Rhabdomyosarcoma of the maxillofacial region in children and adolescents: Report of 9 cases and literature review

Long-Term Outcome and Quality of Life in Patients Treated for Head and Neck Sarcoma during Pediatric Age: Considerations from a Series of 4 Cases

Pediatric sarcomas are rare malignancies accounting for about 10% of solid tumors in childhood. Sarcomas represent a heterogeneous group of malignancies, especially they include Rhabdomyosarcoma (RMS) and Non-Rhabdomyosarcoma Type Sarcomas (STSNR). Therapeutic management of pediatric sarcomas is challenging. Multidisciplinary approach including chemotherapy, surgery and radiotherapy is the treatment of choice. The correct management of affected patients can be demanding, especially in terms of preserving a good quality of life (QoL). In the present study we described our experience with a series of patients diagnosed with head and neck non-metastatic sarcoma between January 1995 and December 2020, referred to Pediatric Oncology or to Maxillo-Facial Surgery of University Hospital of Modena and Reggio Emilia.The survivors were asked to complete questionnaires on health-related quality of life (HRQoL; PedsQL and EORTC QLQ-H&N 43). We found satisfactory results in terms of global HRQoL; although outstanding issues persist, such as deterioration in masticatory function, and speech. Long-term sequelae of multimodality treatment may lead to both significant aesthetic-functional and psychosocial implications that need to be further investigate during the whole the care pathway.

A rare presentation of a bilateral intracranial parameningeal embryonal rhabdomyosarcoma mimicking vestibular schwannoma in a two-year-old child: a case report

Intracranial parameningeal rhabdomyosarcomas are rare, aggressive, rapidly progressive paediatric malignancies that carry a poor prognosis. The authors report a case of a 2-year-old boy who initially presented with a left facial palsy, ataxia and, shortly after, bloody otorrhoea. MRI imaging was initially suggestive of a vestibular schwannoma. However, there was rapid progression of symptoms and further MRI imaging showed very rapid increase in tumour size with mass effect and development of a similar tumour on the contralateral side. A histological diagnosis of bilateral parameningeal embryonal rhabdomyosarcoma was made. Despite treatment, progression led to hydrocephalus and diffuse leptomeningeal disease, from which the patient did not survive. Few intracranial parameningeal rhabdomyosarcomas have previously been reported and these report similar presenting symptoms and rapid disease progression. However, this is the first reported case of a bilateral intracranial parameningeal embryonal rhabdomyosarcoma which, on initial presentation and imaging, appeared to mimic a vestibular schwannoma.

Heparanase-1 is downregulated in chemoradiotherapy orbital rhabdomyosarcoma and relates with tumor growth as well as angiogenesis

AIM

To determine the role of heparanase-1 (HPSE-1) in orbital rhabdomyosarcoma (RMS), and to investigate the feasibility of HPSE-1 targeted therapy for RMS.

METHODS

Immunohistochemistry was performed to analyze HPSE-1 expression in 51 cases of orbital RMS patients (including 28 cases of embryonal RMS and 23 cases of alveolar RMS), among whom there were 27 treated and 24 untreated with preoperative chemoradiotherapy. In vitro, studies were conducted to examine the effect of HPSE-1 silencing on RMS cell proliferation and tube formation of human umbilical vein endothelial cells (HUVECs). RD cells (an RMS cell line) and HUVECs were infected with HPSE-1 shRNA lentivirus at a multiplicity of infection (MOI) of 10 and 30 separately. Real-time PCR and Western blot were applied to detect the mRNA and protein expression levels of HPSE-1. Cell viability of treated or control RD cells was evaluated by cell counting kit-8 (CCK-8) assay. Matrigel tube formation assay was used to evaluate the effect of HPSE-1 RNAi on the tube formation of HUVECs.

RESULTS

Immunohistochemistry showed that the expression rate of HPSE-1 protein was 92.9% in orbital embryonal RMS and 91.3% in orbital alveolar RMS. Tissue from alveolar orbital RMS did not show relatively stronger staining than that from the embryonal orbital RMS. However, despite the types of RMS, comparing the cases treated chemoradiotherapy with those untreated, we have observed that chemoradiotherapy resulted in weaker staining in patients' tissues. The expression levels of HPSE-1 declined significantly in both the mRNA and protein levels in HPSE-1 shRNA transfected RD cells. The CCK-8 assay showed that lentivirus-mediated HPSE-1 silencing resulted in significantly reduced RD cells viability in vitro. Silencing HPSE-1 expression also inhibited VEGF-induced tube formation of HUVECs in Matrigel.

CONCLUSION

HPSE-1 silencing may be a promising therapy for the inhibition of orbital RMS progression.

An Atypical Presentation of Sinonasal Tract Alveolar Rhabdomyosarcoma in a Young Male Patient Submitted to Multimodality Treatment

Rhabdomyosarcoma (RMS), a malignant tumor derived from the neoplastic proliferation of striated skeletal muscle cells, is the most common pediatric soft tissue sarcoma. Its treatment is mainly based on neoadjuvant chemotherapy (QT+), surgical resection, and adjuvant radiotherapy (RT+). RT+ has shown satisfactory results for locoregional control of the disease, in spite of promoting local side effects. The present case report was aimed at describing the clinical and therapeutic characteristics and the management of complications resulting from multimodal therapy in a patient with an atypical presentation of RMS in the sinonasal tract. A 20-year-old Afro-descendant man complained of an expansive tumor lesion, with left eye proptosis that reduced visual acuity and caused severe regional pain. Imaging analysis showed an extensive and infiltrative lesion in the periorbital region, sinonasal tract, left maxilla, and orbital roof. According to the histopathological analysis, the diagnosis was established corresponding to parameningeal alveolar RMS that was unresectable. Treatment was initiated with three cycles of QT+ which showed partial response and later RT+. After completing half of the RT+ sessions, the patient showed a complete response with reduction in tumor volume and improvement in pain and local conditions. Side effects such as alopecia and dermatological changes induced by radiation were observed. Moreover, painful erythematous areas were observed in the region of the hard and soft palate, uvula, and oropharynx, compatible with Grade 2 mucositis lesions. After the cytological swab test, some of them were diagnosed as herpes simplex lesions; thickening and decrease in salivary flow were also found. A local drug therapy approach was instituted, and photobiomodulation was performed to manage oral complications. RT+ was shown to be effective in locoregional control of the disease; however, the early management of its undesirable effects on the surrounding tissues was required.

Computed tomography (CT) features of pelvic rhabdomyosarcoma (RMS) in children

BACKGROUND

Currently, there are few literature reports on the CT features of pelvic rhabdomyosarcoma, most of which exist in the form of case reports, and some literature reports have suggested that CT features of pelvic rhabdomyosarcoma lack specificity. This study was designed to investigate the CT features of pelvic RMS in children to provide imaging evidence for clinical diagnosis.

METHODS

We retrospectively reviewed radiographic and clinical data of all paediatric patients with pelvic neoplastic lesions pathologically proven to be malignant in our hospitals from January 2012 through March 2021. The data of the included paediatric patients were divided into two groups according to whether the pathology results indicated RMS. CT features of RMS (n= 37) and non-RMS (n= 91) were compared by two abdominal radiologists.

RESULTS

A total of 9 CT features were statistically significant for the diagnosis of pelvic RMS in children (p＜0.05). The sensitivity (range, 0.64-0.74) and specificity (range, 0.86-0.93) of the CT features showing multinodular fusion, surrounding blood vessels, and heterogeneous progressive centripetal enhancement were both relatively high. The CT features indicating lower than muscle density, necrosis, non-calcification and non-haemorrhage exhibited high specificity (range, 0.86-0.97), but the sensitivity (range, 0.32-0.40) was relatively low, while the sensitivity (range, 0.37-0.46) and specificity (range, 0.75-0.83) of other CT features used for diagnosing pelvic RMS, namely, lobulated and lymphatic metastasis, were both relatively low.

CONCLUSION

Pelvic rhabdomyosarcoma in children has its own specific CT features.

Parameningeal alveolar rhabdomyosarcoma in a child

This is the case of a parameningeal alveolar rhabdomyosarcoma (ARMS) in a 13-year-old boy who presented with painless loss of vision in the right eye, but very few other physical signs. The ARMS diagnosis was confirmed with imaging and molecular characterisation of the tumour. Despite tolerating the initial chemotherapy and radiotherapy regimens, there was leptomeningeal recurrence and the patient unfortunately passed away. Parameningeal ARMS occurs in an area of the body, which leads to a wide variety of possible presenting symptoms, creating a long list of differentials that can delay treatment. This tumour subtype has a poor prognosis, and due to the location of the tumour around vital structures in the head, treatment toxicities must be taken into account. This highlights the necessity for having a strong index of suspicion for this tumour in atypical presentations in children, and the necessity for prompt treatment to prevent leptomeningeal disease from occurring.

Role of Surgery in Rhabdomyosarcoma of the Head and Neck in Children

OBJECTIVES

Rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma in children. The goal of this research is to analyze the role of surgery in the management of pediatric parameningeal (PM) and non-PM head and neck RMS (HNRMS).

STUDY DESIGN

Retrospective review.

METHODS

Retrospective chart review of patients <20 years of age treated for HNRMS between 1970 and 2015. Clinical presentation, tumor characteristics, treatment, recurrence, follow-up, and outcome data were collected.

RESULTS

Of 97 patients with HNRMS, 56% were male. Overall median (IQR: interquartile range) age at diagnosis was 5.8 (3.3-9.8) years. Sixty-five patients (67%) had PM tumors. Of 75 patients with histologic subtype identified, 51 (53%) had embryonal and 20 (21%) alveolar RMS. Almost all patients received chemotherapy (99%) and radiotherapy (95%). Forty-four patients (45%) underwent surgery. Surgery was more likely to be conducted in patients with lesions of a non-PM site. Median follow-up time was 3.4 years (IQR: 1.1-10.8). In 5 years of follow-up, 20% (17 of 85) died and 29% (20 of 70) had recurrence. The estimated 5-year survival rate was 72% (95% CI, 57.8, 81.5%). Surgery was associated with a reduced risk of mortality after accounting for TNM stage 4 and tumor site (adjusted HR 0.24; 95% CI, 0.07, 0.79; P = .02). The association between surgery and risk of mortality was similar in PM and non-PM tumors.

CONCLUSION

A multimodal protocol for treatment including chemotherapy, surgery, and radiotherapy is the mainstay for management of children with HNRMS. While surgery is more commonly used to treat non-PM HNRMS, patients who are able to undergo surgery have significantly higher 5-year survival.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E984-E992, 2021.

Oral and Dental Abnormalities Caused by a Pediatric Rhabdomyosarcoma Tumor Treatment: A Clinical Case Report

Rhabdomyosarcoma is one of the most common soft-tissue sarcomas in children. The therapy for this condition has evolved significantly over recent decades, as has survival rates. Nevertheless, multiagent chemotherapy, radiation therapy, surgical resection or a combination of these modalities still have to be performed. This case report presents a 16-year-old boy with oral and dental effects after rhabdomyosarcoma treatment, diagnosed at the age of 4 years old. This report highlights the key role of dentists in the clinical management of rhabdomyosarcoma cases before, during and after treatment, and its potential side effects.

A subset of epithelioid and spindle cell rhabdomyosarcomas is associated with TFCP2 fusions and common ALK upregulation

Rhabdomyosarcomas with TFCP2 fusions represent an emerging subtype of tumors, initially discovered by RNA-sequencing. We report herein the clinicopathological, transcriptional, and genomic features of a series of 14 cases. Cases were retrospectively and prospectively recruited and studied by immunohistochemistry (MYF4, MYOD1, S100, AE1/E3, ALK), fluorescence in situ hybridization with TFCP2 break-apart probe (n = 10/14), array-comparative genomic hybridization (Agilent), whole RNA-sequencing (Truseq Exome, Illumina), or anchored multiplex PCR-based targeted next-generation sequencing (Archer® FusionPlex® Sarcoma kit). Patient's age ranged between 11 and 86 years, including 5 pediatric cases. Tumors were located in the bone (n = 12/14) and soft tissue (n = 2/14). Most bone tumors invaded surrounding soft tissue. Craniofacial bones were over-represented (n = 8/12). Median survival was 8 months and five patients are currently alive with a median follow-up of 20 months. Most tumors displayed a mixed spindle cell and epithelioid pattern with frequent vesicular nuclei. All tumors expressed keratins and showed a rhabdomyogenic phenotype (defined as expression of MYF4 and/or MYOD1). ALK was overexpressed in all but three cases without underlying ALK fusion on break-apart FISH (n = 5) nor next-generation sequencing (n = 14). ALK upregulation was frequently associated with an internal deletion at genomic level. TFCP2 was fused in 5' either to EWSR1 (n = 6) or FUS (n = 8). EWSR1 was involved in both soft tissue cases. FISH with TFCP2 break-apart probe was positive in all tested cases (n = 8), including one case with unbalanced signal. On array-CGH, all tested tumors displayed complex genetic profiles with genomic indexes ranging from 13 to 107.55 and recurrent CDKN2A deletions. FET-TFCP2 rhabdomyosarcomas clustered together and distinctly from other rhabdomyosarcomas subgroups. Altogether, our data confirm and expand the spectrum of the new family of FET-TFCP2 rhabdomyosarcomas, which are associated with a predilection for the craniofacial bones, an aggressive course, and recurrent pathological features. Their association with ALK overexpression might represent a therapeutic vulnerability.

Expanding the Spectrum of Intraosseous Rhabdomyosarcoma: Correlation Between 2 Distinct Gene Fusions and Phenotype

Primary intraosseous rhabdomyosarcomas (RMSs) are extremely rare. Recently 2 studies reported 4 cases of primary intraosseous RMS with EWSR1/FUS-TFCP2 gene fusions, associated with somewhat conflicting histologic features, ranging from spindle to epithelioid. In this study we sought to further investigate the pathologic and molecular abnormalities of a larger group of intraosseous RMSs by a combined approach using targeted RNA sequencing analysis and fluorescence in situ hybridization (FISH). We identified 7 cases, 3 males and 4 females, all in young adults, age range 20 to 39 years (median, 27 y). Three cases involved the pelvis, 2 involved the femur and 1 each involved the maxilla and the skull. Molecular studies identified recurrent gene fusions in all 7 cases tested, including: a novel MEIS1-NCOA2 fusion in 2 cases, EWSR1-TFCP2 in 3 cases, and FUS-TFCP2 gene fusions in 1 case. One case showed a FUS gene rearrangement, without a TFCP2 gene abnormality by FISH. The MEIS1-NCOA2-positive cases were characterized by a more primitive and fascicular spindle cell appearance, while the EWSR1/FUS rearranged tumors had a hybrid spindle and epithelioid phenotype, with more abundant eosinophilic cytoplasm and mild nuclear pleomorphism. Immunohistochemically, all tumors were positive for desmin and myogenin (focal). In addition, 4 tumors with TFCP2-associated gene fusions also coexpressed ALK and cytokeratin. In conclusion, our results suggest a high incidence of gene fusions in primary RMSs of bone, with 2 molecular subsets emerging, defined by either MEIS1-NCOA2 or EWSR1/FUS-TFCP2 fusions, showing distinct morphology and immunophenotype. Additional studies with larger numbers of cases and longer follow-up data are required to definitively evaluate the biological behavior of these tumors and to establish their relationship to other spindle cell RMS genetic groups.

Surgical treatment of pediatric rhabdomyosarcoma in the parameningeal-nonparameningeal region

OBJECTIVES

Rhabdomyosarcoma (RMS) involving the parameningeal-nonparameningeal region (PNP) is relatively rare in pediatric patients (PPs). The current study aimed to report the outcomes of RMS-PNP-PPs who received surgical resection combined with concurrent flap reconstruction.

METHODS

A retrospective study was conducted concerning RMS-PNP-PPs who received combined skull-maxillofacial resection with flap reconstruction during the period from 2012 to 2016. Predictive factors for recurrence-free survival (RFS), metastasis-free survival (MFS), and overall survival (OS) were preliminarily identified by Kaplan-Meier analysis.

RESULTS

A total of 16 RMS-PNP-PPs were finally enrolled; recurrence, metastasis and death were found in 7, 7 and 5 patients, respectively. Following surgical ablation involving the skull base and maxillofacial region, reconstruction was performed with a local flap in 9 patients, a latissimus dorsi flap in 3 patients, and an anterolateral thigh flap in 4 patients. Through univariate analysis, we demonstrated that the primary site + surgical margins, postoperative RT/CT + Ki-67/Bcl-2 IHC, and surgical margins + Ki-67/Bcl-2 IHC could be used as the preliminarily prognostic factors for RFS, MFS and OS, respectively.

CONCLUSIONS

RMS-PNP-PPs showed poor prognosis even when surgical resection combined with flap reconstructions was performed. Achieving a clear surgical margin and good conduction of postoperative RT/CT should be taken into consideration to acquiring a better surgical outcome.

Retrospective analysis of rhabdomyosarcoma (RMS) in children in a single center

Background

This study was conducted to explore the influence of clinical features of rhabdomyosarcoma (RMS) and a refined therapeutic protocol on the therapeutic efficacy and prognosis in children in the past five years.

Methods

Forty children diagnosed with RMS were retrospectively studied, using a version of the therapeutic protocol refined by Shanghai Children's Medical Center (version 2009.9.1). The patients’ demographic characteristics, clinical manifestations, pathological features, therapeutic efficacy, and prognosis were analyzed.

Results

Of the 40 children, 17 abandoned treatment. Of the remaining 23 cases, two children were rated as low risk, 12 as medium risk, and nine as high risk, and all received treatment. Patients in the low and medium‐risk groups had better prognosis than those in the high‐risk group, and treated patients had higher survival rates and longer survival than untreated patients.

Conclusion

Children with RMS should be treated positively. Combined treatment shows better therapeutic efficacy and prognosis. The refined therapeutic protocol seems more effective than the standard treatment, with a significant impact on long‐term RMS prognosis.

Prosthetic rehabilitation for a patient treated for embryonal rhabdomyosarcoma

A female patient, now aged 17 years, was diagnosed with rhabdomyosarcoma (RMS) in the right pterygopalatine fossa when she was 3 years old. The RMS was successfully treated by excision, but the subsequent radiation and polychemotherapy resulted in the complete anesthesia of the distribution area of the right trigeminal nerve and loss of vision in the right eye. The patient also experienced pain in the mandibular joints and masticatory muscles. Panoramic radiographs displayed a multiple agenesia of the permanent teeth and underdeveloped apices. Treatment involved the fabrication of a complete maxillary denture. A removable device was fabricated to evaluate her response to an occlusal vertical dimension increase of 6 mm and provide a stable intercuspal position. After wearing the prosthesis for 6 months, the patient reported that she was completely free of symptoms.

Clinicopathological analysis of head and neck rhabdomyosarcoma: A series of 10 cases and literature review

Background

To describe the clinicopathological characteristics of a series of head and neck rhabdomyosarcoma (RMS) and to review the literature.

Material and Methods

Cases diagnosed as RMS affecting the head and neck region were retrospectively retrieved from the files of two Brazilian institutions from January 2006 to January 2017. Data on clinical features (sex, age and affected site), microscopic subtype, immunohistochemical results, treatment employed and follow-up status were obtained from the patient’s medical charts.

Results

During the period considered, 10 cases of RMS were identified. Females predominated (4M:6F), the mean age at diagnosis was 16.5 years-old and the orbit was the most affected site (4 cases). Microscopically, most cases were classified as embryonal RMS (6 cases) and the Desmin/Myogenin/Myo-D1 immunohistochemical positivity was useful to confirm the diagnosis. Chemotherapy and radiotherapy were applied to 9 and 8 patients respectively, whereas 2 patients were treated by surgery. Recurrences occurred in 3 patients and distant metastasis in 2 cases. Nine patients were alive in their last follow-up, 3 of them with disease, whereas 1 patient died due to the disease.

Conclusions

Head and neck RMS is an aggressive malignant neoplasm which demands especial concern to achieve early diagnosis and successful treatment.

Key words:Rhabdomyosarcoma, soft tissue tumors, head and neck, oral cavity, chemotherapy.

Rhabdomyosarcoma of the maxillary gingiva

Rhabdomyosarcoma is a malignant skeletal muscle neoplasm. The tumor is much more common in children, and the most frequent site is head and neck region. Since this tumor is less frequent than other neoplasms in oral cavity, the clinicians sometimes ignore it, working the patients up. Rhabdomyosarcoma is a high-grade malignancy with poor prognosis. Considering the aggressive behavior and various clinical or histopathologic presentations of the tumor, early diagnosis has a significant impact on the treatment outcome and prognosis of the patients. We highlight the importance of combining the clinical, radiographic, and histopathologic examination to obtain a definitive diagnosis in sarcomas of the head and neck region, especially rhabdomyosarcoma. A case of rhabdomyosarcoma of the maxillary gingiva is presented in a 32-year-old woman in which the primary incisional biopsy was erroneously interpreted as an inflammatory process and consequently, the accurate diagnosis postponed for about 10 months.