Soft tissue sarcoma of the hand

Analysis of foot-originating malignant bone tumors: Epidemiology, characteristics, and survival outcomes

BACKGROUND

The study examines the characteristics and outcomes of foot-originating malignant bone tumors via Surveillance Epidemiology and End Results (SEER) database analysis.

METHODS

A retrospective review of 14,695 malignant bone tumor cases from 2000 to 2019 was conducted.

RESULTS

Of the eligible cases, 147 (2.3 %) were foot-origin tumors, typically smaller and more commonly treated with surgery than those in other locations. These tumors were more frequently treated with surgical resection, with a higher proportion undergoing amputation. In contrast, foot-origin tumors were less often managed with chemotherapy and radiation. Foot-origin tumors exhibited higher survival rates compared to non-foot-origin tumors as shown in univariate analysis, although multivariate analysis did not reflect significant differences.

CONCLUSION

Foot-originating malignant bone tumors tend to be smaller and are frequently surgically treated, correlating with favorable survival outcomes. These findings point to early detection as a potential factor in the improved survival rates, not necessarily the tumor's origin.

Primary leiomyosarcoma of the small finger treated with ray amputation: A case report

INTRODUCTION

Malignant sarcomas of the upper extremity are rare tumors that can have an overwhelming impact on a patient's function, quality of life, and life expectancy. Rarer still is the malignant tumor of the hand or digits, which represent an incredibly small percentage of upper extremity tumors. This paucity of cases can lead to difficult decision making and treatment options that may not always have clearly established results and outcomes.

CASE

In this case, we present a young, otherwise healthy patient that was diagnosed with a primary leiomyosarcoma of the small finger. After her diagnosis, she underwent extensive oncologic workup, and subsequently underwent successful ray amputation with an excellent outcome. She remains disease free.

DISCUSSION

Leiomyosarcoma is a malignant cancer that can be troublesome to diagnose in the extremities, as it is usually found in the smooth muscle of organs and the pelvis. Local control of the tumor is critical to successful, disease free treatment. Good functional and clinical outcomes can be attained with ray amputation, as seen in this patient.

CONCLUSION

This case demonstrates a successful treatment approach to the patient with a primary malignant soft tissue sarcoma who was treated with a ray amputation. The clinician and surgeon must maintain a high index of suspicion of soft tissue malignancies, as a prompt diagnosis and treatment is critical to a good outcome and survival.

Hand Masses

Hand and wrist soft tissue masses may be classified as pseudotumors, benign neoplasms, or malignant neoplasms. The vast majority of hand lesions are benign. Consideration of the location of the lesion and its imaging characteristics often leads to a specific diagnosis. Pseudotumors discussed in this article are ganglion cysts, accessory muscles, and inflammatory lesions. True tumors are described according to their tissue type: nerve sheath tumors, adipocytic tumors, so-called fibrohistiocytic tumors, pericytic tumors, and vascular lesions. We also outline the imaging features of masses encountered in the hand and wrist.

Epithelioid Sarcoma of Upper Extremity: Diagnostic Dilemma With Therapeutic Challenges

Epithelioid sarcoma is a rare, slow-growing, malignant tumor with multivariate presentation and a high rate of recurrence following surgery. Diagnosis is often missed or delayed due to its infrequent nature and confusing clinical and pathological presentation. This is compounded by the fact that this tumor is aggressive with a propensity for metastases without being detected. The treatment of this deadly tumor is controversial with no clear-cut consensus. The author presents a case of epithelioid sarcoma in the finger of a young patient with subsequent recurrence after surgery and a review of current literature pertaining to this aggressive tumor. This report would like to stress the importance of a multimodal approach in combatting this tumor as prompt diagnosis and aggressive therapy can significantly reduce the poor outcomes associated with this disease.

Soft-tissue Sarcoma of the Hand: Patient Characteristics, Treatment, and Oncologic Outcomes

INTRODUCTION

The aim of this study was to describe patient characteristics, treatment, and oncologic outcomes of soft-tissue sarcomas (STSs) of the hand.

METHODS

Sixty-nine STSs of the hand in adult patients treated at a tertiary referral center were retrospectively included. We describe patient and tumor characteristics along with oncologic outcomes.

RESULTS

Epithelioid sarcoma (23%) was the most common histologic subtype, followed by synovial sarcoma (15%). Of all tumors, 17 (25%) were grade I, 22 (32%) were grade II, and 30 (44%) were grade III. The 5-year disease-free survival for epithelioid sarcomas was 75% with a disease survival of 100%, along with a metastatic rate of 15%. Of the patients with a synovial sarcoma, 40% developed metastases, and the 5-year disease-free survival was 68% and the 5-year disease survival was 73%.

CONCLUSION

Hand STSs are aggressive tumors with a high metastatic potential. Even with adequate oncologic treatment, long-term clinical follow-up (10 years) in these tumors is advised. The treating surgical oncologist should not be deceived by their smaller size.

Epithelioid sarcoma: A clinicopathological study of 12 head and neck cases

OBJECTIVES

To determine the clinicopathological features of epithelioid sarcoma presenting in head and neck region (HNES) and elucidate diagnostic key points and treatment options for HNES.

MATERIALS AND METHODS

A total of 12 HNES cases were collected in our department from 2010 to 2020. Their clinical information and pathological features were documented, and relevant follow-up was performed. Immunohistochemistry was carried to analyze the protein markers of HNES.

RESULTS

Of the 12 HNES cases, 10 were primary tumors and 2 were metastasized from foot and shoulder, respectively. The patients with primary tumors were significantly younger than those with metastasized ones (22.7 vs 41.5, p = .0157), and male patients outnumbered female patients (3:1). Of all HNES cases, 9 were classic subtype, and 3 were proximal subtype. HNES patients had a poor prognosis, with 5-year overall survival of 41.5% and 5-year relapse-free survival of 22.5%. A loss of INI1 was identified as the hallmark of HNES with 83.3% (10/12) of HNES cases presenting as EZH2 positive.

CONCLUSIONS

HNES is more prevalent at younger ages and in males, has a poor prognosis, and exhibits a greater proportion of classic subtype than proximal subtype. EZH2 inhibitor has therapeutic potential in HNES.

Synovial sarcoma of the hand-wrist: a case report and review of the literature

Background

Synovial sarcomas are infrequent malignant tumors occurring mostly in adolescents and young adults. The occurrence of synovial sarcoma in the hand-wrist area is rare (4 to 8.5% of all synovial sarcomas in different studies).

Case presentation

This report documents an uncommon case of synovial sarcoma occurring in the hand-wrist of a 69-year-old Caucasian woman. She was subsequently treated with surgical excision and radiotherapy without recurrence after follow up.

Conclusions

This paper aims to characterize the demographic, pathologic, and clinical features with a literature review. The present literature review confirms that hand-wrist synovial sarcomas are more frequent among males and subjects 10 to 40 years old. Most cases in this location are usually not larger than 5 cm in size. The five-year survival rate is higher than that reported in a previous review on hand synovial sarcomas, and this suggests an improved survival in recent decades.

Epithelioid sarcoma of the hand: a wolf in sheep's clothing

Epithelioid sarcoma (ES) of the hand is a rare, aggressive cutaneous malignancy with high rates of recurrence, metastases and mortality. With an incidence rate of 0.4 cases/y per one million population, which compromise for approximately 1-1.4% of all soft tissue sarcoma, ES accounts for 10% of soft tissues sarcomas of the hand and foot. Its aggressiveness and propensity to spread and metastases without being noticed, makes it unique and potentially lethal. Missed or delayed diagnosis are often encountered as this tumor can mimic variety of different entities and due to the infrequent nature of this lesion, treatment options are still controversial. The authors provide systemic review of the current literature on epidemiology, etiology, pathogenesis, management and outcomes of this disease as well as a case presentation and a proposed treatment algorithm. The choice of treatment option depends on disease characteristics, staging at presentation, regional lymph node involvement, comorbidities and performance status of the patient. Emphasis on a multidisciplinary coordinated care is crucial as early diagnosis and treatment can decrease morbidity and mortality rates.

Epithelioid Sarcoma-From Genetics to Clinical Practice

Epithelioid sarcoma is a mesenchymal soft tissue sarcoma often arising in the extremities, usually in young adults with a pick of incidence at 35 years of age. Epithelioid sarcoma (ES) is characterized by the loss of SMARCB1/INI1 (integrase interactor 1) or other proteins of the SWI/SNF complex. Two distinct types, proximal and distal, with varying biology and treatment outcomes, are distinguished. ES is known for aggressive behavior, including a high recurrence rate and regional lymph node metastases. An optimal long-term management strategy is still to be defined. The best treatment of localized ES is wide surgical resection. Neo-adjuvant or adjuvant radiotherapy may be recommended, as it reduces the local recurrence rate. Sentinel lymph node biopsy should be considered in ES patients. Patients with metastatic ES have a poor prognosis with an expected median overall survival of about a year. Doxorubicin-based regimens are recommended for advanced ES. Tazemetostat, an EZH2 methyltransferase, has shown promising results in ES patients. Novel therapies, including immunotherapy, are still needed.

Primary appendicular soft-tissue sarcoma resection: What tumour parameters affect wound closure planning?

Wound closure after wide, local excision of an appendicular soft-tissue sarcoma (STS) can be challenging. This study evaluates the value of magnetic resonance imaging (MRI)-based tumour parameters in planning wound closure. A total of 71 patients with a primary limb-based STS, excluding vascular or osseous involvement, excluding the shoulder or hand and hip or foot were included. Axial MRI images were used to measure the circumferences and cross-sectional areas of the limb, bone, and tumour. The tumour diameter, length, and depth at the level of maximal tumour dimension were measured to identify the tumour's relative contribution to the planning of optimal wound closure management through primary closure (PC) or reconstructive surgery (RS). Eighteen patients required planned wound RS. Wound complications occurred in 14% overall. Tumours, which were closed by PC, were of significantly greater depth, shorter radial diameter, and shorter tumour circumference relative to those closed by RS. On multivariate analysis, tumour depth was the greatest contributory factor in predicting type of wound closure. A quantitative analysis of MRI-based tumour parameters demonstrates tumour depth as the most predictive factor in planning for the type of wound closure and may prove beneficial in providing greater insight into planned wound management of sarcoma resection.

Management and outcome of acral soft-tissue sarcomas

Aims

The aim of this study was to evaluate the surgical management and outcome of patients with an acral soft-tissue sarcoma of the hand or foot.

Patients and Methods

We identified 63 patients with an acral soft-tissue sarcoma who presented to our tertiary referral sarcoma service between 2000 and 2016. There were 35 men and 28 women with a mean age of 49 years (sd 21). Of the 63 sarcomas, 27 were in the hands and 36 in the feet. The commonest subtypes were epithelioid sarcoma in the hand (n = 8) and synovial sarcoma in the foot (n = 11).

Results

In 41 patients (65%), the tumour measured less than 5 cm in its largest dimension (median size 3 cm (2 to 6)); 27 patients (43%) were diagnosed after inadvertent excision prior to their referral to the specialist sarcoma unit. After biopsy and staging, primary surgical intervention at the sarcoma unit was excision and limb salvage in 43 (68%), partial (digit or ray) amputation in 14 (22%), and more proximal amputation in six (10%). At final follow up, local recurrence had been treated by one partial amputation and six amputations, resulting in a partial amputation rate of 24% and a proximal amputation rate of 19%. The five-year survival rate was 82%. Patients who underwent inadvertent excision showed no statistically significant difference in survival or local recurrence, but were more likely to undergo amputation (p = 0.008). Large tumour size (> 5 cm) was associated with lower survival (p = 0.04) and a higher risk of local recurrence (p = 0.009;).

Conclusion

Most acral soft-tissue sarcomas measure less than 5 cm at presentation, indicating that while size can be a useful prognostic factor, it should not be used as a diagnostic threshold for referral. Increased tumour size is associated with a higher rate of local recurrence and reduced survival. Sarcoma excision with limb preservation does not result in an increased risk of local recurrence. Cite this article: Bone Joint J 2018;100-B:1518–23.

A Well-Differentiated Liposarcoma in the Digit: A Case Report of the 5-Year Post-Surgical Follow-Up

A liposarcoma is extremely rare in the digits. A 73-year-old woman was diagnosed with a lipoma in her middle finger 10 years ago. As this tumor increased in size and presented with imaging findings that were atypical of lipomas, careful marginal resection biopsy outside the pseudo-capsule was performed, and the tumor was diagnosed as a well-differentiated liposarcoma. At the 5-year follow-up, the patient showed no evidence of local recurrence or metastasis, with no loss of hand function. The findings from this case suggest that even for a lipomatous tumor in the digits, further imaging examination and resection biopsy should be considered if the tumor presents with features that are atypical of lipomas.

Intramuscular Epithelioid Sarcoma Presenting as Extrinsic Flexor Tightness in the Forearm

Epithelioid sarcoma is an uncommon soft tissue sarcoma involving predominantly the distal extremities of adolescents and young adults. Its rarity makes it difficult to diagnose accurately and treat properly in the early stages. We discuss the delayed diagnosis of a 37-year-old man who presented with extrinsic flexor tightness of the wrist and fingers. We initially thought that the lesion resulted from inflamed soft tissue of the flexor muscles causing contracture. However, histological examination of a biopsy specimen revealed nodular proliferation of epithelioid and spindle cells, which were immunoreactive to epithelial and nonepithelial markers, respectively, leading to the final diagnosis of epithelioid sarcoma.

Soft Tissue Sarcoma of the Hand and Wrist: Epidemiology and Management Challenges

Soft tissue sarcomas (STSs) of the hand and wrist are rare and confer a unique set of management challenges. We present a 15-year review and discussion of the epidemiology, tumor characteristics, treatment, and reconstructive strategies for such cases presenting to our regional sarcoma service. Three case examples are described. Of 218 STSs of the upper limb, 17 involved the hand or wrist. Alveolar rhabdomyosarcoma, synovial, and myxofibrosarcoma were the most common ones. Two patients required amputation for recurrence. Eight patients required flap reconstruction, of which five were free flaps with no failures or wound healing complications. Two-year overall survival rate was 92%. Local recurrence occurred in 12%. Limb-sparing surgery is possible in most patients, although there is often a degree of functional loss due to the surgical resection, and complex multistage reconstruction may be required. These lesions are still often incidental or unexpected findings when patients are treated for a presumed benign swelling. Clinicians treating localized swellings of the hand and wrist should maintain vigilance toward the possibility of a sarcoma diagnosis, to avoid delays in definitive treatment.

What Factors Influence the Outcome of Surgically Treated Soft Tissue Sarcomas of the Hand and Wrist?

BACKGROUND

Soft tissue sarcomas (STS) of the hand are exceedingly rare. The aim of this study was to review our institution's experience with STS of the hand to identify factors affecting outcomes and survivorship.

METHODS

We retrospectively reviewed the records of 46 hand STS treated with definitive surgery at our institution between 1992 and 2013. Pertinent demographics as well as information regarding the surgical procedure, and disease status at latest follow-up were reviewed. Mean age at diagnosis was 38 years with a mean follow-up of 5 years.

RESULTS

The most common tumor subtypes were epithelioid (n = 10) and synovial sarcoma (n = 8). Sixty-one percent were superficial in location. Thirty-three patients had had a nononcologic resection prior to definitive surgical treatment at our institution. Ultimately, negative margins were obtained in all cases. Local recurrence was observed in 5 patients and distant metastases in 14 patients. Tumor sizes ≥2 cm, American Joint Committee on Cancer (AJCC) grade, and depth of the tumor were found to adversely affect the outcome in terms of disease-free and overall survival. Reexcision of an inadvertently excised tumor at an outside institution did not adversely affect the outcome. The 10-year overall and disease-free survival was 72% and 63%.

CONCLUSIONS

Local recurrence after a wide excision was observed infrequently; however, distant disease was relatively common. Tumors with a size ≥2 cm were associated with a worse disease-free and overall survival, highlighting the aggressive nature of these tumors.

Improvement in Overall Survival from Extremity Soft Tissue Sarcoma over Twenty Years

Several patient demographic factors, including marital status, have been demonstrated to have prognostic significance for survival in extremity soft tissue sarcoma (ESTS). A study population of 12,546 adult patients diagnosed with ESTS from 1991 to 2010 was identified from the SEER database, a large population-based registry, in order to determine whether overall survival had changed over this recent 20-year period. The study population was divided into three groups by year of diagnosis: 1991–1996, 1997–2003, and 2004–2010. We used the Kaplan-Meier method and Cox proportional hazards regression to assess survival differences between different demographic groups and prognostic clinical characteristics. Over the course of time, the 5-year overall survival rates have increased from 28% in the earliest time period to 62% in the latest (P < 0.0001). On multivariate analysis, the mortality rate progressively declined from the 1991–1996 group (HR: 3.02, CI: 2.78–3.29) to the 1997–2003 group (HR: 2.21, CI: 2.06–2.37), with the 2004–2010 group having the best overall survival, despite increases in the proportion of patients with tumors greater than 5 cm in size (P < 0.0001), and those presenting with metastasis (P < 0.0001).

Clinical outcomes for patients with synovial sarcoma of the hand

Purpose

Soft tissue sarcoma of the hand is rare, and one of the most common histological diagnosis is synovial sarcoma. We report the clinical outcomes of patients with synovial sarcoma of the hand and discuss treatment strategies.

Methods

We reviewed five patients with synovial sarcoma of the hand treated at our institutions from 1983 to 2013. The mean patient age at the time of diagnosis was 36.6 years (range, 20–62 years). Two patients underwent marginal excision after neoadjuvant chemotherapy, followed by radiation therapy, one underwent wide local excision and two received chemotherapy and radiation therapy.

Results

The average duration of follow-up for all patients was 88.2 months (range, 14–218 months). Two patients continuously remained disease free, two experienced local recurrence requiring additional surgery and then showed no evidence of disease, and one who had distant metastasis at diagnosis died of the disease. No patients developed lymph node metastasis. The estimated 5-year overall survival was 80%.

Conclusions

Our case series suggests that patients with localised synovial sarcoma of the hand may have favourable outcomes. Wide excision or marginal excision, followed by radiation therapy combined with chemotherapy, represent acceptable treatment strategies for synovial sarcoma of the hand. Regional lymph node dissection does not seem to be essential for synovial sarcoma of the hand.

Limb salvage in malignant tumors

Limb-sparing resection and reconstruction has become the treatment of choice in extremity malignancies, as amputation does not provide better long-term survival rates or functional advantages. R0 resection, the removal of the tumor in sano, remains the prerequisite and most important oncologic parameter to avoid local recurrence. Successful treatment requires the combination of surgical eradication and the patient's specific functional and aesthetic rehabilitation. Our clinical rationale resulting from more than 2000 cases will be demonstrated. The problematic aspects of different tumor entities and the locoregional clearance of lymphatic pathways will be discussed. Differential diagnosis and multimodality treatment in high-volume tumor centers is likely to achieve superior oncologic statistics. Long-term survivors after microsurgical reconstructions and possible secondary malignancies will be addressed.

Soft-tissue coverage of the hand following sarcoma resection

BACKGROUND

Hand-sparing surgery is now the most common option for sarcomas of the hand. The importance of obtaining widely negative margins has increased the complexity of operations and the importance of soft-tissue and bony reconstruction. The authors review the experience at a single institution of hand reconstruction following sarcoma resection based on prospectively collected data.

METHODS

Data were collected for all patients undergoing sarcoma resection by a single surgeon. Variables evaluated included patient demographics, tumor pathologic findings, location, size, depth, grade, stage, method of resection and reconstruction, adjuvant therapies, complications, and patient outcomes.

RESULTS

Fifty-five patients (30 male and 25 female) fulfilled eligibility criteria. The median age was 36 years (range, 1 to 80 years). The most common abnormalities were epithelioid sarcoma (n = 9), soft-tissue malignant fibrous histiocytoma (n = 8), synovial sarcoma (n = 6), and fibrosarcoma (n = 4). Flap reconstructions were required in 27 patients. The most common reconstruction method was a finger fillet flap in eight patients, followed by the radial forearm flap in five patients and the gracilis flap and skin grafting in three patients each. A suboptimal biopsy before presentation was strongly predictive of the need for flap reconstruction (p < 0.001). Nine patients had complications (delayed healing or skin necrosis, fracture, nonunion, epidermolysis, and tendon adhesion). No microvascular complications occurred.

CONCLUSIONS

The choice of hand reconstruction method following sarcoma resection depends on a complete knowledge of options, risks, and benefits. Extensive use of a limited number of techniques by the authors' institution appears to contribute to excellent success and complication rates, with safe, reliable, and effective soft-tissue coverage.

Soft-tissue sarcomas of the hand

We have investigated the oncological outcome of 63 patients with soft-tissue sarcomas of the hand managed at three major centres in the United Kingdom. There were 44 males and 19 females with a mean age of 45 years (11 to 92). The three most common diagnoses were synovial sarcoma, clear cell sarcoma and epithelioid sarcoma. Local excision was carried out in 45 patients (71%) and amputation in 18 (29%). All those treated by amputation had a wide margin of excision but this was only achieved in 58% of those treated by local excision. The risk of local recurrence was 6% in those treated by amputation compared with 42% for those who underwent attempted limb salvage. An inadequate margin of excision resulted in a 12 times greater risk of local recurrence when compared with those in whom a wide margin of excision had been achieved. We were unable to demonstrate any role for radiotherapy in decreasing the risk of local recurrence when there was an inadequate margin of excision. Patients with an inadequate margin of excision had a much higher risk of both local recurrence and metastasis than those with wide margins. The overall survival rate at five years was 87% and was related to the grade and size of the tumour and to the surgical margin.

We have shown that a clear margin of excision is essential to achieve local control of a soft-tissue sarcoma in the hand and that failure to achieve this results in a high risk of both local recurrence and metastastic disease.

Soft Tissue Tumors of the Hand. 2. Malignant

Soft tissue tumors of the hand arise from skin, subcutaneous tissue, tendons, nerve, and blood vessels. Many of these lesions occur on other parts of the body; however, the hand remains a unique site because these tumors have symptoms, appearances, treatments, and prognoses that may be quite different than when on other parts of the body. Their characteristics and the severity of symptoms vary markedly depending on the exact location, size, and type of tumor-and many of these tumors can have multiple forms of presentation. Two articles are intended to provide an overview of benign (previous article) and malignant tumors (this article) of the hand. The rarer and more deleterious tumors are discussed in detail while the common tumors and epidermal lesions with which practitioners are familiar are briefly overviewed. At the completion of these review articles, participants should be able to identify and diagnose various benign and malignant hand tumors as well as understand the accepted current treatment of these growths.

Reconstruction of the hand and upper extremity after tumor resection

This article reviews the surgical options available for reconstruction of the upper extremity following tumor resection. In order to achieve maximum function and limb salvage a multidisciplinary approach to patient care is emphasized. With proper preoperative planning, salvage of limb form and function can be accomplished in over 95% of cases. Successful reconstruction is measured by preservation of patient health, limb function, limb sensation and cosmesis and stable wound coverage. Important adjuncts to reconstruction include adequate postoperative splinting and aggressive rehabilitation to maximize long-term upper extremity function.

Uncommon hand tumours

This paper presented clinical examples of some rare or uncommon presentations of tumours of the hand, including glomus tumour, intraosseous dermoid, fibrolipoma of the radial nerve, blastomycotic cyst and synovial sarcoma. Each lesion is illustrated by review of case histories, radiological and pathological features.