arising in association with a bone infarct

Both primary leiomyosarcoma of bone and sarcoma arising in association with a bone infarct are rare events. In this case report we describe for the first time a case of leiomyosarcoma arising in a bone infarct. The tumour arose in a medullary infarct in the proximal femur of an elderly patient. As in other cases of sarcoma arising in a bone infarct, the prognosis was poor, the patient dying within 6 months of diagnosis.

Primary leiomyosarcoma of bone--a clinicopathologic study of 8 uncommon cases with immunohistochemical analysis and clinical outcomes

Primary leiomyosarcoma of bone is a rare and a diagnostically challenging tumor entity. Over a 7-year period, we identified 8 such cases that fulfilled the diagnostic criteria in 6 men and 2 women, with age ranging from 25 to 59 years (mean, 42.7 years). All cases were noted in the lower limbs, including femur and tibia as the commonly involved bones in 4 and 3 cases, respectively. On radiography, the most consistent feature was a solitary osteolytic lesion with cortical destruction, unassociated with matrix formation. On histopathology, all cases showed spindly sarcomatous cells, mostly arranged in fascicles and whorls. Of 8 cases, 6 (75%) were of high grade. Prominent vasculature was noted in 5 cases. Two cases displayed focal mineralization, including calcification and heterotropic woven bone formation in 1 case each, but lacked malignant osteoid or chondroid matrix. One case showed osteoclast-like giant cells. On immunohistochemistry, smooth muscle actin was diffusely positive in all cases (100%), desmin was positive in 6 (75%) of 8 cases, and h-caldesmon was positive in 5 (83.3%) of 6 cases. Five cases underwent surgery, including 3 amputations and 2 wide excisions. One case underwent chemotherapy. On follow-up, 5 cases developed metastasis, including 1 case with another, who died within 17 and 5 months. Leiomyosarcoma of bone is uncommon and diagnostically challenging. An index of suspicion is necessary for this diagnosis, especially in cases of lytic, destructive bone lesions, unassociated with matrix production, that show spindly sarcomatous cells on histopathology. Immunohistochemical analysis, including an optimum panel formed by smooth muscle actin (diffuse positivity), desmin, and h-caldesmon, is necessary for substantiating this diagnosis. Surgery forms the treatment mainstay. The prognosis appears to be dismal.

Primary leiomyosarcoma of extragnathic bone: clinicopathologic features and reevaluation of prognosis

CONTEXT

Leiomyosarcoma most commonly involves the female genital tract and occasionally arises within the retroperitoneum, abdominal cavity, or the soft tissues of the extremity. Presentation as a primary bone tumor is extraordinarily uncommon, potentially leading to misdiagnosis. The prognosis is traditionally thought to be dismal. However, this conclusion is largely based on individual case reports and small series, in some of which the pathologic diagnosis is not well documented.

OBJECTIVE

To review the clinicopathologic features of well-established cases of primary skeletal leiomyosarcoma and reevaluate the prognostic implications thereof.

DATA SOURCES

A National Center for Biotechnology Information PubMed search of the English language literature identified 104 authenticated cases of primary leiomyosarcoma of extragnathic bone. An additional 3 cases are reported and illustrated herein.

CONCLUSIONS

Approximately half of all patients with primary skeletal leiomyosarcoma either presented with metastatic disease or developed metastases within 1 year of diagnosis. The 5-year overall and disease-free survival rates were 59% and 41%, respectively, comparable to that of other skeletal sarcomas. As for other bone and soft tissue sarcomas, high histologic grade and tumor stage are predictive of poor outcome.

Subperiosteal leiomyosarcoma of the tibia

Primary leiomyosarcoma of bone is a rare malignant tumor of smooth muscle. We report a case of low-grade subperiosteal primary bone leiomyosarcoma in the tibial diaphysis, which radiologically appeared to be osteoid osteoma. A 35-year-old man presented with a several-year history of a palpable hard nodule in the distal left leg, which had enlarged and become painful over the previous 2 years. Radiographs showed solid periosteal reaction with a well-defined lytic lesion in the posteromedial cortical border of the left tibial diaphysis. Computed tomography demonstrated a small, well-defined lytic lesion, not calcified, in a subperiosteal location, surrounded by solid periosteal bone formation. The lesion was excised en bloc and the histological diagnosis of a low-grade leiomyosarcoma was made. To the best of our knowledge, the surface location of primary bone leiomyosarcoma has not been previously described in the literature.

Leiomyosarcoma of the lumbar spine: case report

STUDY DESIGN

A primary leiomyosarcoma in the L2 vertebral body without any neurologic deficit is reported. The radiologic diagnosis was a metastasis, and the histologic diagnosis was confirmed by transpedicular needle biopsy.

OBJECTIVE

To emphasize the occurrence of primary leiomyosarcoma in the lumbar spine.

SUMMARY OF BACKGROUND DATA

Leiomyosarcoma is a rare malignant neoplasm of the bone, and only one report of the primary spinal tumor exists. In the case of leiomyosarcoma of the bone, metastasis, most commonly of the uterus or gastrointestinal tract, must be carefully ruled out before the diagnosis of primary leiomyosarcoma in the bone is confirmed.

METHODS

Leiomyosarcoma of the second lumbar vertebra in a 47-year-old woman with no neurologic deficit is reported. Imaging findings indicated a nonspecific high-grade lesion. A total spondylectomy of L2 with en bloc excision of the lower half of L1 and the upper third of L3 vertebral bodies was performed after preoperative radiation therapy. The defect of the vertebral body was reconstructed by titanium mesh cage, and T11 to S1 vertebrae were instrumented by the pedicle screw and rod system.

RESULTS

The surgical margin was marginal. Histologically, the tumor cells were elongated, with abundant cytoplasm and cigar-shaped nuclei, showing proliferation in fascicles and bundles. No sign of local recurrence or metastasis was evident 2 years and 1 month after surgery.

CONCLUSIONS

Leiomyosarcoma should be included in the differential diagnosis of spindle cell tumor of the spine, and it should be confirmed or excluded by immunohistochemical and/or ultrastructural studies. If the expected surgical margin is definitive, a total en bloc spondylectomy should be performed.

Cytological diagnosis of primary leiomyosarcoma of bone: case report

We report on a case of primary leiomyosarcoma of the bone in a 77-yr-old man. The patient presented with a painful, enlarging mass in the left shoulder of 6 mo duration. Radiography and computed tomography (CT) revealed a large destructive intramedullary lesion of the proximal humerus, with massive extension into the surrounding soft tissues. CT-guided fine-needle aspiration biopsies (FNAB) of both the bony and soft-tissue lesions were performed. Cytological examination showed a neoplastic process composed of spindle cells mixed with pleomorphic cells. The smooth muscle origin of the neoplastic cells was confirmed by immunocytochemical analysis. We describe the cytological features of this rare primary tumor of bone, and consider the differential diagnosis of spindle-cell neoplasms.

Primary leiomyosarcoma with the invasion into the intertrabecular space of bone: a case report and the review of the literatures

Primary leiomyosarcoma of bone is very rare. Most of reported cases were osteolytic. We report a primary leiomyosarcoma arising from the neck of the femur of a 43-year-old woman who had no remarkable abnormalities on plain radiographs. Magnetic resonance imaging (MRI) clearly depicted the lesion. Biopsy revealed it leiomyosarcoma. Gynecological and gastrointestinal examinations ruled out metastatic leiomyosarcoma. Wide excision of the tumor was performed and followed by endoprosthetic replacement of the proximal femur. Microscopic examination revealed tumor cells infiltrating into the intertrabecular space.