Hepatic metastases from leiomyosarcoma: A single-center experience with 34 liver resections during a 15-year period

Curative resection of leiomyosarcoma of the descending colon with metachronous liver metastasis: A case report

BACKGROUND

Leiomyosarcoma (LMS) has a poor prognosis and rarely originates from the colon. If resection is possible, surgery is the first treatment most commonly considered. Unfortunately, no standard treatment exists for hepatic metastasis of LMS; although, several treatments, such as chemotherapy, radiotherapy, and surgery, have been used. Subsequently, the management of liver metastases remains controversial.

CASE SUMMARY

We present a rare case of metachronous liver metastasis in a patient with LMS originating from the descending colon. A 38-year-old man initially reported abdominal pain and diarrhea over the previous two months. Colonoscopy revealed a 4-cm diameter mass in the descending colon, 40 cm from the anal verge. Computed tomography revealed intussusception of the descending colon due to the 4-cm mass. The patient underwent a left hemicolectomy. Immunohistochemical analysis of the tumor revealed that it was positive for smooth muscle actin and desmin, and negative for cluster of differentiation 34 (CD34), CD117, and discovered on gastrointestinal stromal tumor (GIST)-1, which are characteristic of gastrointestinal LMS. A single liver metastasis developed 11 mo post-operatively; the patient subsequently underwent curative resection thereof. The patient remained disease-free after six cycles of adjuvant chemotherapy (doxorubicin and ifosfamide), and 40 and 52 mo after liver resection and primary surgery, respectively. Similar cases were obtained from a search of Embase, PubMed, MEDLINE, and Google Scholar.

CONCLUSION

Early diagnosis and surgical resection may be the only potential curative options for liver metastasis of gastrointestinal LMS.

Metastasectomy in Leiomyosarcoma: A Systematic Review and Pooled Survival Analysis

Simple Summary

Leiomyosarcoma (LMS) is an aggressive soft tissue sarcoma with a poor prognosis. Approximately 40% of patients will develop metastatic disease. The optimal treatment for patients with metastatic LMS is not well established, and there are no randomized controlled trials regarding metastasectomy. This systematic review and pooled survival analysis aims to assess the survival in patients undergoing a metastasectomy for LMS and compare the outcomes based on the site of metastasectomy. We identified that patients with LMS metastases in the lungs, liver, spine, and brain can undergo metastasectomy with acceptable survival. Two studies have compared survival outcomes between patients treated and not treated with metastasectomy; despite their low quality, these studies support a survival benefit associated with metastasectomy.

Abstract

This study assesses the survival in patients undergoing metastasectomy for leiomyosarcoma (LMS) and compares the outcomes by the site of metastasectomy. We conducted a systematic review and pooled survival analysis of patients undergoing metastasectomy for LMS. Survival was compared between sites of metastasectomy. We identified 23 studies including 573 patients undergoing metastasectomy for LMS. The pooled median survival was 59.6 months (95% CI 33.3 to 66.0). The pooled median survival was longest for lung metastasectomy (72.8 months 95% CI 63.0 to 82.5), followed by liver (34.8 months 95% CI 22.3 to 47.2), spine (14.1 months 95% CI 8.6 to 19.7), and brain (14 months 95% CI 6.7 to 21.3). Two studies compared the survival outcomes between patients who did, versus who did not undergo metastasectomy; both demonstrated a significantly improved survival with metastasectomy. We conclude that surgery is currently being utilized for LMS metastases to the lung, liver, spine, and brain with acceptable survival. Although low quality, comparative studies support a survival benefit with metastasectomy. In the absence of randomized studies, it is impossible to determine whether the survival benefit associated with metastasectomy is due to careful patient selection rather than a surgical advantage; limited data were included about patient selection.

Laparoscopic liver resection for liver metastasis of leiomyosarcoma of the thigh: a case report

Background

Although there is no established treatment strategy for liver metastasis of leiomyosarcoma, liver resection has been reported to be effective in some cases. However, almost all liver resections performed for liver metastasis of primary leiomyosarcoma are reported to be open resections, and there are few reports of liver resection performed by laparoscopy. Here, we report a case of laparoscopic liver resection for liver metastasis of a leiomyosarcoma in the right thigh.

Case presentation

An 80-year-old man was diagnosed with leiomyosarcoma of the right thigh with liver metastasis. The primary tumor was first resected, and he was discharged on the 25th postoperative day. Four months after primary tumor resection, a laparoscopic right posterior sectionectomy was performed. There were no postoperative complications, and the patient was discharged on the 11th postoperative day with a histopathological diagnosis of liver metastasis of leiomyosarcoma and negative resection margins. Currently, 9 months have passed since the resection of the primary tumor, and 5 months have passed since the laparoscopic liver resection; there is no recurrence.

Conclusions

The liver metastasis of leiomyosarcoma was successfully removed, with good short-term outcomes after the laparoscopic liver resection. Laparoscopic liver resection seems to be effective for liver metastasis of leiomyosarcoma, which is characterized by a high recurrence rate after surgery. However, more case studies may be necessary to examine the effectiveness and long-term results of laparoscopic liver resection for the treatment of liver metastasis of leiomyosarcoma.

Metastatic Pattern of Truncal and Extremity Leiomyosarcoma: Retrospective Analysis of Predictors, Outcomes, and Detection

Leiomyosarcomas (LMS) are a heterogenous group of malignant mesenchymal neoplasms with smooth muscle origin and are classified as either non-uterine (NULMS) or uterine (ULMS). Metastatic pattern, prognostic factors, and ideal staging/surveillance studies for truncal and extremity LMS have not been defined. A retrospective analysis of patients diagnosed with histopathology-confirmed truncal or extremity LMS between 2009 and 2019 was conducted. Data collected included demographics, tumor characteristics, staging, surveillance, and survival endpoints. The primary site was defined as: (1) extremity, (2) flank/Pelvis, or (3) chest wall/Spine. We identified 73 patients, 23.3% of which had metastatic LMS at primary diagnosis, while 68.5% developed metastatic disease at any point. The mean metastatic-free survival from primary diagnosis of localized LMS was 3.0 ± 2.8 years. Analysis of prognostic factors revealed that greater age (≥50 years) at initial diagnosis (OR = 3.74, p = 0.0003), higher tumor differentiation scores (OR = 12.09, p = 0.002), and higher tumor necrosis scores (OR = 3.65, p = 0.026) were significantly associated with metastases. Older patients (≥50 years, OR = 4.76, p = 0.017), patients with larger tumors (≥5 cm or ≥10 cm, OR = 2.12, p = 0.02, OR = 1.92, p = 0.029, respectively), higher differentiation scores (OR = 15.92, p = 0.013), and higher necrosis scores (OR = 4.68, p = 0.044) show worse survival outcomes. Analysis of imaging modality during initial staging and during surveillance showed greater tumor detection frequency when PET imaging was employed, compared to CT imaging (p < 0.0001). In conclusion, truncal and peripheral extremity LMS is an aggressive tumor with high metastatic potential and mortality. While there is a significant risk of metastases to lungs, extra-pulmonary tumors are relatively frequent, and broad surveillance may be warranted.

Long-term survival by repeat resection for metastases from primary retroperitoneal leiomyosarcoma: A case report

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Retroperitoneal (RP) leiomyosarcoma (LMS) is rare, with a high recurrence rate.

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A woman with RP LMS underwent over 20 surgeries for recurrence over 24 years.

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Long-term survival of 29 years was achieved after these resections.

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Aggressive and radical repeat resections may be beneficial in such patients.

Backgound

Retroperitoneal (RP) leiomyosarcoma (LMS) is a rare type of cancer, accounting for 0.1% of all malignancies. The gold-standard treatment for sarcoma is complete resection, and a 50% 5-year overall survival (OS) rate can be achieved by curative surgery. The survival benefits of radiotherapy and systemic chemotherapy for recurrence are not as good as those of surgical resection. To the best of our knowledge, there are a few reports that aggressive radical surgery significantly prolonged the survival period as our case. This case was reported in accordance with the SCARE 2020 Guideline (Ref).

Case presentation

An 84-year-old woman was referred to our hospital for treatment of a primary RP tumour. At the age of 52-year-old, she underwent complete resection of an RP mass in 1991. Twenty-four years after the primary resection, metachronous recurrences occurred within the soft tissues, which were repeatedly resected. From 2015–2019, liver resections were performed thrice, and the patient survived with no signs of recurrence 1 year after the last surgery.

Conclusion

Long-term survival of 29 years was achieved after undergoing over 20 surgical resections. Herein, we report the long-term survival of a patient who underwent repeated aggressive surgical resections for RP LMS recurrence anda literature review.

Surgical Management of Large Liver Metastases from Urinary Bladder Leiomyosarcoma

Leiomyosarcoma is a malignant tumor developed from the smooth muscle. It can arise in different sites especiallyin gastrointestinal tract (stomach, small bowel and colon), genitourinary tract (uterus, bladder and kidney) and the retroperitoneum (inferior vena cava) (1,2). It’s localization in the bladder is rare, representing 0.5% of all urinary bladder malignancies. There are over 210 cases reported in literature(3).Ten to 30% of the patients willpossibly develop metastases and the most common sites are lungs, liver and bone(4,5). There is no concensus on a standard treatment due to its very low incidence.

We report here a rare case of a surgical management of large liver metastases from urinary bladder leiomyosarcoma.

Leiomyosarcoma: a rare presentation as multifocal lesion

Leiomyosarcoma is a rare type of connective tissue cancer, accounting for 5–10% of all soft tissue sarcomas. We present a case of leiomyosarcoma as unusual multifocal presentation. Retroperitoneal, mediastinal, pulmonary, uterine and bony regions were all involved at the time of presentation. The liver was normal without detected lesions.

Metastases of soft tissue sarcoma to the liver: A Historical Cohort Study from a Hospital-based Cancer Registry

BACKGROUND

Hepatic metastasis of soft tissue sarcoma is rare compared to lung metastasis, and the literature is scarce. We examined the risk of hepatic metastasis according to the site of occurrence and histological type.

METHODS

From a Hospital-based Cancer Registry, 658 patients registered between 2007 and 2017 with soft tissue sarcomas were evaluated. The exclusion criteria were gastrointestinal stromal tumors, tumors of unknown origin, and follow-up periods of less than 1 month. SPSS 25 was used for statistical analysis.

RESULTS

The risk of hepatic metastasis was significantly higher in the retroperitoneum (HR, 5.981; 95% CI, 2.793-12.808) and leiomyosarcoma (HR, 4.303; 95% CI, 1.782-10.390). Multivariate analysis showed that the risk of hepatic metastasis as first distant metastasis was high in leiomyosarcoma (HR, 4.546; 95% CI, 2.275-9.086) and retroperitoneal onset (HR, 4.588; 95% CI, 2.280-9.231). The 2-year survival rate after hepatic metastasis was 21.7%.

CONCLUSIONS

The onset of hepatic metastasis indicates a poor prognosis. However, hepatic metastasis from retroperitoneal sarcoma and leiomyosarcoma may be the first distant metastasis in some cases. For retroperitoneal sarcoma and leiomyosarcoma, additional screening for hepatic metastasis such as contrast CT should be considered during staging and follow-up after treatment.

Survival by histology among patients with bone and soft tissue sarcoma who undergo metastasectomy: protocol for a systematic review and meta-analysis

BACKGROUND

Metastasectomy is performed on a select cohort of patients with advanced and/or recurrent bone and soft tissue sarcomas because of the potential for long term relapse free and overall survival associated with the procedure. However, the evidence supporting metastasectomy is difficult to summarize without a systematic examination of existing literature. The objective of this systematic review will be to examine survival among both adults and children with advanced and recurrent bone and STS who undergo metastasectomy.

METHODS

We designed and registered a study protocol for a systematic review and meta-analysis. We will include data from survival studies (e.g., randomized trials, cohort studies, routine case registries, and case control) conducted in children and adults with advanced and recurrent bone and soft tissue sarcoma who undergo metastasectomy. The primary outcome will be overall survival. Secondary outcomes will be 30-day post-operative mortality, recurrence-free survival, time off systemic therapy, and patient-reported outcomes including quality of life end points where available. Literature searches will be performed in multiple electronic databases including Ovid MEDLINE ® (1946 to present), Ovid EMBASE (1974 to present), Web of Science, and Cochrane Library. Grey literature will be identified through searching references, conference abstracts, Papers First, and Google Scholar. Two investigators will independently screen all citations, full-text articles, and abstract data. Full-text articles selected for analysis will be assessed for quality and risk of bias. If feasible, we will conduct a random effects meta-analysis. Estimates will be stratified according to histology comparing survival based on organ of metastasectomy. Additional analysis will be conducted to explore the potential sources of heterogeneity according to various patient, disease, and treatment characteristics (e.g., metastasis status, age, disease burden, and concomitant interventions).

DISCUSSION

This systematic review and meta-analysis will identify, evaluate, and integrate data on survival of metastasectomy of bone and soft tissue sarcoma by organ of metastasis. Our findings may have implications for clinicians, patients, and their families when considering selection for resection of oligometastatic disease in de novo, or recurrent bone and soft tissue sarcoma. Implications for future research will be identified to improve the outcomes of these complex patients.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019126906.

Liver resection for sarcoma metastases: A systematic review and experience from two European centres

INTRODUCTION

Studies reporting outcomes of liver resection for sarcoma metastases (LRSM) typically include gastrointestinal stromal tumours (GIST), or pooled analyses of "non-colorectal liver metastases", which do not reflect the subgroup of patients with sarcomatous liver metastases. This study aimed to perform a systematic review to evaluate oncological and surgical outcomes in patients undergoing LRSM, and to report new data from two tertiary institutions.

METHODS

MEDLINE and the Cochrane Library were searched for studies reporting oncological and surgical outcomes after LRSM, following PRISMA guidelines. Studies reporting liver resection for GIST were excluded. The resulting studies were pooled, with data from two European centres.

RESULTS

Six studies of LSRM were included, comprising 212 patients from previously reported series and 24 patients from ours, with median follow-up times of 18-53 months. Postoperative mortality rates ranged from 0 to 9%, and the pooled overall survival (OS) was 89% (95% CI: 83-96%), and 31% (95% CI: 14-47%) at one and five years, respectively (median: 36 months). The presence of synchronous extra-hepatic metastases was found to be a significant risk factor for shorter OS in two cohorts, with hazard ratios of 3.7 (p < 0.001) and 9.1 (p = 0.016), respectively. The largest reported series also found larger metastases (≥100 mm), lack of response to chemotherapy and a shorter disease-free interval to be associated with significantly shorter OS after LSRM.

CONCLUSIONS

Patients undergoing LRSM with negative prognostic factors such as the presence of extra-hepatic metastases are unlikely to benefit from surgery. Acceptable medium- and long-term survival may be achievable in highly selected patients.

Management of metastatic retroperitoneal sarcoma: a consensus approach from the Trans-Atlantic Retroperitoneal Sarcoma Working Group (TARPSWG)

Introduction

Retroperitoneal sarcoma (RPS) is a rare disease accounting for 0.1%-0.2% of all malignancies. Management of RPS is complex and requires multidisciplinary, tailored treatment strategies at all stages, but especially in the context of metastatic or multifocal recurrent disease. Due to the rarity and heterogeneity of this family of diseases, the literature to guide management is limited.

Methods

The Trans-Atlantic Retroperitoneal Sarcoma Working Group (TARPSWG) is an international collaboration of sarcoma experts from all disciplines convened in an effort to overcome these limitations. The TARPSWG has compiled the available evidence surrounding metastatic and multifocally recurrent RPS along with expert opinion in an iterative process to generate a consensus document regarding the complex management of this disease. The objective of this document is to guide sarcoma specialists from all disciplines in the diagnosis and treatment of multifocal recurrent or metastatic RPS.

Results

All aspects of patient assessment, diagnostic processes, local and systemic treatments, and palliation are reviewed in this document, and consensus recommendations provided accordingly. Recommendations were guided by available evidence, in conjunction with expert opinion where evidence was lacking.

Conclusions

This consensus document combines the available literature regarding the management of multifocally recurrent or metastastic RPS with the practical expertise of high-volume sarcoma centers from multiple countries. It is designed as a tool for decision making in the complex multidisciplinary management of this condition and is expected to standardize management across centers, thereby ensuring that patients receive the highest quality care.

Liver Resection for Hepatic Metastases from Soft Tissue Sarcoma: A Nationwide Study

BACKGROUND

This study aims to evaluate the feasibility and safety of resection of sarcoma liver metastases, and to identify possible prognostic factors for long-term survival.

METHODS

All patients who underwent resection of liver metastases of sarcoma in the Netherlands from 1998 to 2014 were included. Study data was retrospectively collected from patient files. Survival rates were calculated using Kaplan-Meier survival analysis.

RESULTS

Some 38 patients treated in 16 hospitals were included (15 male, 23 female). The median age was 57 years (37-80 years). The most common histological subtype was leiomyosarcoma (63%). The predominant site of primary tumour was the abdomen (59%). R0 resection was achieved in 16 patients. Mortality was 3 and 16% of included patients had 1 or more complications. The median follow-up period was 18 months (range 1-161). After liver resection, 1-, 3-, and 5-year survival were 88, 54, and 42% respectively. Median overall survival was 46 months (1-161 months). One- and three-year progression-free survival (PFS) after liver resection were 54 and 19% respectively. Median PFS was 16 months (1-61 months).

CONCLUSIONS

Liver surgery for sarcoma metastases is safe and leads to a relatively good survival. The choice for surgical treatment should always be discussed in a multidisciplinary sarcoma and liver team.

Multimodality palliative treatment with transarterial chemoembolization and high-intensity focused ultrasound for gastric leiomyosarcoma multiple liver metastasis pain: A case report

INTRODUCTION

Gastric leiomyosarcoma (LMS) is a rare malignancy with minimal therapeutic options and has poor prognosis once metastasis develops.

PATIENT CONCERNS

A case of gastric LMS with multiple metastases, pain, and progressive anemia 13 months after the initial diagnosis in a 43-year-old woman.

DIAGNOSIS

Gastric LMS with liver metastases and multiple retroperitoneal lymphatic metastases.

INTERVENTIONS

Minimally invasive therapies of repeated tetrahydropalmatine and oxaliplatin-based transarterial chemoembolization and high-intensity focused ultrasound treatment were performed.

OUTCOMES

The treatments resulted in significant pain relief (numerical rating scale from 8-2 points) after the initial treatment, improvement in performance status and quality of life, and a progression-free survival of 4 months after treatment.

CONCLUSION

This combined modality palliative treatment approach was well tolerated with noticeable pain relief.

Hepatic Arterial Infusion Chemotherapy in Sarcoma Liver Metastases: A Report of 6 Cases

Aims and background

Liver metastases in patients with sarcoma are rare and associated with a poor prognosis. The experience with liver-directed therapies, eg hepatic arterial infusion, in these patients is limited.

Methods

Six patients with sarcoma metastatic to the liver (4 patients with gastrointestinal stromal tumors and 2 patients with leiomyosarcoma) were treated by hepatic arterial infusion in our center over a 12-year period. Since the experience was limited, a pooled analysis of reports with data on survival of 22 individual patients was performed.

Results

None of the 5 assessable patients responded to the therapy, and liver metastases progressed in all patients. The median survival was 20 months. In the pooled analysis, partial response was observed in 10 of 21 assessable patients (48%) and median survival was 20 months. The survival was significantly longer in responding patients compared to nonresponders (35 vs 14 months; logrank test, P= 0.009).

Conclusions

Hepatic arterial infusion has little efficacy in the treatment of sarcoma metastatic to the liver. More promising results have been reported for chemoembolization. The survival of responding patients seems to be better compared to non-responders.

Multimodal treatments of right gastroepiploic arterial leiomyosarcoma with hepatic metastasis: A case report and review of the literature

Leiomyosarcoma of an artery is very rare, and cases with hepatic metastasis are even rarer. We describe a case of a 70-year-old man who after follow up due to rectal cancer, presented with an intra-abdominal hypervascular mass and a hepatic mass. After surgical resection, it was diagnosed as a leiomyosarcoma of the right gastroepiploic artery with hepatic metastasis. Multiple metastases had recurred at the liver. He has survived more than 53 mo through multimodal treatments (three surgical resections, radiofrequency ablation, transarterial chemoembolization, chemotherapies, and targeted therapy). Multimodal treatments, including active surgical resection, may be helpful in the treatment of aggressive diseases such as arterial leiomyosarcoma with metastasis.

Recurrence of Primary Vascular Leiomyosarcoma Five Years after Initial Diagnosis in the Lower Extremity

Primary leiomyosarcomas of vascular origin are rare tumors. They frequently arise within the inferior vena cava; however, the peripheral vein was also affected. To date, only a few hundred cases have been reported in the world literature. Although it is an extremely aggressive tumor, the symptoms may be unspecific, especially in the lower extremities. In this report, we present a case of primary vascular leiomyosarcoma, arising from the short saphenous vein, with symptoms mimicking thrombus in the initial diagnosis. The diagnosis of leiomyosarcomas was confirmed by standard H&E staining and immunohistochemical staining. Recurrence of the tumor has been observed five years after surgical treatment. Due to its rarity, experience in the management of this type of tumor is limited. The mainstay of treatment for these tumors is complete surgical resection. The purpose of the presented case is to discuss the clinicopathological features and management options of this tumor, under the light of the most recent literatures.

Hepatic metastases from primary extremity leiomyosarcomas: Two case reports

INTRODUCTION

Leiomyosarcoma is a highly malignant soft tissue sarcoma. Most leiomyosarcomas of the extremities metastasize initially to the lungs, with few metastasizing to the liver. Also, it is difficult to diagnose metastases to other regions of the lung during follow-up.

CASE PRESENTATION

The first patient was a 51-year-old Japanese woman diagnosed with a leiomyosarcoma of the left distal femur. She underwent chemotherapy, followed by wide tumor excision and reconstruction using frozen autograft with total knee arthroplasty. Eleven months later, a focal lesion was observed in her right liver, despite the absence of lung metastases. Partial hepatic resection was performed, and the hepatic lesion was diagnosed a metastasis of leiomyosarcoma. Two years later, there has been no evidence of local recurrence. The second patient was a 60-year-old Japanese male diagnosed with a leiomyosarcoma of the left thigh. He underwent preoperative chemotherapy followed by wide excision. Three years later, a focal lesion was found in his medial liver, despite the absence of lung metastases. Partial hepatic resection was performed, and the hepatic lesion was diagnosed as a metastasis of leiomyosarcoma. At the latest follow-up, there has been no evidence of local recurrence.

CONCLUSIONS

The lung is the most common site of metastases from leiomyosarcomas of the extremeties, because these metastases are hematogenous. Both our patients presented with metastases of the liver, despite the absence of lung metastases. Hepatic metastasis is commonly found in computed tomography (CT) scan. Periodic CT scans of the chest and abdomen are necessary in following-up patients who undergo resection of primary leiomyosarcomas of the extremities.

Imaging features of rare mesenychmal liver tumours: beyond haemangiomas

Tumours arising from mesenchymal tissue components such as vascular, fibrous and adipose tissue can manifest in the liver. Although histopathology is often necessary for definitive diagnosis, many of these lesions exhibit characteristic imaging features. The radiologist plays an important role in suggesting the diagnosis, which can direct appropriate immunohistochemical staining at histology. The aim of this review is to present clinical and imaging findings of a spectrum of mesenchymal liver tumours such as haemangioma, epithelioid haemangioendothelioma, lipoma, PEComa, angiosarcoma, inflammatory myofibroblastic tumour, solitary fibrous tumour, leiomyoma, leiomyosarcoma, Kaposi sarcoma, mesenchymal hamartoma, undifferentiated embryonal sarcoma, rhabdomyosarcoma and hepatic metastases. Knowledge of the characteristic features of these tumours will aid in guiding the radiologic diagnosis and appropriate patient management.

Prognostic Factors Affecting Long-Term Survival after Resection for Noncolorectal, Nonneuroendocrine, and Nonsarcoma Liver Metastases

AIM

To evaluate feasibility and long-term outcome after hepatic resection for noncolorectal, nonneuroendocrine, and nonsarcoma (NCNNNS) liver metastases in a single center.

METHODS

We retrospectively reviewed our experience on patients who underwent surgery for NCNNNS liver metastases from 1995 to 2015. Patient baseline characteristics, tumor features, treatment options, and postoperative outcome were retrieved.

RESULTS

We included 47 patients. The overall 5-year survival (OS) rate after hepatectomy was 27.6%, with a median survival of 21 months. Overall survival was significantly longer for patients operated for nongastrointestinal liver metastases when compared with gastrointestinal (41 versus 10 months; p = 0.027). OS was significantly worse in patients with synchronous metastases than in those with metachronous disease (10 versus 22 months; p = 0.021). The occurrence of major postoperative complication negatively affected long-term prognosis (OS 23.5 versus 9.0 months; p = 0.028). Preoperative tumor characteristics (number and size of the lesions), intraoperative features (extension of resection, need for transfusions, and Pringle's maneuver), and R0 at pathology were not associated with differences in overall survival.

CONCLUSION

Liver resection represents a possible curative option for patients with NCNNNS metastases. The origin of the primary tumor and the timing of metastases presentation may help clinicians to better select which patients could take advantages from surgical intervention.

Surgery and imatinib therapy for liver oligometastasis of GIST: a study of Japanese Study Group on GIST

We conducted a multicenter prospective study to clarify the efficacy and safety of surgery and imatinib for liver oligometastasis of gastrointestinal stromal tumors. Eligible gastrointestinal stromal tumor patients were enrolled in the surgery trial or the imatinib trial. Primary endpoints were recurrence-free survival and progression-free survival, respectively. The trials were prematurely terminated due to amendment of guidelines for adjuvant imatinib therapy and low patient accrual. In the surgery trial, all the six patients showed hepatic recurrence: median recurrence-free survival was 145 days (range: 62-1366 days). Of the five patients receiving salvage imatinib therapy, two showed progressive disease although no death was observed. Of the five patients enrolled in the imatinib trial, one died of pneumonia after progressive disease, and four had not shown progressive disease as of last visit. The results suggest that liver oligometastasis of gastrointestinal stromal tumor may not be controllable by surgery alone and require concomitant imatinib therapy.

Synchronous coexistence of liver metastases from cecal leiomyosarcoma and rectal adenocarcinoma: A case report

Multiple liver tumors represent a challenging condition for abdominal surgeons both in the selection of technique and the rarity of diagnosis. There are no case reports on co-existence of liver metastases from both intestinal leiomyosarcoma and adenocarcinoma. The patient described in this report successfully underwent resection of both primary lesions and liver metastases in combination with chemotherapy. As for the leiomyosarcoma, the primary cecal lesion was revealed more than three years after the patient's first visit. Peritoneal, lymph-node, and lung recurrences were observed afterward, and thus surgeries on those regions were performed. Pathologically, the peritoneal and lung recurrences comprised leiomyosarcoma and the lymph-node recurrence was diagnosed as adenocarcinoma. Despite newly discovered multiple lung recurrences and regional lymph-node metastases, the patient lived a normal life for 73 mo after the initial operation based on multidisciplinary therapy. He ultimately died of liver failure due to invasive lymph-node recurrence from the rectal adenocarcinoma, in addition to multiple lung recurrences from the leiomyosarcoma. Hepatic recurrence did not occur in this patient's case, which appears to be one reason for his long-term survival.

Role of surgical resection for non-colorectal non-neuroendocrine liver metastases

It is widely accepted that the indications for hepatectomy in colorectal cancer liver metastases and liver metastases of neuro-endocrine tumors result in relatively better prognoses, whereas, the indications and prognoses of hepatectomy for non-colorectal non-neuroendocrine liver metastases (NCNNLM) remain controversial owing to the limited number of cases and the heterogeneity of the primary diseases. There have been many publications on NCNNLM; however, its background heterogeneity makes it difficult to reach a specific conclusion. This heterogeneous disease group should be discussed in the order from its general to specific aspect. The present review paper describes the general prognosis and risk factors associated with NCNNLM while specifically focusing on the liver metastases of each primary disease. A multidisciplinary approach that takes into consideration appropriate timing for hepatectomy combined with chemotherapy may prolong survival and/or contribute to the improvement of the quality of life while giving respite from systemic chemotherapy.

Experiences with surgically treated primary or secondary hepatic sarcoma

PURPOSE

Liver resection in hepatic sarcoma is rare, but other alternative treatment options are scarce. Surgery offers the only aggressive approach to achieve a tumour-free state. The aim of this investigation was to evaluate the outcome and survival of these patients at a single hepato-biliary university hospital.

METHODS

Between January 2004 and July 2013, 896 anatomical liver resections were performed. Eleven liver resections (1.2%) were performed due to primary hepatic sarcoma or hepatic sarcoma metastases. The demographic and clinical parameters were collected from the institutional patients' records.

RESULTS

In eight patients (83%), liver resection was performed due to hepatic sarcoma metastases. The surgical procedures were as follows: two patients (18%) had segmentectomy, six patients (55%) had hemihepatectomy or extended hemihepatectomy and three patients (27%) had multivisceral resections. In nine patients (82%), the resection margins were tumour free. In 55% (n = 6) of the patients, the maximal tumour diameter was greater than 10 cm. The postoperative morbidity was low with a Clavien-Dindo score of 2 (range 0-5). One patient died on postoperative day 2 after multivisceral resection. During the follow-up of 932 days (range 2-2.220 days) the 1-, 2- and 3-year survival rates were 91, 63 and 45%, respectively. Tumour recurrence was detected in seven patients (63%).

CONCLUSIONS

Liver resections in patients with primary or secondary hepatic sarcoma are rare. The main goal in these patients is to achieve complete tumour resection because chemotherapy offers no suitable alternative, but the long-term survival rates are limited because of high a recurrence rate even after aggressive surgical approaches.

Percutaneous thermal ablation: A new treatment line in the multidisciplinary management of metastatic leiomyosarcoma?

BACKGROUND

The role of percutaneous thermal ablation (PTA) in the multidisciplinary management of metastatic leiomyosarcoma (LMS) has not been thoroughly evaluated.

MATERIALS AND METHODS

Single institution retrospective review of all patients with LMS metastases treated with PTA from June 2004 to December 2014. Iterative PTAs were performed as a multifocal treatment for all recurrent or residual macroscopic metastases discovered on imaging after completion of systemic treatment, or alternatively as a targeted treatment of selective metastases found to be progressive on systemic treatment. The primary endpoint was the time to untreatable progression (TTUP), recorded as the time elapsed between the first PTA and the re-initiation of systemic chemotherapy to treat disease progression. Secondary endpoints were overall survival, the 1, 3 and 5-year survival rates, and local control rate.

RESULTS

A total of 93 LMS metastases (average diameter 18.2 mm, range 3-45 mm) were successfully treated in 30 patients over 50 treatment sessions with a median follow-up of 34.6 months. The median TTUP was 14.2 months (range 2.4-122.8). The median overall survival after PTA was 48.3 months and the 1, 3 and 5-year overall survival rates were 96.7% (95%CI 84.3-100.0%), 62.0% (95%CI 45.8-84.0%), and 28.3% (95%CI 13.5-59.1%) respectively. Local control rate at 1 year was 95.2% and at 3 years was 89.4%.

CONCLUSION

Iterative PTA is an effective treatment line option for appropriately selected patients with metastatic LMS that can delay re-initiation of systemic chemotherapy.

A Rare Case of Colonic Leiomyosarcoma in Association with Ulcerative Colitis

Ulcerative colitis (UC) is known to be associated with an increased risk of colorectal cancer. However, the occurrence of non-epithelial malignancies is uncommon. An elevated lesion in the descending colon was found in a 51-year-old woman with a 30-year history of UC. Despite tumor progression, repeated biopsies showed no cancerous findings. Because the lesion was highly suspected to be a malignant tumor, a partial colectomy was performed. The pathological diagnosis was leiomyosarcoma. Leiomyosarcoma of the gastrointestinal tract is rare, and this is only the third known case reported in patients with UC.

Long-term survival in metastasized leiomyosarcoma: a case report and review of the literature

BACKGROUND

Leiomyosarcoma of the mesosigma is a very rare entity, with low 5-year survival rates. Treatment consists of resection of the primary tumor and, if applicable, of synchronous or metachronous metastases. Local treatment options for metastatic disease should be exploited as long as possible, as response to chemotherapy is reportedly disappointing. Stereotactic radiotherapy is a fairly new locally effective treatment option which has been well established in stereotactic radiotherapy of lung tumors. Whether repeated stereotactic radiotherapy sessions for treatment of lung metastases can be safely and successfully performed over a long time period is not yet well documented.

CASE REPORT

We present the case of a 71-year-old female patient who had a primary diagnosis of lung metastases 12 years ago. Atypical resections of 4 lung metastases were performed in 2001 and 2002. Between 2004 and 2011, 7 sessions of stereotactic body irradiation of lung metastases were performed. All stereotactic treatment were tolerated well (no radiation pneumonitis, FEV1 was 1.3 L [67.8%] in 2004 and 0.99 L [56.3%] in 2011).

CONCLUSIONS

The present case could demonstrate that a repetitive treatment of lung metastases with multiple stereotactic radiotherapy sessions can lead to long-term survival with a good quality of life.

Liver metastases from non-gastrointestinal non-neuroendocrine tumours: review of the literature

Liver resection is integrated in the oncological surgical management of metastatic gastrointestinal and neuroendocrine tumours. However, the good prognosis reached in these cases has not been obtained for metastatic tumours of other histological types. In this review, we analysed the published case reports and series of hepatectomies in patients with metastatic breast cancer, melanoma, sarcoma, genitourinary tumours, pulmonary and adrenocortical tumours. From the reported data the surgical resection of oligometastases yields good results in terms of improved survival, in particular when the disease-free time period is longer than 1 year. Hepatic resection can be a valid surgical strategy to obtain a survival benefit in patients with liver metastases from non-gastrointestinal, non-neuroendocrine tumours. However, a careful patient selection is needed in order to obtain a real survival benefit; patients with a good performance status, with a disease-free period longer than 1 year and with oligometastases may obtain the best advantage from this approach.

Survival After Resection of Gastrointestinal Stromal Tumor and Sarcoma Liver Metastases in 146 Patients

BACKGROUND

We investigated outcomes by primary tumor type in patients who underwent resection of liver metastases from gastrointestinal stromal tumors (GIST), leiomyosarcomas, and other sarcomas.

METHOD

Our institutional liver database was used to identify patients who underwent resection from 1998 through 2013. Histopathological, clinical, and survival data were analyzed.

RESULTS

One hundred forty-six patients underwent resection of liver metastases from GIST (n = 49), leiomyosarcomas (n = 47), or other sarcomas (n = 50). The 5-year overall survival (OS) rates in patients with GIST, leiomyosarcomas, and other sarcomas were 55.3, 48.4, and 44.9%, respectively, and the 10-year OS rates were 52.5, 9.2, and 23.0%, respectively. The 5-year recurrence-free survival (RFS) rate was better for GIST (35.7%; p = 0.003) than for leiomyosarcomas (3.4%) and other sarcomas (21.4%). Lung recurrence was more common for leiomyosarcomas (36% of patients; p < 0.0001) than for other sarcomas (12%) and GIST (2%). For GIST, the findings support a benefit of imatinib regarding the 5-year RFS rate compared to resection alone (47.1 vs. 9.5%; p = 0.013). For leiomyosarcoma, primary tumor location did not affect the 5-year RFS rate (intraabdominal 14.5%; other location 0%; p = 0.182).

CONCLUSION

Liver metastases from GIST, leiomyosarcomas, and other sarcomas should be assessed separately as their survival and recurrence patterns are different. This is especially important for GIST, for which imatinib is now available.

Metastatic liver disease from non-colorectal, non-neuroendocrine, non-sarcoma cancers: a systematic review

BACKGROUND

Hepatic resection of liver metastases of non-colorectal, non-neuroendocrine, and non-sarcoma (NCNNNS) primary malignancies seems to improve survival in selected patients. The aims of the current review were to describe long-term results of surgery and to evaluate prognostic factors for survival in patients who underwent resection of NCNNNS liver metastases.

METHODS

We identified 30 full texts (25 single-center and 5 multicenter studies) published after year 1995 and published in English with a total of 3849 patients. For NCNNNS liver metastases, 83.4 % of these subjects were resected.

RESULTS

No prior systematic reviews or meta-analyses on this topic were identified. All studies were case series without matching control groups. The most common primary sites were breast (23.8 %), genito-urinary (21.8 %), and gastrointestinal tract (19.8 %). The median 5- and 10-year overall survival were 32.3 % (range 19-42 %) and 24 % (indicated only in two studies, range 23-25 %), respectively, with 71 % of R0 resections.

CONCLUSIONS

There is evidence suggesting that surgery of NCNNNS metastases is safe, feasible, and effective if treatment is part of a multidisciplinary approach and if indication is based on the prognostic factors underlined in literature analysis.

Contemporary management and classification of hepatic leiomyosarcoma

BACKGROUND

Hepatic leiomyosarcomas are rare soft-tissue tumours. The majority of lesions previously considered as leiomyosarcomas have been identified as gastrointestinal stromal tumours (GISTs). Consequently, understanding of the role of liver resection for true leiomyosarcoma is limited, a fact that is exacerbated by the increasing recognition of leiomyosarcoma subtypes. This study presents data on the outcomes of liver resection for leiomyosarcoma and suggests an algorithm for its pathological assessment and treatment.

METHODS

Patients were identified from a prospectively collected departmental database. All tumours were negative for c-kit expression. Immunohistochemistry was performed to identify the presence of oestrogen or progesterone receptor (OR/PR) expression or Epstein-Barr virus (EBV) and patients were stratified according to this profile.

RESULTS

Eight patients (of whom seven were female) underwent a total of 11 liver resections over a 12-year period. One patient had a primary hepatic leiomyosarcoma. Of those with metastatic leiomyosarcomas, the primary tumours were located in the mesentery, gynaecological organs and retroperitoneum in four, two and one patient, respectively. Both leiomyosarcomas of gynaecological origin stained positive for OR/PR expression. One patient had previously undergone renal transplantation; this leiomyosarcoma was associated with EBV expression. Median survival was 56 months (range: 22-132 months) and eight, six and four patients remained alive at 1, 3 and 5 years, respectively.

CONCLUSIONS

Hepatic resection for leiomyosarcoma is associated with encouraging rates of 5-year overall and disease-free survival. The worse outcome that had been expected based on data derived from historical cohorts (partly comprising subjects with GIST) was not observed. An algorithm for pathological classification and treatment is suggested.

Leiomyosarcoma of the sigmoid colon with multiple liver metastases and gastric cancer: a case report

Background

Leiomyosarcoma (LMS) of the gastrointestinal tract is an extremely rare high-grade neoplasm with poor prognosis. For advanced LMS with distant metastasis, the decision as to the choice of the most appropriate therapeutic strategy, including chemotherapy and surgery, is difficult. Here, we present an unusual case of LMS of the sigmoid colon with liver metastases and gastric cancer. The survival of this patient was prolonged by a combined modality therapy involving chemotherapy and surgery.

Case presentation

A 66-year-old woman who had been diagnosed with advanced gastric cancer and multiple liver metastases was referred to our hospital. The initial treatment with docetaxel and S-1 considerably reduced both the gastric cancer and liver tumors; consequently we performed surgical resection. Pathological examination revealed that no viable tumor cells remained in the stomach and chemotherapy resulted in complete remission of the gastric cancer. The liver tumors were immunohistochemically diagnosed as LMS. A tumor of the sigmoid colon was subsequently discovered and the liver tumors were found to have recurred. The surgically resected sigmoid colon and liver tumors were all immunohistochemically diagnosed as LMS. These findings indicated that the multiple liver metastases arose from the LMS in the sigmoid colon, and that they were accompanied by advanced gastric cancer. We performed another surgical resection and administered chemotherapy to treat the recurring liver metastases. The patient survived for 4 years and 10 months after initial presentation at our hospital.

Conclusion

Colonic LMS is rare and its joint occurrence with gastric cancer is extremely unusual. Although LMS is a high-grade neoplasm, a multimodal therapeutic approach can increase patient survival time even when multiple liver metastases are present.

Diagnosis and treatment of sarcoma of the uterus. A review

BACKGROUND

The histopathological classification and staging system for uterine sarcoma (US) were revised in 2003 and 2009, respectively. However, there is currently no consensus on the significance of various prognostic factors. Therefore the available clinicopathological data on US are summarized in this review.

METHODS

Articles on uterine sarcoma published in English from 1970 to 2011 were identified systematically by computer-based searches in Medline and the Cochrane Library.

RESULTS

Prognosis of US is poor, with a five-year survival rate as low as 30%. The most common histological types are leiomyosarcoma (LMS, 63%), endometrial stromal sarcoma (ESS, 21%), adenosarcoma (6%), undifferentiated sarcoma (5%) and other types (5%). Carcinosarcoma is a mixed tumor, which is today regarded as a subset of endometrial carcinoma. Disease stage is the most important prognostic factor for all types of US. However, the prognosis of stage I LMS is also significantly related to tumor size and mitotic index (MI), and stage I ESS is related to MI and tumor cell necrosis (TCN). In adenosarcoma, TCN is the only significant histopathological prognostic factor. Information on the use of preoperative imaging for staging purposes is lacking. Total hysterectomy is the cornerstone of US treatment. The ovary can be preserved in premenopausal women with early-stage LMS and ESS, and routine lymphadenectomy is not necessary unless enlarged lymph nodes are present. As tumor-free resection margins at primary surgery are the most important prognostic factor for survival, sarcoma surgery should be centralized. Adjuvant treatment has changed from radiation therapy to chemotherapy over the last decades, without any change in survival.

CONCLUSION

There are differences in survival between histological types of US. LMS and ESS can be divided into different prognostic groups and should be treated separately.

Outcomes of single-centre experience of hepatic resection and cryoablation of sarcoma liver metastases

BACKGROUND

Liver metastasis from sarcoma in metastatic disease is common and its effect on prognosis remains ill defined. Surgery remains paramount in sarcoma management; however, there is inadequate literature reporting the role of hepatic surgery as treatment for sarcoma liver metastases.

METHODS

Fifteen patients who underwent hepatic resection for metastatic sarcoma between January 1, 1995 and January 1, 2009 were identified from a prospective hepatobiliary database. Clinicopathologic, operative, recurrence, and long-term survival data are presented.

RESULTS

Three patients had synchronous liver metastases. The median time to developing liver metastasis was 26 (range, 0-206) months. The overall median survival from hepatic resection of liver metastasis was 103 (95% confidence interval, 6-200) months with a 5- and 10-year survival of 51% and 37%, respectively. The median disease-free survival from hepatic resection was 14 (95% confidence interval, 11-18) months. CD117 positive tumors was associated with an improved survival with a 3-year survival of 80% compared with 33% in CD117 negative tumors (P = 0.02).

CONCLUSIONS

Hepatic resection for sarcoma liver metastases with or without extrahepatic disease is a reasonable management strategy if a complete resection may be achieved. Concomitant treatment of CD117 positive tumors with imatinib leads to long-term survival.

Surgery for liver metastases originating from sarcoma-case series

INTRODUCTION

Liver metastases originating from various types of sarcoma are a rare reason for hepatic resection. So far, even multicentre studies do hardly provide statistically relevant sample sizes. Thus, review of available data can provide surgeons with useful information in similar cases. Therefore, this study can be regarded more as a contribution to this pool of data than as a stand-alone paper.

PATIENTS AND METHODS

The study includes 10 women and five men who underwent subtotal hepatic resection for solitary (n = 4) and multiple (n = 11) liver metastases originating from sarcoma. The median tumour diameter was 60 mm (range 20-200 mm).

RESULTS

Morbidity was 33%. One patient died within 30 days after surgery. Resection was complete (R0) in 67%. Median overall survival was 33.6 months, 5-year survival 27%. The use of Pringle manoeuvre was significantly associated with poorer outcome (p = 0.014) and shorter period of recurrence-free survival (p = 0.012). Diameter of liver lesion over 50 mm showed significantly shorter recurrence-free survival (p = 0.042).

CONCLUSION

Hepatic resection may be beneficial in patients with isolated sarcoma metastasis in the liver.

Multicentric hepatic EBV-associated smooth muscle tumors in an AIDS patient: a case report, investigation of mTOR activation and review of the literature

Epstein-Barr virus (EBV) - associated smooth muscle tumors (EBV-SMT) are a rare, recently recognized distinct group of mesenchymal tumors that develop exclusively in patients with immunosuppression. It is believed that tumorigenesis is, at least in part, through the activation of the Akt/mammalian target of rapamycin (mTOR) signal pathway. We describe the clinicopathologic and immunohistochemical features of a multifocal hepatic EBV-SMT in a 34-year-old acquired immunodeficiency syndrome (AIDS) patient and investigate the activation status of the mTOR signal pathway in this tumor. In addition, we provide a review of the literature on the clinicopathologic findings of hepatic EBV-SMT in adult AIDS patients, and discuss their biologies and possible therapeutic strategies.

Leiomyosarcoma of the inferior vena cava: case report and treatment of recurrence with repeat surgery

Leiomyosarcoma of the inferior vena cava (IVC) is an extremely rare malignancy with poor prognosis due to late diagnosis. Surgical resection currently remains the best treatment; however, recurrence frequently occurs and the 5-year survival rate is only 31%. The aim of this study is to report a case of IVC leiomyosarcoma and treatment of recurrence with repeat surgery. A 36-year-old woman with a high-grade leiomyosarcoma originating from the infrahepatic IVC underwent an en bloc excision of the tumor. Eleven months after the initial operation, two metastases to the omentum were observed. Since the patient showed no response to adjuvant chemotherapy (i.e., a combination of 5-fluorouracil and gemcitabine), repeat operations were used as the main treatment modality for recurrence. The median time to recurrence was 15 months (range 8-27). The middle and upper IVC segments were involved in the local recurrence, and metastatic lesions occurred in multiple sites including the stomach, omentum, mesentery, left liver, and pelvic cavity. Repeat operations to remove the recurrent and metastatic tumors led to a long-term (at least 7 years) survival, and the patient is still alive. Postoperative recoveries were uneventful. Neither complication related to the venous blood flow in the IVC nor renal impairment was noted. Our results suggest that in the setting of chemotherapy-refractory IVC leiomyosarcoma repeat surgery may be an alternative treatment for recurrence and improve survival time.

Fluorodeoxyglucose positron emission tomography in leiomyosarcoma: imaging characteristics

OBJECTIVE

Leiomyosarcoma, a malignant neoplasm of smooth muscle, accounts for 7% of the sarcomas. Patients with leiomyosarcoma tumors have an average survival of 5 years. These tumors, which are derived from mesenchymal tissues, are difficult to diagnose, and treatment options remain controversial. The relatively rare incidence of this soft tissue sarcoma subtype has limited the number of patients available for studies and research. This study examines whether the imaging characteristics of positron emission tomography (PET) with radiolabeled fluorodeoxyglucose (FDG) provide a reliable, noninvasive means to predict tumor behavior in patients with leiomyosarcomas.

METHODS

[18F]-FDG-PET was performed on the tumors of participating patients before the neoadjuvant chemotherapy or resection, and a maximum tumor standard uptake value (SUVmax) was calculated.

RESULTS

The SUVmax was correlated with tumor grade (P=0.001) and tumor size as greatest dimension (P=0.004). Analysis of these data indicated the potential effectiveness of FDG-PET imaging in predicting tumor grade.

CONCLUSION

In leiomyosarcoma, the SUVmax from FDG-PET is a likely predictor of tumor behavior. The results of this study suggest that a large (by greatest dimension) intermediate grade tumor is expected to have the same predicted outcome as a high-grade tumor and should be treated in the same manner, as they share the same prognosis by definition of tumor grade. Improvements made in the clinical treatment of leiomyosarcomas by use of FDG-PET imaging data may lead to an increase in patient survival.

Hepatic metastasectomy for soft-tissue sarcomas: is it justified?

BACKGROUND

Except for patients with gastrointestinal stromal tumors (GIST), systemic chemotherapy in patients with liver metastasis of soft-tissue sarcoma (STS) is not effective. Therefore, all patients with resectable liver metastases underwent surgical therapy. We present our experience with this approach during the last 13 years.

METHODS

All patients (n=45) with liver metastasis of STS undergoing surgical therapy were prospectively analyzed. Clinical and histopathological parameters as well as the postoperative course were recorded. Survival data were analyzed by using the Kaplan-Meier method and the log-rank test.

RESULTS

Twenty-seven of 45 patients with liver metastasis underwent hepatic resection; 59% of these patients had a solitary metastasis, 22% had two metastases, and 18% had three or more metastatic nodules. The surgical perioperative mortality was 7%. The median survival was 44 (range, 1-123) months, and the 5-year survival was 49%. Repeated resection for recurrent tumor was performed in eight patients, which yielded a median survival of 76 months.

CONCLUSIONS

Patients who have hepatic metastases that are functionally and technically resectable should be considered for surgery because this treatment offers the chance for long-term survival (>5 years).

[Uterine sarcoma treatment]

There are many common features between uterine sarcomas - leiomyosarcoma, endometrial stromal sarcoma, undifferentiated endometrial sarcoma and adenosarcoma -with regards to course, therapy and follow-up, such as post-menopausal bleeding or additional premenopausal bleeding, as well as rapid growth. There is a new staging system according to FIGO and new therapy recommendations according to NCCN. Prior to therapy, imaging staging of the pelvis, abdomen and chest should be carried out due to the frequency with which metastases are found at the time of diagnosis. In the case of disease spread in uterine sarcomas and malignant mixed tumors, good supportive therapy is a possible therapy option instead of chemo- or radiotherapy. The approach - observation, surgery, lymphonodectomy, mono- or polychemotherapy, radiotherapy, hormone therapy - is chosen according to the extent of spread and the resection status. Neoadjuvant therapies are not as yet established.

Developments in the Management of Extremity Soft Tissue Sarcomas

Soft tissue sarcomas, a rare and extremely low prevalence tumor, has no uniform treatment recommendation because there have been few randomized prospective trials to guide management. Recently, there have been surgical, medical, biologic, and genetic advances toward improved treatment. A multidisciplinary approach at specialized treatment centers should be sought because the skill set necessary to implement these advances can be provided and outcomes improved. Centralized care will be crucial to improving survival and functional outcome because it will allow for patients to be effectively entered into prospective randomized trials and create regional and national tissue banks to generate meaningful data.

Hepatectomia para o tratamento de metástases colorretais e não-colorretais: análise comparativa em 30 casos operados

RACIONAL: Hepatectomia é a melhor opção terapêutica curativa para metástases hepáticas de origem colorretal. Mais recentemente, ressecção hepática também tem sido realizada para metástases de etiologia não-colorretal. OBJETIVO: Comparar os resultados em curto e longo prazo de uma série de hepatectomias para 20 doentes com metástase colorretal com uma série de 10 doentes com metástase não-colorretal realizadas pelo Serviço de Cirurgia Geral (Disciplina de Cirurgia do Aparelho Digestivo) da Faculdade Medicina do ABC (Santo André - Brasil). MÉTODOS: Os dados completos de 30 doentes submetidos à hepatectomia por metástase metacrônica entre o período de Janeiro de 2001 e Setembro de 2007 foram avaliados. Vinte com metástase colorretal (Grupo 1) foram comparados com dez com metástase não-colorretal (Grupo 2). Foi realizada análise multivariada dos fatores prognósticos com o programa Epi-Info para Windows. RESULTADOS: Foram realizadas vinte hepatectomias maiores e dez hepatectomias menores. A morbidade foi similar entre os grupos (p >0,05). A mortalidade cirúrgica foi maior no Grupo 1 do que no Grupo 2 (5 % X 0 %), mas não houve significância estatística (p>0,05). Os índices de sobrevida global em 3 e 5 anos foram comparáveis entre os dois grupos (p>0,05). CONCLUSÃO: Nessa amostra, a ressecção hepática para metástase de etiologia não-colorretal apresenta resultados similares aos da metástase colorretal com sobrevida em cinco anos de 20 %. Foram fatores prognósticos adversos: mais que uma metástase e linfonodo positivo.

Diagnosis and multi-disciplinary management of hepatic metastases from gastrointestinal stromal tumour (GIST)

AIM

To explore the present application of diagnosis and management of hepatic metastases from GIST.

METHODS

We performed a systematic review of the literature for studies concerning hepatic metastases from GIST. A literature search was performed using the Medline/PubMed databases to identify publications relevant to the review published from January 1998 to December 2008. Totally 113 relevant articles were retrieved. Abstracts from recent ASCO symposia were hand searched for relevant articles. After the primary filtration, articles on review and with repetitive content were excluded. The articles on clinical research, which were issued in authorized journals, were selected. At last, totally 69 articles were included for review.

FINDINGS

The rate of liver metastases was reported as 15.9% in primary GISTs. The recurrence rate following surgical resection for hepatic metastases from GIST had been reported as 70-77%. For metastatic GIST patients with tyrosine kinase inhibitor (TKI) treatment, it demonstrated rates of CR, PR and SD respectively of 5.84%, 50.7%, and 32.4%. Combining repeated surgery with TKI treatment, R0/R1 resection rates range in various series between 48 and 82%. For those patients with unresectable disease confined to the liver or unable to tolerate liver resection due to co-morbidity or advanced age, RFA, HACE, TKI therapy, or even liver transplantation, can also improve survival.

CONCLUSIONS

The liver is a common metastatic site for gastrointestinal stromal tumour (GIST). Appropriate initial evaluation remains paramount for selecting the correct management strategy. Multi-disciplinary management (which includes pathology, medical oncology, surgical oncology, and imaging expertise) of this disease is important for both curative and palliative treatment in these patients. Combining repeated surgery with TKI treatment may be the most effective management for GIST patients with liver metastases.

Surgical management of leiomyosarcoma of the inferior vena cava

INTRODUCTION

Leiomyosarcoma of the inferior vena cava (IVC) is a rare tumor for which en bloc resection offers the only chance of cure. Due to its rarity, however, optimal strategies for the management of the primary tumor and subsequent recurrences are not well defined.

METHODS

We performed a retrospective review of patients who underwent surgical resection of IVC leiomyosarcoma. We evaluated clinical presentations, operative techniques, patterns of recurrence and survival.

RESULTS

From 1990 to 2008, nine patients (four females) were identified. Median age was 55 years (40-76). Presentations included abdominal pain (n = 5), back pain (n = 2), leg swelling (n = 4) and abdominal mass (n = 2). Pre-operative imaging studies showed tumor location to be from the right atrium to renal veins (n = 1), retrohepatic (n = 5), and from hepatic veins to the iliac bifurcations (n = 3). En bloc resection included right nephrectomy (n = 5), right adrenalectomy (n = 4), pancreaticoduodenectomy (n = 1), right hepatic trisectionectomy (n = 1) and right hemicolectomy (n = 1). The IVC was ligated in six patients, and a prosthetic graft was used for IVC reconstruction in three patients. Resection margins were negative in seven cases. Median length of stay was 12 days (range, 6-22 days). Major morbidity included renal failure (n = 1) and there was one post-operative mortality. Five patients had leg edema post-operatively, four of whom had IVC ligation. Median survival was 47 months (range, 1-181 months). Four patients had recurrence and the median time to recurrence was 14 months (range, 3-25 months). Two patients underwent successful resection of recurrence.

CONCLUSIONS

Curative resection of IVC leiomyosarcoma can lead to long-term survival. However, recurrence is common, and effective adjuvant treatments are needed. In selected cases, aggressive surgical treatment of recurrence should be considered.

Patient selection and outcome of hepatectomy for noncolorectal non-neuroendocrine liver metastases

Improved patient selection, introduction of more effective systemic treatments including targeted biologic and combined therapies, and the low morbidity and mortality rates of hepatobiliary surgery in centers of excellence are likely to provide continued improvements in outcomes for patients with noncolorectal non-neuroendocrine liver metastases. Further advances in treatment may emerge from better understanding of the underlying tumor biology for each cancer type and application of individualized care to each patient.