Malignant smooth-muscle tumors (leiomyosarcomas) of soft-tissue origin

Cutaneous leiomyosarcoma: dermal and subcutaneous

BACKGROUND AND OBJECTIVES

Leiomyosarcoma of skin (LMS) can be sub-classified on pathology appearances as Dermal or Subcutaneous. The aim of this study was to provide treatment recommendations for these uncommon tumours.

METHODS

A retrospective review of all patients with dermal and subcutaneous leiomyosarcoma managed at the Peter MacCallum Cancer Centre, Australia from January 2003 to December 2018 was performed. Eighty-three patients were identified (64 dermal leiomyosarcoma, 19 subcutaneous leiomyosarcoma).

RESULTS

Subcutaneous leiomyosarcoma were larger (median size 14 mm dermal, 49 mm subcutaneous, P = 0.01). No patient with a dermal leiomyosarcoma developed metastatic disease compared to 4 of the 19 subcutaneous leiomyosarcoma (5-year overall survivals, 98% and 88%, respectively, P = 0.03). The most common site of metastasis was to the lung. No difference in risk of local recurrence was apparent (5-year recurrence-free survivals were 85% and 78%, respectively, P = 0.17). Adjuvant radiotherapy was used in 16 (25%) dermal leiomyosarcoma patients and 13 (68%) subcutaneous leiomyosarcoma patients (P < 0.001). Local recurrence was uncommon in both tumour subtypes when patients received definitive surgical excision (minimum histological margins of 10 mm as per institutional protocol) regardless of whether radiotherapy was used. The 5-year local recurrence-free survival for dermal leiomyosarcoma treated with radiotherapy was 93% versus 83% without radiotherapy (P = 0.7) and for subcutaneous leiomyosarcoma was 69% and 100%, respectively (P = 0.9).

CONCLUSIONS

Dermal leiomyosarcoma have an excellent prognosis, particularly after definitive surgical excision with margins of at least 10 mm. Subcutaneous leiomyosarcoma has poorer outcomes and should be managed by wider excision and considered for adjuvant radiotherapy.

Skin and Soft Tissue Lesions in a District Hospital in Central Nigeria: A Histopathological Study

Introduction. Skin and soft tissue diseases form a large and heterogeneous group of mesenchymal extraskeletal and dermatologic lesions in humans. Diseases of the skin and soft tissue can develop virtually anywhere in the body, extremities, the trunk, the retroperitoneum, the head, and the neck. Our study aims to review skin and soft tissue specimens from our centre describing the histopathological patterns.

Primary leiomyosarcoma of the skin: a comprehensive review on diagnosis and treatment

Sarcomas are a heterogeneous group of mesenchymal tumors which can affect bone and soft tissue. Leiomyosarcoma (LMS) is a rare subtype localized to the skin or subcutaneous tissue. Due to the heterogeneity of sarcomas, reviews and guidelines with an in-depth focus specifically on primary LMS of the skin are sparse. This article is intended to provide an up to date and systematic overview on diagnosis, treatment, and surveillance of this rare entity to provide a framework for decision making and management for dermato-oncologists. We discuss novel treatment options for advanced disease such as targeted therapy with kinase inhibitors and immune checkpoint blockade which may improve the prognosis even in advanced stages of LMS.

Leiomyosarcoma of somatic soft tissues

Leiomyosarcoma is a rare, aggressively malignant connective tissue tumor of mature adults, which arises from smooth muscle. It occurs most frequently in the uterus, bowel, vascular tissues, and less commonly in somatic soft tissue or bone. The tumor when it arises in soft tissue has distinctive histologic features which somewhat resemble malignant fibrous histiocytoma (otherwise known as myxofibrosarcoma). The Orthopaedic Oncology Service at our institution has treated 66 patients with these lesions and thus far, 1/2 of the patients have died of disease at a mean of 3 years after discovery. Factors that increase the death rate include size of the tumor, Musculoskeletal Tumor Society Stage of disease, and to a lesser extent particularly in the lower extremities, anatomic site. Radiation and chemotherapy had little direct effect on the outcome but patients treated with surgery and adjunctive agents seemed to live longer than their cohorts treated with surgery alone. The purpose of this study is a general review of the clinical and prognostic features of this cancer.

Criteria for malignancy in nonvisceral smooth muscle tumors

Reliable prediction of the behavior of smooth muscle tumors is notoriously problematic at many anatomic locations. Relatively few studies have addressed the minimal histologic criteria for malignancy in smooth muscle tumors of soft tissue and the presently available criteria are not only inconsistently applied but also vary at different anatomic sites. It has been widely believed that the presence of any mitotic activity in a deep-seated smooth muscle tumor should lead to a diagnosis of leiomyosarcoma. Until very recently, the existence of leiomyomas in deep soft tissue has been disputed. Using presently available data, this review examines criteria for malignancy in smooth muscle tumors in each of the following anatomic compartments: deep soft tissue, including retroperitoneum/abdominal cavity; skin; subcutis; and external genitalia. Distinct criteria for assessing malignancy should be applied to smooth muscle tumors at each of these locations.

Leiomyosarcoma of the sinonasal tract: a case report and literature review

Leiomyosarcoma of the paranasal sinuses is uncommon and has an aggressive clinical behavior. Only 28 cases have been described in the literature, and, of these, only 3 patients treated with surgery had a disease-free survival. In this report, we describe the clinical history of a 57-year-old woman with a leiomyosarcoma of the paranasal sinuses successfully treated with a combination of surgery, radiation therapy, and chemotherapy. We obtained a total response with ifosfamide, doxorubicin, dacarbazine, and epirubicin. This case report emphasizes the possibility of treating this aggressive tumor with chemotherapy in accordance with the same therapy used in the treatment of uterine leiomyosarcomas.

Leiomyosarcoma of somatic soft tissues: a tumor of vascular origin with multivariate analysis of outcome in 42 cases

Leiomyosarcomas of the somatic soft tissues (SST) are rare compared with their retroperitoneal and cutaneous counterparts and, therefore, have not been extensively studied. We have analyzed the clinicopathologic features of 42 SST leiomyosarcomas referred in consultation to determine what factors affect outcome. Cutaneous, visceral, retroperitoneal, uterine, gastrointestinal, and major vessel leiomyosarcomas were excluded. By definition all lesions possessed at least focal cytologic atypia and mitotic activity, although the latter varied from <1/10 high power fields to 66/10 high power fields. The patients (21 females and 21 males) ranged in age from 26 to 86 years (mean 60 years); tumors developed in the lower (n = 28) or upper extremity (n = 11) and trunk (n = 3). Most arose in deep (n = 27) as opposed to superficial (n = 15) soft tissue; 39 arose from a small vein. During the follow-up period (mean 47 months, range 9-162 months), 3 of 38 (8%) patients developed local recurrence and 17 of 38 metastasized (45%) mostly to the lungs. In a univariate analysis age >62 years, size >4 cm, extensive necrosis, modified updated French Federation of Cancer Centers (FFCC) grade, and whether the tumor had been "disrupted" by a previous incisional biopsy or incomplete excision were significantly correlated with metastasis. AJCC stage also approached significance (p = 0.096) but could not be reliably tested because of the sparseness of the data. In multivariate analyses the logistic regression model that best predicted metastasis at 36 months incorporated the effects of age, FFCC grade, and disruption and had a sensitivity of 94.1% and a specificity of 95.2%. Disruption was the only significant risk factor for metastasis in a multivariate analysis (relative risk 2.70; p = 0.0001) but was strongly correlated with large size and deep location. Other parameters did not improve the predictive power of the model significantly. We concluded that the majority of SST leiomyosarcomas are actually of vascular origin, an observation that has clinical and possibly biologic ramifications. Our histologic definition of leiomyosarcoma to include atypia and any level of mitotic activity appears warranted by the biologic outcome in our cases. The risk of metastasis can be calculated from a model incorporating age, FFCC grade, and disruption. Because disruption correlates with size and depth, it could represent a surrogate as opposed to causal marker for metastasis. Nevertheless, in view of their vascular origin, the possibility that tumor disruption may facilitate or promote access to the bloodstream merits further study.

Rare incidence of three consecutive primary tumors in the maxillofacial region: retinoblastoma, leiomyosarcoma, and choriocarcinoma: case report

Multiple primary tumors occur more commonly in the region of the head and neck than elsewhere in the body. The chance of this is particularly high in patients treated for retinoblastoma, in part because of a genetic predisposition, and in part because of the possibility of irradiation treatment. However, triple tumors occur in only 0.5% of multiple tumors. A rare case of a triple (metachronous) tumor is reported: 12 years after the treatment of bilateral retinoblastoma (enucleation and irradiation), secondary leiomyosarcoma developed in the maxillofacial region, followed 5 years later by choriocarcinoma. Surgery was performed on all three types of tumor. As a result, the female patient (currently 21 years old) is now free of complaints and has married. It is extremely rare for either leiomyosarcoma or choriocarcinoma (CHC) to appear in the maxillofacial region. The long-term, systematic control of such patients is absolutely necessary, for the multiple tumors tend to develop only after a long latency period of 10 to 20 years.

Adult perineal sarcomas

BACKGROUND AND OBJECTIVES

Primary perineal sarcoma in adults is a rare disease that has only been documented to occur in isolated case reports.

METHODS

To better characterize and define the natural history of perineal sarcoma in adults (> or = 18 years), we reviewed our experience with treatment of perineal sarcoma between 1982 and 1999 (nine cases).

RESULTS

Epithelioid sarcoma (n = 4) was the most common histologic subtype. Seven cases (78%) were histologically high grade, and lesions were most commonly < 5 cm. All patients were treated with wide local excision. External beam radiation was the most commonly used form of adjuvant therapy (n = 6). Recurrences were noted in five patients, and the recurrences were most commonly local (60%). Median time to first recurrence was 21 months. Six of nine patients are alive with a median follow-up of 54 months. Three died of recurrent/metastatic disease at 16, 51, and 54 months after initial surgery.

CONCLUSIONS

Aggressive therapy and follow-up beginning with wide excision can be associated with long-term survival in adults with primary perineal sarcoma.

Recognition and management of unusual cutaneous tumors

This article has briefly outlined some of the more unusual cutaneous neoplasms that may be encountered in a dermatologic practice. Although rare, they must always be kept in mind and included in the differential diagnosis. Because of the highly aggressive nature of many of these tumors, delay in diagnosis and treatment could be fatal. A high level of suspicion is necessary for the correct prebiopsy diagnosis.

Unusual cutaneous malignancies

The most commonly occurring cutaneous malignancies are basal cell and squamous cell carcinoma. There are, however, other rare malignancies that are encountered and should be included in the differential, in which both the clinical and the histological diagnosis may be difficult. Here, the clinical and histological features, management, and prognostic factors of merkel cell carcinoma, microcystic adnexal carcinoma, leiomyosarcoma, dermatofibrosarcoma protuberans, and angiosarcoma are reviewed.

A case of leiomyosarcoma of the sphenoid sinus

A 43-year-old man with a primary leiomyosarcoma of the left sphenoid sinus is presented. To our knowledge, this is an unusual case of leiomyosarcoma, which has never been reported in the literature. Accurate and safe diagnosis was obtained by an endonasal endoscopic approach with minimal tissue invasion.

Cutaneous pilar leiomyoma: clinicopathologic analysis of 53 lesions in 45 patients

As cutaneous pilar leiomyomas have received little attention in the recent literature, 53 lesions from 45 patients were studied to analyze their clinicopathologic features. There was an equal distribution between both sexes; most patients were adults with a wide age distribution. Both multiple (29 lesions from 21 patients) and solitary tumors (18 patients) were included. Lesions on the extremity (29 tumors) were common in both groups, whereas truncal tumors (11) were confined largely to patients with multiple lesions. In six patients the number of lesions was not specified. The tumors were painful in 17 patients. Three patients had a positive family history of similar lesions. Histologic study revealed ill-defined bundles of well-differentiated smooth muscle cells in the reticular dermis in all cases, although nine lesions had a more nodular pattern. Overlying epidermal hyperplasia was noted in 29 cases (54.7%). Immunohistochemically there appeared to be an increased number of nerve fibers within and surrounding the tumors. Mitotic activity was observed in 15 lesions (28.3%), 13 of which had <1 mitosis per 10 high power fields (HPF); the remaining two lesions had 1-2 mitoses per 10 HPF. Follow-up was available in 10 of these mitotically active tumors and ranged from 9 months to 7 years. There was no recurrence in any of them. We have concluded tentatively that leiomyomas of arrector pili origin may exhibit a low mitotic activity of <1 per 10 HPF and that this does not adversely affect the prognosis for these patients.

Tumors with smooth muscle differentiation

BACKGROUND

In the classification of tumors of soft tissue, modern schemes describe tumors by the normal adult tissue type the tumor resembles. Thus, tumors are described as smooth muscle tumors if the cells are differentiating towards smooth muscle. We may infer that in fact the tumor arose from smooth muscle, but this is only an inference. Tumors showing differentiation towards smooth muscle include hamartomas, benign tumors, and malignant tumors.

OBJECTIVE

This review article describes the clinical presentation and course, histology, and treatment recommendations for benign and malignant smooth muscle tumors.

METHODS

An extensive literature review of tumors with differentiation towards smooth muscle.

RESULTS

Benign tumors exhibiting differentiation towards smooth muscle include smooth muscle hamartoma and leiomyoma. Myofibroma is a third tumor that some have argued is a smooth muscle tumor rather than a fibroblastic tumor. Characteristic fusiform shaped cells with a round central nucleus arranged in fasicles suggest smooth muscle differentiation. Special stains such as phosphotungenistic acid-hemotoxilin, analine blue, and Masson's trichrome are helpful in differentiating muscle from collagen. Immunohistochemical stains are also helpful in establishing a diagnosis. With solitary tumors, treatment for cosmesis or for painful leiomyomas is not a problem. Multiple leiomyomas, which may be painful or sensitive to cold or touch, are a therapeutic challenge, with reports of multiple medications being attempted in the literature. Leiomyosarcoma are malignant tumors of smooth muscle. They may be cutaneous and presumably arise from the arrector pilorum muscle, or subcutaneous, where they are believed to arise from vascular smooth muscle. Cutaneous leiomyosarcomas frequently reoccur following excision, but rarely metastasize. Subcutaneous leiomyosarcomas frequently reoccur following excision and have a high metastatic rate. Several recent reports have documented an increased frequency of visceral leiomyosarcomas in immunosuppressed patients. These tumors have been found to contain the Epstein Barr virus. Treatment of leiomyosarcoma is wide excision.

CONCLUSIONS

Smooth muscle tumors are rare neoplasms that may confront the dermatologic surgeon. While leiomyomas are benign, their frequent sensitivity or pain necessitates treatment. Leiomyosarcomas are malignancies with a high reoccurrence rate, and when deep, a high metastatic rate. The finding of an increased frequency of visceral leiomyomas and leiomyosarcomas in immunosuppressed patients may imply an increased frequency of cutaneous leiomyomas and leiomyosarcomas in this patient population.

Leiomyosarcoma of the skin. Treatment of 34 cases

BACKGROUND

Leiomyosarcoma is a rare soft tissue sarcoma that is one of the least common malignant lesions found in the skin.

OBJECTIVE

We discuss the clinical, histopathologic, and prognostic factors related to superficial leiomyosarcoma from cases reported in the literature as well as from the Mayo Clinic experience from 1964 through 1994 with 34 patients.

CONCLUSIONS

The vast majority of tumors were treated by excisional surgery with wide margins, but conceptually, Mohs' micrographic surgery should prove useful for the treatment of this tumor as it has with other skin cancers displaying contiguous growth.

Vulvar sarcoma: clinical implications

This is a review of the histories of 47 patients with vulvar sarcoma, consisting of leiomyosarcoma (25), malignant fibrous histiocytoma (5), epithelioid sarcoma (8), dermatofibrosarcoma protuberans (9), including 7 from our own institute. When compared to the biological behaviour of sarcomas from other anatomic sites of the body, no essential differences were found. The prognosis after the appearance of regional or distant recurrence was poor and prevention of local recurrence by wide excision was the best way to improve the prognosis of leiomyosarcoma and dermatofibrosarcoma protuberans. However, the poor prognosis of epitheloid sarcoma did not change. Elective treatment of regional lymph nodes was not indicated in the four tumor types discussed and dissection of metastatic inguinal nodes was rarely beneficial. However, distressing local problems were prevented in a patient with epithelioid sarcoma and lasting benefit was seen in a patient with malignant fibrous histiocytoma who developed an inguinal metastasis after a 3-year disease-free interval. The beneficial effect of resection of pulmonary metastasis needs more attention.

Leiomyosarcomas of the oral cavity. Report of four cases and review of the literature

Leiomyosarcomas (LMS) make up 7% of all soft tissue sarcomas. In the oral cavity, the LMS is rare due to the paucity of smooth muscle in that region. Four cases of intraoral LMS are reported, plus 34 cases found in the literature reviewed. There were 24 males and 14 females. The age range at presentation was 10 months to 88 years with no predilection for any particular age group. The commonest presenting symptom was a mass. The intraoral LMS occurred most commonly in the jaws (59% of cases). The mass was painful in 61% of cases. Follow-up of the case reports was assessed. Recurrence occurred in 36% of cases. Distant metastases occurred in 39% of cases, most commonly to the lungs. Cervical nodal metastasis was reported in 15% of cases. The 5-year survival rate determined on cases with adequate follow-up (n = 13) was 23% free of disease, 8% alive with disease and 69% who died of disease. In comparison with stage I and stage II tongue squamous cell carcinomas, the intraoral LMS is very aggressive. It is best treated surgically, early and aggressively.

Superficial perineal leiomyosarcoma in an adolescent female and a review of the literature including vulvar leiomyosarcomas

Superficial perineal leiomyosarcomas are rare, with only three previously reported examples. We encountered a superficial (deep subcutaneous) perineal leiomyosarcoma in a 17-year-old female. At follow-up two years after a wide excision, there were no signs of recurrence. The tumour was well differentiated and showed immunoreactivity for alpha-smooth muscle actin and desmin. A review of the literature on superficial leiomyosarcomas indicates that superficial perineal leiomyosarcomas may be more aggressive than superficial leiomyosarcomas in general. As the presented tumour occurred in a female, it was compared with vulvar leiomyosarcomas.

Recurrent cutaneous leiomyosarcoma

BACKGROUND

Soft tissue sarcomas comprise approximately 0.7% of all malignant neoplasms. Superficial leiomyosarcoma, a rare malignant lesion, constitutes 4.0-6.5% of all soft tissue sarcomas, an overall incidence of approximately 0.04% among all cancers. Currently, less than 125 cumulative cases of cutaneous and subcutaneous leiomyosarcoma have been reported in the English literature.

METHODS

The authors report the case of a 70-year-old Japanese man with recurrent cutaneous leiomyosarcoma who was treated by wide local excision. A comprehensive literature survey is also presented.

RESULTS

The patient is free from recurrence 1 year after wide local excision of a second recurrence of cutaneous leiomyosarcoma. Moreover, superficial leiomyosarcoma can be subdivided into cutaneous leiomyosarcoma and subcutaneous leiomyosarcoma, based on histopathologic and prognostic differences.

CONCLUSIONS

The treatment of choice of superficial leiomyosarcoma is wide local excision. Cutaneous leiomyosarcoma is associated with local recurrence only, although subcutaneous leiomyosarcoma undergoes metastatic spread in 30-60% of cases, with a 30-40% mortality rate.

Cervical paravertebral leiomyosarcoma mimicking a nerve sheath tumor

A rare case of leiomyosarcoma attached to the C6 nerve root with extension through the intervertebral foramen into the spinal canal is described. Clinically and at the time of frozen section, this was considered to be a nerve sheath tumor. A definitive histologic diagnosis was made on the basis of the ultrastructural features of the tumor. Complete remission was achieved following extensive surgical removal and postoperative radiotherapy. The possible origin of this neoplasm is discussed.

Leiomyosarcoma of the skin and subcutaneous tissue of the hand and wrist

Leiomyosarcoma of the skin and subcutaneous tissues is a rare tumor of smooth muscle origin. A case report of leiomyosarcoma of the hand is presented. The lesion was treated with wide local excision and has shown no recurrence in 2 years of follow-up.

Leiomyosarcoma of somatic soft tissues in childhood: an immunohistochemical analysis of six cases with ultrastructural correlation

Leiomyosarcoma (LMS) of soft tissue is a rare tumor in children. Although LMS may exhibit clinical and histologic features that are typical of smooth muscle neoplasms in adults, they may often be confused with or resemble tumors of presumed fibroblastic, myofibroblastic, or rhabdomyoblastic differentiation. As a result, the diagnosis of LMS in children is often difficult to establish with confidence. To address this problem, we analyzed the immunohistochemical features of six LMS in children (one of deep soft tissue of an extremity, one of paravertebral tissue, one of the retroperitoneum, two of oropharyngeal soft tissue, and one of subcutis); the ultrastructural features of four of these tumors were also studied. Histologically, each of the three tumors of deep soft tissue and one of the retromolar trigone were composed of pleomorphic spindle cells arranged in interweaving fascicles. In contrast, the subcutaneous tumor and the lesion of the hard palate had an epithelioid appearance. Ultrastructural features were typical of adult type LMS. Immunohistochemically, these neoplasms were diffusely reactive for vimentin, while each was negative for cytokeratin, epithelial membrane antigen, and S-100 protein. Desmin was present in all cases, but was expressed only focally in three; a similar pattern of staining was noted for muscle-specific actin, although staining was generally noted in a larger population of cells. alpha-1-Antichymotrypsin was found in five tumors, and cathepsin B reactivity was encountered in four cases. Leu-7 antigen and myelin basic protein were coexpressed by one tumor, but neither was found in the remaining cases. These results indicate that immunohistochemical detection of desmin and muscle-specific actin may be useful in the differential diagnosis of spindle or epithelioid cell proliferations in childhood when ultrastructural analysis in unavailable.

Leiomyosarcoma of the buttock

A 56-year-old man had a deeply invasive leiomyosarcoma of the right buttock. Leiomyosarcomas of the skin and subcutaneous tissues are rare, and most occur on the extremities. Wide local excision is the therapy of choice.

Leiomyosarcomas of the extremities

Leiomyosarcomas are uncommon malignant neoplasms that rarely arise in the extremities. We report on the clinical characteristics of 17 cases seen at the Memorial Sloan-Kettering Cancer Center over a 32 year period. Most neoplasms occurred in the lower extremities, and most of the tumors recurred after surgery alone, with several late recurrences. The overall prognosis was grim, with a median survival of 24 months. More aggressive multidisciplinary approaches to this disease are warranted.

Primary cutaneous leiomyosarcoma. A histological and immunohistochemical study of 9 cases, with ultrastructural correlation

Leiomyosarcoma (LMS) of dermal and subcutaneous tissues is an uncommon neoplasm. In order to analyze the specialized pathologic features of this tumor, we undertook a histological, ultrastructural, and immunohistochemical study of 9 superficial LMS, including 7 dermal lesions and 2 subcutaneous neoplasms. These were compared with 12 examples of "deep" extracutaneous LMS. Metastases to the skin from two of the latter neoplasms were also examined. Immunohistochemistry was found to be a useful diagnostic adjunct to light microscopic and ultrastructural studies in that all LMS coexpressed vimentin and desmin, regardless of site, and 90% also expressed muscle-specific actin. Variable expression of cathepsin B and myelin basic protein was noted in 8 and 10 tumors, respectively, whereas none contained cytokeratin. Weak cytoplasmic positivity for epithelial membrane antigen was seen in 1 dermal and 3 extracutaneous LMS. Of 7 dermal LMS, 4 contained S-100 protein, whereas this determinant was found in only 1 of 12 extracutaneous tumors. Conversely, Leu 7 reactivity was present in 7 of 12 extracutaneous LMS, but only 2 of 9 superficial lesions. Review of clinical features confirmed that subcutaneous LMS is capable of aggressive behaviour, whereas dermal LMS was more likely to behave in an indolent fashion. However, one example of dermal LMS exhibited aggressive local recurrences and distant metastasis, ultimately leading to the death of the patient. Therefore, careful clinical followup is indicated in all cases.

Leiomyosarcoma of the forearm: treatment with wide local excision and a lateral arm flap

Leiomyosarcomas of the subcutaneous tissues in the upper extremity are extremely rare tumors. We report a subcutaneous leiomyosarcoma of the forearm in a 52-year-old man who was treated with wide local excision and reconstruction with a free lateral arm flap.

Leiomyosarcoma of the external soft tissues. A clinicopathologic, immunohistochemical, and electron microscopic study

This clinicopathologic study concerns 25 cases of leiomyosarcoma of the external soft tissues, including an immunohistochemical survey of 19 cases and an electron microscopic examination of six. There was a female preponderance in a ratio of 16:9. The most common site of tumors was the thigh (nine cases), followed by the knee (five cases). Three tumors were located in the dermis, 9 were confined down to the subcutis, 2 involved the deep fascia, and 11 involved the skeletal muscle. Superficially located tumors were smaller than deeply located ones. According to the predominant histologic features, the tumors were classified into well (6), moderately (14), and poorly (5) differentiated. In addition to the classical microscopic features, dedifferentiated areas resembling malignant fibrous histiocytoma were noted in three primary tumors and one recurrent tumor. In six tumors, the anatomical location and histologic features were highly suggestive of leiomyosarcoma arising in the venous wall. Many tumor cells immunoreactive for actin were seen in 13 and for desmin in 9 of the 19 cases. Four tumors contained a few tumor giant cells positive for alpha-1-antichymotrypsin. Ultrastructurally, the tumors were characterized by smooth muscle tumor cells showing a spectrum of differentiation of varying degrees. In two cases, histiocyte-like tumor cells were detected. The most reliable prognostic parameter was the depth of the initial tumors; all patients with a leiomyosarcoma confined down to the subcutis are living, most of them more than 5 years after excision, whereas seven of the nine patients with a tumor involving the muscle have died within 5 years after excision.

Cerebral metastases from perineal leiomyosarcoma

A case of cerebral metastases from perineal cutaneous leiomyosarcoma is described and documented by the histological and CT findings.

Subcutaneous leiomyosarcoma with lymphomatous elements: histogenetic implications of an unusual sarcoma

A 49-year-old woman had an unusual sarcoma that recurred three times in four years. The tumor manifested initially as a subcutaneous abdominal wall nodule composed of lymphohistiocytic malignant lymphoma and spindle cell sarcoma with epithelioid and clear cell elements. The neoplasm recurred first as a spindle cell sarcoma in the lumbar area, second as a malignant lymphoma in the subcutaneous tissue of the right shoulder, and third as a spindle cell sarcoma with lymphohistiocytic areas in the abdominal wall. Ultrastructural studies of this last tumor nodule demonstrated the unequivocal smooth muscle features of the spindle cells. Histogenetic implications of this neoplasm are discussed. It is proposed that the tumor represents an unusual variant of malignant mesenchymoma of soft tissues.

Leiomyosarcoma of soft tissue: a clinicopathologic study

The case records and histologic material of 28 patients with leiomyosarcoma of soft tissue treated at M. D. Anderson Hospital between 1948 and 1975 were reviewed. These included patients in whom the tumors arose in the retroperitoneum (16), major blood vessels (3), and other soft-tissue sites, collectively designated peripheral soft tissue (9). Follow-up was complete in all cases. A striking preponderance of female patients was observed in the group with retroperitoneal tumors, in contrast to the male preponderance in the vascular and peripheral soft tissue tumor groups. Tumor size and location were the major prognostic factors; large size (greater than 5 cm) and retroperitoneal origin were associated with a much poorer clinical outcome than smaller size (less than 5 cm) and origin elsewhere than the retroperitoneum. These factors were related, since all retroperitoneal tumors were large. Microscopic appearance did not correlate significantly with clinical course. The clinical approach to these tumors is discussed in light of the findings of this study.

Leiomyosarcoma of the skin and subcutaneous tissue

In a study of 65 primary cutaneous leiomyosarcomas and 15 primary superficial subcutaneous leiomyosarcomas, tumors occurred at any age but were more common in middle age and most common on the extremities. They developed as solitary painful or tender intracutaneous or subcutaneous nodules. Microscopically, the cutaneous leiomyosarcomas consist of a poorly delineated proliferation of spindle-shaped atypical myomatous cells arranged in interlacing fascicles which merge into collagenous stroma. Subcutaneous leiomyosarcomas are more sharply circumscribed and typically include a vascular pattern. About 40% of the cutaneous leiomyosarcomas recurred, but none metastasized despite a high mitotic frequency and marked cytologic atypia. Among the 12 patients with subcutaneous leiomyosarcomas, one-half of the tumors recurred and one-third eventuated in metastasis or tumor-related death. Cutaneous leiomyosarcomas have a relatively benign biologic course and may be excised conservatively, but are less likely to recur if the local excision is wide enough to require a skin graft for closure of the surgical defect. For primary subcutaneous leiomyosarcoma, early wide local excision with adequate clear histologic borders constitutes rational treatment.

Leiomyosarcoma of the adrenal gland and its angiographic features: a case report

A case of leiomyosarcoma of the adrenal gland is reported. This is a rare neoplasm at this location and actually may arise from the venous wall of the gland. Angiographically, this lesion is demonstrated as a vascular mass with early draining of the vein.

Massive leiomyosarcoma of the chest wall in a young child

An unusual instance of a very large primary leimyosarcoma of the chest wall is presented. It was asymptomatic but a swelling had been noted between the left clavicle and nipple by the parents. Chest x-ray showed a massive tumor with mediastinal involvement. Preliminary biopsy indicated a leiomyosarcoma. Wide an bloc excision of the chest wall was done, including much of the 1, 2, and 3 ribs and a piece of lung. The defect was closed with Marlex mesh and covered with a U-shaped flap of pectoralis major muscle and skin. There were 4000 rads of radiotherapy plus 15 mo of chemotherapy added. To date, she remains clinically well and apparently tumor-free.

Vascular leiomyosarcoma: the malignant counterpart of vascular leiomyoma

The clinical and pathological findings of six cases of leiomyosarcoma arising from blood vessels of different caliber are described. The term vascular leiomyosarcoma, having both a topographic and morphologic significance, is proposed for these tumors. The histologic pattern is characterized by a proliferation of atypical smooth muscle cells with a large number of intermingled blood vessels. Mitoses were counted per 10 high power field (hpf) and tumors were divided in three groups I, 10 to 20 mitoses, group II, 20 to 35 mitoses, and group III, more than 35 mitoses per 10 hpf. The mitotic index seems to be the most important pathological feature on which a prognostic evaluation for vascular leiomyosarcoma can be based. Tumors in group I had neither local recurrences nor metastases; the one tumor in group II had one local recurrence, but the patient is free of disease 6 years after surgical treatment; the three tumors in group III developed distant metastases and constitutional symptoms. Vascular leiomyoma, bizarre leiomyoma, and hemangiopericytoma are included in the differential diagnosis of vascular leimyosarcoma. The possibility that vascular leiomyosarcoma arising from small vessels represents the malignant counterpart of vascular leiomyoma is proposed.

Leiomyosarcomas of the extremities: angiography as a diagnostic aid

Thirteen cases of leiomyosarcomas of the extremities are reported. Most of the cases were operated on without information concerning benignancy or malignancy. Plain radiographs showed amorphous calcification in two cases. Three cases had angiographic study and all revealed malignant neovascularity. In no literature that we reviewed was angiography mentioned in the cases of leiomyosarcomas of the extremities. Venography alone has been done in many reported cases. The leiomyosarcoma of the extremities looks often benign but is notorious for local recurrences and distant metastases.

Primary leiomyosarcoma of skin: a report and critical appraisal

A primary leiomyosarcoma of skin was studied by light and electron microscopy and by histochemistry. Systematic evaluation of the entire neoplasm suggested that a single biopsy sample would show little cellular pleomorphism but could vary considerably in number of mitoses per mm2. Electron microscopy revealed a high degree of cytologic differentiation. Strong myosin ATPase activity and negative demonstrations for hydrolytic enzymes suggest a diagnostic profile which will clearly separate this neoplasm from malignant fibrous histiocytoma. High mitoses counts, the conventional criterion for malignancy of non-cutaneous smooth muscle tumors, may not be appropriately applied to primary leiomyosarcomas arising in the dermis. The findings in this case and a critical review of the literature suggest that reliable criteria for diagnosis of primary cutaneous leiomyosarcoma by light microscopy remain to be established.