Alveolar soft part sarcoma. a report of 15 cases

Alveolar soft part sarcoma: a clinicopathological and immunohistochemical analysis of 26 cases emphasizing risk factors and prognosis

OBJECTIVE

This study aimed to investigate the clinicopathological features and prognostic indicators of alveolar soft part sarcoma (ASPS).

METHODS

The characteristics of 26 ASPS patients diagnosed at our hospital between January 2011 and January 2019 were retrospectively analysed.

RESULTS

The data for 12 male and 14 female patients, with a median age of 27.5 years, were assessed. The clinical symptoms mainly included painless enlarged masses in deep soft tissues. ASPS had a characteristic pathological morphology. Twenty-four patients were positive for TFE3, and TFE3 gene rearrangement was detected in 12 patients. Among the 26 patients who completed follow-up, 14 had metastasis, 1 had local recurrence, and 7 died. Kaplan-Meier survival analysis revealed that prognosis was significantly correlated with sex, tumour size and metastasis (P < 0.05). Multivariate Cox regression analysis revealed that sex and metastasis were independent prognostic risk factors for patients with ASPS (P < 0.05).

CONCLUSION

ASPS is a rare soft tissue sarcoma of unknown origin that occurs in young people, has a slow but metastatic course, and is associated with a poor 5-year survival rate among patients with metastasis. ASPS has character TFE3 protein and gene expression, and the diagnosis is relatively specific. The diagnosis requires comprehensive analysis of clinical history, histological morphology, and immunohistochemistry.

Primary Alveolar Soft-Part Sarcoma of the Liver: Anomalous Presentation of a Rare Disease

Alveolar soft-part sarcoma is a highly vascular soft-tissue tumor that is uniformly malignant. It comprises less than 1 per cent of all soft-tissue sarcomas. Patients with alveolar soft-part sarcoma most frequently are aged 15 to 35 years, and the soft tissues of the lower extremities typically are affected. In the pediatric population, it most frequently occurs in the head and neck and particularly affects the tongue and orbit. Alveolar soft-part sarcoma has been described as a primary lesion in the trunk, upper extremities, and retroperitoneum; more novel locations include the mediastinum, female genital tract, stomach, bone, and larynx. Numerous case reports describe alveolar soft-part sarcoma in diverse anatomic locations, but this report is, to our knowledge, the first documentation of primary alveolar soft-part sarcoma of the liver. We describe a 47-year-old woman with such a manifestation. Despite surgical resection and numerous chemotherapeutic regimens, this patient had widespread metastasis and died approximately 2 years after the diagnosis was established.

Resection of pancreatic and splenic metastases from alveolar soft part sarcoma: a case report

Background

We present a case of pancreatic and splenic metastases following alveolar soft part sarcoma (ASPS), which was successfully treated by surgery.

Case presentation

A 41-year-old male was referred to our hospital in 2012. Computed tomography (CT) showed the presence of a pancreatic tumor. In 2002, the patient had undergone surgical resection of an ASPS of the anal region. In 2009, during follow-up, CT revealed lung metastases, which prompted surgical resection of the lung, followed by resection of the head skin in 2011. Abdominal ultrasonography (US) revealed the presence of isodense masses sized 34 mm in the pancreatic head and 60 mm within the spleen. The contrast-enhanced US revealed a solitary lesion with enhancement. Contrast-enhanced CT revealed solitary lesions with enhancement within the pancreatic head, spleen, and liver. The patient underwent metastasectomies from the pancreas, spleen, and liver. The patient was discharged on postoperative day 22 without recurrence for 18 months after metastasectomy. Twelve years after primary resection and 2 years after metastasectomy, the patient died as a consequence of multiple metastases.

Conclusions

We have presented a rare case of pancreatic and spleen metastases from ASPS. Resection by radical metastasectomy was successful without morbidity. Thus, for improved survival of patients with multiple metastases from ASPS, metastasectomy may be indicated. If multiple metastases are resectable, surgical approaches may be the preferred treatment.

A Phase II Trial of Pazopanib in Patients with Metastatic Alveolar Soft Part Sarcoma

Lessons Learned.

Pazopanib shows a modest efficacy in metastatic alveolar soft part sarcoma.

Clinical outcomes were comparable to those in previous studies using antiangiogenic drugs.

Further prospective studies evaluating the benefit of pazopanib in alveolar soft part sarcoma with a larger sample are warranted to validate results.

Background.

Alveolar soft part sarcoma (ASPS) is a rare mesenchymal malignant tumor characterized by an unbalanced translocation, t(X;17)(p11.2;q25), which leads to the fusion of ASPSCR1 to the TFE3 transcription factor. Because this results in the upregulation of angiogenesis‐related transcripts, antiangiogenic drugs have been used in ASPS patients.

Methods.

This open‐label, single‐arm, multicenter, investigator‐initiated phase II trial was designed to evaluate efficacy and safety of pazopanib 800 mg once daily in patients with metastatic ASPS. The primary endpoint was investigator‐assessed overall response rate (ORR), and secondary endpoints were toxicity, progression‐free survival (PFS), and overall survival (OS). ⁶⁸Ga‐RGD (Arg‐Gly‐Asp) positron emission tomography (PET) scan and gene expression profiling using NanoString platform were performed for biomarker analysis.

Results.

Six patients with histologically confirmed metastatic ASPS were enrolled between December 2013 and November 2014. Among six patients, one achieved a partial response (PR) (ORR 16.7%) and five patients showed stable disease (SD). With a median follow‐up of 33 months (range 18.7–39.3 months), median PFS was 5.5 months (95% confidence interval [CI] 3.4–7.6 months), and median OS was not reached. There were no severe toxicities except one patient with grade 3 diarrhea.

Conclusion.

Pazopanib showed modest antitumor activity with manageable toxicities for patients with metastatic ASPS.

Diagnosis, Classification, and Management of Soft Tissue Sarcomas

BACKGROUND

Soft tissue sarcomas are challenging to oncologists due to their unique character, the infrequency of their occurrence, and the difficulties in predicting outcomes. Advances in imaging, as well as improvements in surgical techniques and adjunctive treatment methods, have improved care for patients with these unusual disorders.

METHODS

The various types of soft tissue tumors are defined, and the statistics for the Orthopaedic Oncology Group in relation to them are reviewed and compared with literature references.

RESULTS

The overall survival rate for 1,220 tumors treated at our institute from June 1972 to June of 2001 was 72%, with a wide range. Patients with leiomyosarcomas, clear cell sarcomas, and malignant fibrous histiocytomas had a poorer survival rate, while those with fibrosarcomas, liposarcomas, and neurofibrosarcomas fared better. Outcome was affected by patient age, tumor anatomic site, tumor stage, and a history of recurrence.

CONCLUSIONS

Competent imaging, predictive immunological and genetic studies, improved surgery, and newer methods of adjunctive and neoadjunctive treatment should result in improvements in outcomes for patients with these tumors.

Long-term Results of Therapy with Sunitinib in Metastatic Alveolar Soft Part Sarcoma

Background

Alveolar soft part sarcoma (ASPS) is a rare, highly vascularized soft tissue sarcoma characterized by a high frequency of metastatic disease and resistance to classical chemotherapy. The purpose of our analysis was to assess long-term sunitinib activity in the treatment of metastatic ASPS.

Patients and Methods

Between 2009 and 2015, 15 patients were diagnosed with metastatic ASPS and received therapy with sunitinib at initial continuous daily dosing of 37.5 mg. Median age was 32 years. The primary tumor sites were lower extremities ( 8 ), trunk-retroperitoneum/pelvis ( 2 ), upper extremity ( 3 ) and other ( 2 ). All patients had unresectable disease (primary or relapse in the form of metastases to the lungs ± bones). Five patients received systemic therapy before initiating sunitinib. Median follow-up from start of sunitinib was 38 months (range 5-69 months).

Results

At the time of analysis 4 patients continue therapy and 9 are still alive. Six patients had RECIST partial remission as best response, 8 had stable disease, and 1 had disease progression. The median progression-free survival was 19 months, with 86% of patients being free of progression at 6 months. Median overall survival was 56 months; the 5-year overall survival rate was 49%. Five patients were treated with sunitinib longer than 2 years. All patients experienced some side effects: 8 patients (53%) had CTCAE grade 3/4 toxicity, 7 patients required dose reduction. The most common toxicities were neutropenia, thrombocytopenia, hypothyroidism, arterial hypertension, and hand-foot syndrome.

Conclusions

Our analysis confirms the long-term efficacy of sunitinib in patients with advanced ASPS.

Primary alveolar soft part sarcoma of the right femur and primary lymphoma of the left femur: A case report and literature review

Alveolar soft part sarcoma (ASPS) is a rare soft tissue tumor, particularly in bone, which usually affects young patients. Primary lymphoma of bone (PLB) is a rare form of non-Hodgkins lymphoma that occurs primarily in bone. In the present report, the case of a 42-year-old woman affected by ASPS and PLB in the left and right femur, respectively, is presented. The radiological features of digital radiography, computed tomography and magnetic resonance imaging examination are discussed, and compared with previous findings reported in the literature. To the best of our knowledge, the present study is the first case of ASPS and PLB occurring concomitantly in a patient.

Adult alveolar soft part sarcoma of the head and neck: a report of two cases and literature review

Background. Alveolar soft part sarcomas (ASPS) of the head and neck are rare, aggressive soft-tissue malignancies. This study describes the clinical course and management of two patients presenting with ASPS in very rare head and neck locations, the larynx and parotid gland. Methods. We identified two patients presenting with ASPS of the head and neck and treated at the University of North Carolina. We compared our results to the literature from 1987 to 2013. Results. Patient ages at diagnosis were 27 and 39 with presenting symptoms of hoarseness and parotid swelling, respectively. Mean follow-up was 87 months. All patients received surgical resection and adjuvant radiotherapy. There were no recurrences or evidence of distant metastatic spread during the series. Disease-free survival time for the patients was 4 months and 168 months, respectively. Conclusions. Our study suggests that a combined-modality approach is important in the treatment of ASPS of the head and neck even in these rare locations. Continued research into new therapies is necessary to improve historically poor outcomes.

Primary Intracerebral Alveolar Soft Part Sarcoma in an 11-Year-Old Girl: Case Report and Review of the Literature

Alveolar soft part sarcoma (ASPS), a rarely observed tumor, is a soft tissue sarcoma with an unidentified cell origin. It constitutes 0.5–1.0% of all soft tissue sarcomas. It may appear in various parts of the body, but mostly observed in the trunk and the extremities. It has a high metastasis potential. To the best of our knowledge, only three cases of primary intracranial ASPS without a demonstrable lesion elsewhere is encountered. An 11-year-old girl was operated because of fronto-parietal mass lesion by craniotomy. Pathological examination revealed ASPS and no primary focus was detected. In spite of radiotherapy and chemotherapy as an adjuvant therapy, after 45 months she had a second operation for recurrence of the tumor. Since it is possible to observe metastases in late phases, up to 30 years, the patients must be followed up for a long period. Although radiotherapy and chemotherapy followed by surgery is the most accepted treatment strategy, the prognosis is still poor.

Magnetic resonance imaging features of alveolar soft part sarcoma: report of 14 cases

Background

The purpose of this study was to assess the magnetic resonance imaging findings of alveolar soft part sarcoma.

Methods

Magnetic resonance images of pathologically proven alveolar soft part sarcoma in 14 patients were retrospectively reviewed, including lesion location, size and shape, border definition, signals on T1-weighted and T2-weighted images, presence or absence of peritumoral and intratumoral flow voids, and enhancement pattern.

Results

Patients included five women and nine men, ranging in age from 27 to 54 years, with a mean age of 36 years. A slow-growing mass without pain was the chief complaint. Eight patients had pulmonary metastases at presentation. Ten lesions arose from the extremities, two were located in the gluteal regions, one affected the presacral space and one occurred in the back. The mean maximal size of the lesions was 9.8 cm, ranging from 6.2 to 16 cm. All lesions appeared as a round (n = 2), ovoid (n = 8) or irregular (n = 4) shape with ill-defined margins. The lesions mainly demonstrated isointense or mildly hyperintense compared to muscle on T1-weighted images, and heterogeneous high signal intensity on T2-weighted images. Peritumoral edemas were observed in six patients. Ten lesions showed intense inhomogeneous enhancement after contrast. Intra- and peritumoral tubular flow voids representing tortuous dilated vessels with rapid blood flow were present in all cases.

Conclusions

Alveolar soft part sarcoma has some distinctive magnetic resonance imaging features including a slow-growing, large mass in the soft tissue of the extremities in young adults, with numerous signal voids on T1-weighted and T2-weighted images, and strong enhancement after contrast.

Paediatric and adolescent alveolar soft part sarcoma: A joint series from European cooperative groups

BACKGROUND

Alveolar soft part sarcomas (ASPS) are generally chemo- and radio-resistant mesenchymal tumours, with no standardized treatment guidelines. We describe the clinical behaviour of paediatric ASPS and compare these features to previously reported adult series.

PATIENTS AND METHODS

The clinical data of 51 children and adolescents with ASPS, prospectively enrolled in or treated according to seven European Paediatric trials were analysed.

RESULTS

Median age was 13 years [range: 2-21]. Primary sites included mostly limbs (63%). IRS post-surgical staging was: IRS-I (complete resection) 35%, II (microscopic residual disease) 20%, III (gross residual disease) 18% and IV (metastases) 27%. Only 3 of the 18 evaluable patients (17%) obtained a response to conventional chemotherapy. After a median follow-up of 126 months (range: 9-240), 14/18 patients with IRS-I tumour, 10/10 IRS-II, 7/9 IRS-III and 2/14 IRS-IV were alive in remission. Sunitinib treatment achieved two very good partial responses in four patients. Ten-year overall survival (OS) and event free survival (EFS) was 78.0 ± 7% and 62.8 ± 7% respectively. Stage IV, size >5 cm and T2 tumours had a poorer outcome, but only IRS staging was an independent prognostic factor.

CONCLUSIONS

ASPS is a very rare tumour frequently arising in adolescents and in the extremities, and chemo resistant. Local surgical control is critical. ASPS is a poorly chemo sensitive tumour. For IRS-III/IV tumours, delayed radical local therapies including surgery are essential. Metastatic patients had a poor prognosis but targeted therapies showed promising results.

Alveolar soft part sarcoma: a single-center 26-patient case series and review of the literature

Background. Alveolar soft part sarcoma (ASPS) is a rare tumor, and little information is available regarding its clinical features and appropriate treatments. Methods. A retrospective review of 26 consecutive ASPS patients (12 male, 14 female; mean age of 27 years) treated at our institution over 30 years (mean followup; 71 months) was performed. Results. The primary tumor developed in the lower extremity (12), trunk (8), and upper extremity (6), with an average size of 7.2 cm (range, 2–14 cm). The AJCC stage at presentation was IIA (7), III (3), and IV (16). Surgical excision was performed in 20 patients (R0 18, R1 plus radiotherapy 2) without local recurrence. Six patients (stage IIA 3/7, stage III 3/3) later developed metastases after an average period of 28.7 months. The median survival of the 26 patients was 90 months, with overall 5/10-year survival rates of 64%/48%. AJCC stage and tumor size were significant prognostic factors. Significant palliation and slowing of metastasis progression were achieved with gamma knife radiotherapy. Nine patients receiving chemotherapy showed no objective response. Conclusions. ASPS is indolent but has a high propensity for metastasis. Early diagnosis and complete excision of the small primary tumor are essential in the treatment of ASPS.

Classification and pathology

Soft tissue tumors are a heterogeneous group of benign and malignant processes. Some are assumed to be reactive; others are clearly neoplastic. Because of their rarity, they frequently pose diagnostic problems for surgical pathologists. Accurate diagnosis of these tumors is enhanced by knowledge of the clinical features of the given lesions and, at times, by application of immunohistochemical and molecular techniques. In this article the lesions are described essentially in accordance with the World Health Organization classification.

Alveolar soft part sarcoma

This article provides an overview of the pathology of alveolar soft part sarcoma, focused on its morphology, special stains useful in diagnosis, and the clinical and radiographic features of the disease. Alveolar soft part sarcoma is a rare neoplasm of unknown histogenesis with poor prognosis. Although there are several immunohistochemical stains available to help reach the diagnosis, the morphology of the tumor should be considered the main diagnostic feature. The periodic acid-Schiff stain is the best single stain that supports the diagnosis.

Alveolar soft part sarcoma of the larynx

Alveolar soft part sarcoma (ASPS) is a rare malignancy. It has generally a poor prognosis. Survival depends on the presence of metastases. Approximately, one-fourth of the cases are encountered in the head and neck region, mostly in the orbits and tongue. Surgery is accepted as the most effective treatment, radiotherapy and chemotherapy may be used as adjuvant treatments. Since it is a highly vascular tumor, profuse bleeding may occur during surgery. In this article, we report a case of ASPS occurring in the larynx, an extremely rare location for this rather unusual tumor. To our knowledge, only three cases of laryngeal ASPS have been previously reported in the English literature.

Alveolar soft-part sarcoma of the retroperitoneum

A 33-year-old woman was referred to Iida Municipal Hospital because of left back pain. Computed tomography showed a tumor (17 x 11 x 10 cm) in the left retroperitoneal space. T1- and T2-weighted magnetic resonance imaging showed an inhomogeneous mass with marginal blood vessels. The tumor was resected via lumbar oblique incision with the thoraco-abdominal approach. The tumor weighed 1800 g and consisted of nests of 5-100 large, loosely arranged, polygonal cells, surrounded by capillaries, resembling alveoli. The tumor cells were rich in cytoplasm, containing periodic acid-Schiff- and diastase-positive granules and typical crystals. The pathological diagnosis was alveolar soft-part sarcoma (ASPS). Alveolar soft-part sarcoma is a rare soft-tissue tumor that accounts for approximately 0.5-1% of soft-tissue sarcomas. Such tumors originating in the retroperitoneal space are extremely rare. Herein is reported a case of ASPS of the retroperitoneum with radiological and pathological findings.

Alveolar soft part sarcoma: a rare and enigmatic entity

Alveolar soft part sarcoma is a rare malignant tumor with unusual clinical behavior. Treatment of alveolar soft part sarcoma has been difficult to evaluate because of the small numbers of cases seen, but it seemed that although treatment of the primary tumor in alveolar soft part sarcoma often is successful, treatment of metastatic tumors is unsuccessful. A review of outcome after treatment of primary and metastatic disease in the 15 patients in our database with alveolar soft part sarcoma was done in order to evaluate this issue. Nine of 15 patients presented with metastatic disease and one further patient developed metastases. Treatment of primary tumors involved surgical excision in all but one patient and radiation in all patients. Adjuvant chemotherapy was administered to one patient with localized disease and to six patients with metastatic disease. There were no local recurrences. Treatment of metastatic tumors involved chemotherapy in seven patients, metastectomy in three patients, and radiation in two patients. All instances of the metastatic disease either recurred or progressed. Overall survival was 75% at 5 years and 40% at 10 years with a mean survival of 6.5 years, despite the high number of patients with metastatic disease. Current treatment results in good local control of primary tumors, but poor control of metastatic tumors. New approaches to treatment of metastatic alveolar soft part sarcoma must be investigated and applied.

LEVEL OF EVIDENCE

Therapeutic study, Level IV-1 (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Lingual alveolar soft part sarcoma; 14 cases: novel clinical and morphological observations

AIMS

Alveolar soft part sarcoma (ASPS) is a rare sarcoma in the buttocks or thigh of young adults, often with metastases to lung, brain, or bone. This study examines the morphological and clinical features of lingual ASPS.

METHODS AND RESULTS

Fourteen cases, in eight males and six females (ages 3-21 years, median 5 years), ranged from 8 to 50 mm, median 25 mm. All tumours were intramuscular, circumscribed and multinodular. Tumours from all but the oldest patient exhibited a predominantly solid (non-alveolar) growth pattern. Vascular invasion was common. Crystals varied in number from none or extremely rare to nearly 100% of tumour cells. Immunohistochemical results: Fifty percent desmin positive, all focally smooth muscle antigen (SMA) positive; negative for vimentin, neural/melanocytic, myoid, histiocytic, and epithelial markers. All tumours were surgically excised; only two patients received chemotherapy. Follow-up on 10 patients showed that all patients were alive without disease (4-32, median 22 years). Only one patient had a microscopic metastasis to lung (3 years) but was without disease at 11 years.

CONCLUSIONS

Lingual ASPS is a tumour of childhood with a distinctive, predominantly solid growth pattern. Despite typical vascular invasion, the early diagnosis and small tumour size may explain its relatively good outcome.

Alveolar soft-part sarcoma of the orbit

A 10-year-old girl with gradual-onset proptosis in her left eye was diagnosed with orbital alveolar soft-part sarcoma. The tumor and the contiguous medial rectus muscle in the left eye were excised and compensatory strabismus procedures were performed. Five years postoperatively, she has central binocular vision with no evidence of tumor recurrence.

Alveolar soft-part sarcoma responding to interferon alpha-2b

A 23-year-old woman with an alveolar soft-part sarcoma of her calf with pulmonary metastases unresponsive to chemotherapy is described. Interferon (IFN) alpha-2b induced an impressive tumour response still ongoing after IFN treatment had to be stopped because of a psychosis. An explanation of this effect is still speculative.

Chemotherapy in alveolar soft part sarcomas. What do we know?

Alveolar soft part sarcoma (ASPS) is a rare tumour. Published series about treatment and outcome are scarce. Conclusive data about the response to chemotherapy are not available. The aim of this study was to analyse the efficacy of palliative chemotherapeutic treatment options and the incidence and mode of presentation of brain metastases. We retrospectively analysed our own sarcoma data-base and reviewed the literature. From our registry containing 757 patients, we identified 8 patients with ASPS. From the literature, 47 cases of adult patients and 13 children with sufficient data about chemotherapy were identified. Response to first-line chemotherapy in 68 patients was: complete remission (CR) 4%, partial remission (PR) 3%, stable disease (SD) 41%, progressive disease (PD) 51%. 285 patients with stage IV disease were evaluable for the analysis of metastatic sites. The incidence of brain metastases was 30.5% (87/285). Brain metastases were detected at a median interval of 48 months (range 0-396 months) after the primary diagnosis. Median survival after the diagnosis of brain metastases was 12 months. The median survival for patients with stage IV disease treated by chemotherapy was 36+ months (range 10-132 months) (31 patients evaluable) with a median follow-up of 46 months (range 10-135 months). ASPS shows a high incidence of brain metastases, at least 3 times higher than that of other soft tissue sarcomas. Chemotherapeutic regimens used for the treatment of other soft tissue sarcomas lack efficacy in ASPS. Staging investigations for ASPS should routinely include imaging of the brain. ASPS patients should not be treated with chemotherapy outside of controlled clinical trials. New targets for specific biologically-directed therapies need to be developed.