Soft Tissue Sarcomas in Adolescents and Young Adults

Global burden of soft tissue sarcomas in 204 countries and territories from 1990 to 2021: data from the global burden of disease study 2021

BACKGROUND

There is a lack of epidemiological surveys on soft tissue sarcoma (STS) worldwide. This study aims to assess the global disease burden of soft tissue sarcoma in 204 countries and regions.

METHODS

We analyzed the incidence, mortality, and disability-adjusted life years (DALYs) of STS based on the data provided by the Global Burden of Disease (GBD) 2021 study, and assessed the trends in disease burden across different regions, sexes, and age groups. At the same time, we used the Bayesian Age-Period-Cohort (BAPC) model to predict the development trend of the global disease burden of STS.

RESULTS

Globally, over the past 30 years, the number of STS cases has increased from 54,630.92 in 1990 to 96,200.96 in 2021, while the age-standardized incidence rate has decreased by 0.05 per 100,000 people during this period. The age-standardized incidence rate and DALYs rate have respectively declined by 0.14 per 100,000 people and 6.86 years per 100,000 people. In 21 GBD regions, there is a significant positive correlation between Socio-Demographic Index(SDI) and incidence rate (R = 0.4730, P < 0.0001). It is projected that the number of STS cases will peak in 2033, reaching 95,591.93 people.

CONCLUSION

The disease burden of STS has been decreasing, especially regarding mortality and DALYs rates. It's more prevalent in developed regions, males, and older. Focused medical prevention and health measures for these groups can help reduce the global disease burden.

Global patterns and burden of soft tissue and extraosseous sarcomas: trends from 1990 to 2021

BACKGROUND

Soft tissue sarcomas (STS) are a rare group of malignant tumors originating from soft tissues. The study systematically evaluates the global burden of soft tissue and extraosseous sarcomas from 1990 to 2021 across diverse populations.

METHODS

We examined incidence, mortality, and disability-adjusted life years (DALYs) using data from the Global Burden of Disease (GBD) 2021 database. Estimated annual percentage change (EAPC) assessed trends from 1990 to 2021. Cross-country inequality was evaluated using the socio-demographic index (SDI), inequality slope index, and concentration index. Decomposition analysis identified key drivers of changes in disease burden. Frontier analysis pinpointed countries with potential for improvement, while Bayesian age-period-cohort (BAPC) projected trends through 2036.

RESULTS

Although the absolute numbers of cases, deaths, and DALYs increased, the global age-standardized incidence rate (ASIR), mortality (ASMR), and DALYs (ASDR) decreased. Males consistently exhibited higher rates than females, with the highest rates in individuals aged 95 and older. In high-SDI regions, ASIR slightly increased, whereas ASMR and ASDR decreased. The gap between high- and low-SDI countries widened over time. Projections indicate that by 2036, absolute numbers will increase, while age-standardized rates will further decline.

CONCLUSIONS

Despite the increasing absolute burden, the global age-standardized rates have declined, likely reflecting multiple contributing factors. However, the persistent disparities underscore the need for improved access to care and targeted public health interventions to mitigate the global burden.

Anlotinib versus Placebo as Adjuvant Therapy for Localized High-Grade Soft-Tissue Sarcomas: A Phase II, Double-Blinded, Randomized Controlled Trial

PURPOSE

We aimed to investigate the efficacy and safety of anlotinib as adjuvant targeted therapy for completely resected localized high-grade soft-tissue sarcomas (STS).

PATIENTS AND METHODS

Patients with localized high-grade STS after complete resection were randomly assigned in a 1:1 ratio to receive either oral 12 mg anlotinib or placebo once daily on days 1 to 14 every 21 days as a cycle, with up to six cycles until disease relapse, unmanageable toxicity, or death. The efficacy and safety were analyzed. This trial was the first trial exploring adjuvant targeted therapy for STS (NCT03951571).

RESULTS

Between June 2019 and November 2023, 88 patients were randomly assigned to receive anlotinib (n = 44) or placebo (n = 44). With a median follow-up of 30.95 months, the 1- and 2-year disease-free survival rates were 88% and 77% in the anlotinib group compared with 64% and 58% in the placebo group, respectively. Compared with patients treated with surgery alone, patients receiving adjuvant anlotinib combined with surgery had a reduced risk of disease recurrence [HR, 0.47; 95% confidence interval (CI), 0.22-1.00; P = 0.0445]. Based on the tumor histology, the reduced risk of disease recurrence with anlotinib versus placebo was observed in patients with myxofibrosarcoma (HR, 0.54; 95% CI, 0.17-1.65; P = 0.2698) and undifferentiated pleomorphic sarcoma (HR, 0.58; 95% CI, 0.12-2.87; P = 0.4971). Four patients discontinued anlotinib: two for proteinuria/hematuria (2/44, 5%) and two for poor healing of surgical wound (2/44, 5%).

CONCLUSIONS

Compared with surgery alone, adjuvant anlotinib following surgery reduces the incidence of disease relapse in localized high-grade STS, with acceptable toxicity.

Efficacy of triplet antiemetic prophylaxis against chemotherapy-induced nausea and vomiting in patients with soft tissue sarcomas receiving consecutive-day doxorubicin and ifosfamide therapy

BACKGROUND

Doxorubicin and ifosfamide (AI) therapy for soft tissue sarcomas (STS) is given as a 5-day continuous-dose chemotherapy regimen, and classified as carrying high emetic risk. The purpose of this study was to evaluate the efficacy of triplet antiemetic prophylaxis, consisting of a 5-HT3 receptor antagonist, dexamethasone (DEX), and an NK1 receptor antagonist, against chemotherapy-induced nausea and vomiting (CINV) induced by AI therapy, and to determine the prophylactic antiemetic effect of the addition of olanzapine (OLZ) to this triplet antiemetic prophylaxis in cases of poor antiemesis.

PATIENTS AND METHODS

Patients who received AI therapy for STS between October 2011 and October 2022 were included in this retrospective study. Patients who did not receive the standard triplet antiemetic prophylaxis of granisetron, DEX, and aprepitant were excluded. Primary endpoint was the rate of complete response (CR) and secondary endpoint was the rate of significant nausea prevention during the acute (days 1-6), delayed (days 7-10), and overall (days 1-10) periods. In addition, CR rate and significant nausea prevention during the acute phase were compared before and after the addition of OLZ in patients who received OLZ as antiemetic prophylaxis in the subsequent cycle due to poor antiemetic control.

RESULTS

A total of 58 patients were analyzed. CR rate for all patients was 32.8% in the acute phase, 53.4% in the delayed phase, and 29.3% in the overall period. The significant nausea prevention rate was 19.0%, 43.1%, and 13.8%, respectively. Sixteen patients received additional OLZ as an antiemetic prophylaxis. Their CR rate before and after the addition of OLZ during the acute phase improved significantly, from 6.3 to 43.8% (P = 0.041). The rate of significant nausea prevention tended to improve, from 6.3 to 43.8% (P = 0.077).

CONCLUSION

Control of CINV with granisetron, DEX, and aprepitant was poor in patients with STS receiving AI therapy. Addition of OLZ to this standard triplet antiemetic prophylaxis may improve CINV control in the subsequent cycle in patients who experience inadequate CINV control during their first cycle of AI therapy.

Rhabdomyosarcoma in children and young adults

Rhabdomyosarcoma (RMS) is the most common soft tissue malignancy in childhood, accounting for 3% of all pediatric malignancies and 50% of all pediatric soft tissue sarcomas. In adolescents and young adults (AYA) however, RMS comprises only 6.5% of all soft tissue sarcomas. Historically, diagnosis and treatment of RMS was based on histologic recognition of the alveolar subtype, which was associated with a worse prognosis. Within the past 20 years, the biologic characteristics of RMS have become clearer, with canonical fusion drivers, PAX3/7::FOXO1, characterizing the alveolar subtype (ARMS) and in turn associated with poor outcome, while chromosomal gains/losses in addition to RAS pathway alterations characterize the embryonal subtype (ERMS). Accordingly, detection of a FOXO1 gene fusion has become a commonplace diagnostic and prognostic tool allowing tumors to be treated based on presence or absence of a FOXO1 gene fusion. However, these cytogenetic and molecular alterations represent only a portion of the molecular landscape found in RMS, and other alterations are found with increasing frequency in various subsets of RMS. Clinical trials basing risk stratification on the presence or absence of the canonical PAX3/7::FOXO1 fusions have had success in identifying the poor responders. Due to poor outcomes, the presence of MYOD1 and TP53 alterations which are common in spindle cell sclerosing RMS (SSRMS) and RMS with anaplasia have also been integrated into trial risk stratification. Therefore, complete histologic and immunophenotypic characterization remain important to better recognize and study these rare subsets of RMS. This article will discuss the challenges of RMS classification including how to combine morphologic, immunophenotypic and molecular data to arrive at an integrated diagnosis. The use of newer techniques such as liquid biopsy and methylation profiling, will also continue to shape the classification of RMS and may further refine risk stratification and prognosis.

Contemporary surgical management of pediatric non-rhabdomyosarcoma soft tissue sarcoma

Non-rhabdomyosarcoma soft tissue sarcoma (STS) comprises most STS in pediatric patients. It is a diverse set of over 30 histologic subtypes. Treatment is based on risk group determined by tumor size, grade, and the presence of metastases. Surgical resection is a cornerstone of therapy, as tumors are often resistant to chemotherapy or radiation. While patients with isolated tumors less than 5 cm may undergo upfront resection, strong consideration should be given to neoadjuvant chemoradiotherapy to ensure negative margins at surgical resection and optimal outcomes. Sentinel lymph node biopsy is strongly recommended for clear cell and epithelioid sarcomas. The most common metastatic site is the lung, and metastases should be resected at the end of therapy, when feasible. Unfortunately, many high-risk patients progress on therapy, and alternative strategies including earlier metastatic control require investigation.

Low NT5DC2 expression predicts favorable prognosis and suppresses soft tissue sarcoma progression via ECM-receptor interaction pathway

BACKGROUND

Soft tissue sarcoma, a malignant tumor arising from mesenchymal tissues with poor prognosis. 5'-Nucleotidase Domain Containing 2 (NT5DC2) is a novel oncogene, and the precise involvement of NT5DC2 in soft tissue sarcoma were still undefined. Hence, our study aims to investigate NT5DC2 functions in soft tissue sarcoma progression.

METHODS

The tumor immune single-cell hub 2 (TISCH2) website, The Cancer Genome Atlas (TCGA) pan-cancer or sarcoma and Gene Expression Omnibus (GEO, GSE21122) databases were applied to visualize the NT5DC2 status in the sarcoma databases. The NT5DC2 protein expression in sarcoma tissues in our hospital was detected by using immunohistochemistry (IHC) and analyzed the associations between NT5DC2 expression and clinicopathological parameters. Real-time quantitative polymerase chain reaction (RT-qPCR), colony formation, 5-ethynyl-2'-deoxyuridine (EdU) assay, wound healing, transwell, flow cytometry and xenograft model were used to elucidate the effects of NT5DC2 downregulated by lentivirus in sarcoma cell.

RESULTS

The TISCH2 website detection found that NT5DC2 expression is enriched in malignant cells in sarcoma single-cell database. Furthermore, the TCGA-sarcoma database indicated that NT5DC2 expression correlates with metastasis, positive margin status, prognosis, and diagnostic value. Additionally, IHC staining showed that 40 % of soft tissue sarcoma patients present high expression of NT5DC2, and NT5DC2 upregulation is closely associated with poor prognosis. Functional verification analysis further revealed that downregulating NT5DC2 expression can suppress sarcoma progression through the ECM-receptor interaction pathway.

CONCLUSION

Low expression of NT5DC2 predicts a favorable prognosis in soft tissue sarcoma, and downregulated NT5DC2 expression can suppress sarcoma cell progression through the ECM-receptor interaction pathway.

Proteomic features of soft tissue tumours in adolescents and young adults

BACKGROUND

Adolescents and young adult (AYA) patients with soft tissue tumours including sarcomas are an underserved group with disparities in treatment outcomes.

METHODS

To define the molecular features between AYA and older adult (OA) patients, we analysed the proteomic profiles of a large cohort of soft tissue tumours across 10 histological subtypes (AYA n = 66, OA n = 243), and also analysed publicly available functional genomic data from soft tissue tumour cell lines (AYA n = 5, OA n = 8).

RESULTS

Biological hallmarks analysis demonstrates that OA tumours are significantly enriched in MYC targets compared to AYA tumours. By comparing the patient-level proteomic data with functional genomic profiles from sarcoma cell lines, we show that the mRNA splicing pathway is an intrinsic vulnerability in cell lines from OA patients and that components of the spliceosome complex are independent prognostic factors for metastasis free survival in AYA patients.

CONCLUSIONS

Our study highlights the importance of performing age-specific molecular profiling studies to identify risk stratification tools and targeted agents tailored for the clinical management of AYA patients.

Identifying specific TLS-associated genes as potential biomarkers for predicting prognosis and evaluating the efficacy of immunotherapy in soft tissue sarcoma

Background

The tertiary lymphatic structure (TLS) is an important component of the tumor immune microenvironment and has important significance in patient prognosis and response to immune therapy. However, the underlying mechanism of TLS in soft tissue sarcoma remains unclear.

Methods

A total of 256 RNAseq and 7 single-cell sequencing samples were collected from TCGA-SARC and GSE212527 cohorts. Based on published TLS-related gene sets, four TLS scores were established by GSVA algorithm. The immune cell infiltration was calculated via TIMER2.0 and "MCPcounter" algorithms. In addition, the univariate, LASSO, and multivariate-Cox analyses were used to select TLS-related and prognosis-significant hub genes. Single-cell sequencing dataset, clinical immunohistochemical, and cell experiments were utilized to validate the hub genes.

Results

In this study, four TLS-related scores were identified, and the total-gene TLS score more accurately reflected the infiltration level of TLS in STS. We further established two hub genes (DUSP9 and TNFSF14) prognosis markers and risk scores associated with soft tissue sarcoma prognosis and immune therapy response. Flow cytometry analysis showed that the amount of CD3, CD8, CD19, and CD11c positive immune cell infiltration in the tumor tissue dedifferentiated liposarcoma patients was significantly higher than that of liposarcoma patients. Cytological experiments showed that soft tissue sarcoma cell lines overexpressing TNFSF14 could inhibit the proliferation and migration of sarcoma cells.

Conclusion

This study systematically explored the TLS and related genes from the perspectives of bioinformatics, clinical features and cytology experiments. The total-gene TLS score, risk score and TNFSF14 hub gene may be useful biomarkers for predicting the prognosis and immunotherapy efficacy of soft tissue sarcoma.

Soft Tissue Sarcomas with Chromosomal Alterations in the 12q13-15 Region: Differential Diagnosis and Therapeutic Implications

The chromosomal region 12q13-15 is rich in oncogenes and contains several genes involved in the pathogenesis of various mesenchymal neoplasms. Notable genes in this region include MDM2, CDK4, STAT6, DDIT3, and GLI1. Amplification of MDM2 and CDK4 genes can be detected in various mesenchymal and nonmesenchymal neoplasms. Therefore, gene amplification alone is not entirely specific for making a definitive diagnosis and requires the integration of clinical, radiological, morphological, and immunohistochemical findings. Neoplasms with GLI1 alterations may exhibit either GLI1 rearrangements or amplifications of this gene. Despite the diagnostic implications that the overlap of genetic alterations in neoplasms with changes in genes within the 12q13-15 region could create, the discovery of coamplifications of MDM2 with CDK4 and GLI1 offers new therapeutic targets in neoplasms with MDM2/CDK4 amplification. Lastly, it is worth noting that MDM2 or CDK4 amplification is not exclusive to mesenchymal neoplasms; this genetic alteration has also been observed in other epithelial neoplasms or melanomas. This suggests the potential use of MDM2 or CDK4 inhibitors in neoplasms where alterations in these genes do not aid the pathological diagnosis but may help identify potential therapeutic targets. In this review, we delve into the diagnosis and therapeutic implications of tumors with genetic alterations involving the chromosomal region 12q13-15, mainly MDM2, CDK4, and GLI1.