Clinicopathological Profile and Survival Outcomes in Patients with Localised Extremity Synovial Sarcomas

AIMS

Synovial sarcoma is a rare but aggressive variant of soft-tissue sarcoma. Literature is sparse and reported mostly from the West. We analysed the clinical profiles and prognostic factors of extremity synovial sarcoma patients in order to study their clinical journey.

MATERIALS AND METHODS

This was a retrospective analysis. All patients with extremity synovial sarcoma treated between 1992 and 2020 were included. Patients with metastases at presentation were excluded. A descriptive analysis of demographic and clinicopathological features of patients undergoing limb salvage surgery (LSS) or amputation was carried out. Overall survival and disease-free survival were calculated for the entire cohort as well as for the LSS and amputation groups. Factors prognostic for survival were identified.

RESULTS

In total, 157 patients had localised extremity synovial sarcoma. Predominantly, young adults (median 31 years) and males (61%) were affected. Over 70% of patients presented after recurrence or unplanned surgeries. Sixty-seven per cent of tumours were >5 cm, 69% were deep and 23% involved bone. The limb salvage rate was 64%. In the LSS group, adjuvant radiotherapy and chemotherapy were given to 72% and 68% of patients, respectively. In the amputation group, 72% of patients received adjuvant chemotherapy. In a median follow-up of 59 months, 39.4% of patients had recurrences, the majority (61.2%) were systemic. Five-year overall survival and disease-free survival were 53.4% and 49.8%, respectively. Overall survival was 63.9% and 29.7% in the LSS and amputation groups, respectively. On multivariate analysis, tumour size, depth, omission of radiotherapy and bone invasion were found to be the adverse prognostic factors.

CONCLUSION

This is one of the largest studies on extremity synovial sarcoma. Mostly males and young adults were affected. The limb salvage rate was 64%, despite most being referred after unplanned surgery. Almost 70% of patients received radiotherapy and chemotherapy. Overall survival was inferior in the amputation group. Tumour size >5 cm, depth and bone invasion were negative, whereas adjuvant radiotherapy was a positive prognostic factor for survival. Chemotherapy had no impact on survival.

When biopsy goes wrong: a case series of misdiagnoses and complications from biopsies of masses of unknown origin potentially originating from a peripheral nerve

OBJECTIVE

Biopsies of peripheral nerve tumors (PNTs) are often used to plan an efficient treatment strategy. However, performing a biopsy is controversial when the mass is likely to be a benign PNT (BPNT). The aim of this study was to evaluate the side effects of biopsies in patients with potential PNTs.

METHODS

A retrospective and cross-sectional study was conducted on 24 patients who underwent biopsy of a mass of unknown origin potentially originating from a peripheral nerve (MUOPON), performed in nonspecialty services, and who were later referred to the authors' service for resection of their lesion between January 2005 and December 2022. The patients were evaluated for pain score, presence of a motor or sensory deficit, biopsy diagnosis, and definitive histopathological postsurgical diagnosis.

RESULTS

The location of the tumor was supraclavicular in 7 (29.2%) patients, in the axillary region in 3 (12.5%), in the upper limb in 7 (29.2%), and in the lower limb in 7 (29.2%). Twenty-one (87.5%) patients were evaluated by MRI before biopsy, and 3 (12.5%) underwent ultrasound. One patient did not have an examination before the procedure. Based on the biopsy findings, 12 (50%) analyses had an inconclusive histopathological result. The preexisting pain worsened, as measured 1 week after biopsy, in all patients and had remained unchanged at the first evaluation by the authors (median 3 months, range 2-4 months). In 1 case, the open biopsy had to be interrupted because the patient experienced excruciating pain. Four (16.7%) patients developed motor deficits. Subsequent surgery was hampered by scar formation and intratumoral hemorrhage in 5 (20.8%) patients. The initial diagnosis obtained by biopsy differed from the final histopathological diagnosis in all patients, of whom 21 (87.5%) had BPNTs, 2 (8.3%) malignant peripheral nerve sheath tumors, and 1 (4.2%) an ancient schwannoma.

CONCLUSIONS

Biopsies of PNTs are controversial and may result in misdiagnosis, neuropathic pain, or neurological deficit due to axonal damage, and they may also hinder microsurgical resection when if performed when not indicated. Indications for biopsy of an MUOPON must be carefully considered, especially if BPNT is a possible diagnosis.

Solitary Fibrous Tumor in the Retroperitoneal Space Arising from the Diaphragm

BACKGROUND/AIM

We present a case of solitary fibrous tumor, arising from the diaphragm in the retroperitoneal space, that was resected with robotic assistance.

CASE REPORT

An 85-year-old female patient was referred to our hospital for evaluation of a suspected right renal tumor. Abdominal contrast-enhanced computed tomography revealed a tumor (maximum diameter, 36 mm) protruding from the superior pole of the right kidney. The patient was scheduled for robot-assisted, retroperitoneoscopic, partial nephrectomy based on a preoperative diagnosis of renal cell carcinoma. Intraoperative findings revealed that the tumor originated from the diaphragm and had no continuity with the renal parenchyma. Pathological examination revealed a solitary fibrous tumor.

CONCLUSION

Solitary fibrous tumors are rare soft-tissue neoplasms with a distinct molecular feature of the fusion of nerve growth factor-inducible A gene-binding protein 2 with signal transducer and activator of transcription 6 gene (NAB2::STAT6). We believe that this is the first reported case of a solitary fibrous tumor arising from the diaphragm in the retroperitoneal space.

Diagnostic accuracy of multiparametric ultrasound for peripheral nerve schwannoma

BACKGROUND

Ultrasound (US) diagnostic techniques have the advantages of low cost, convenient operation, and high availability.

PURPOSE

To explore the diagnostic accuracy of multiparametric US in evaluating signs of peripheral schwannoma.

MATERIAL AND METHODS

This retrospective case-control study included patients with soft-tissue masses on the limbs (divided into the schwannoma and non-schwannoma groups) between January 2017 and November 2020. US features were compared between the two groups, and receiver operating characteristics analysis was used to evaluate the diagnostic efficacy of these features.

RESULTS

A total of 165 patients were included in this study; of them, 63 (38.2%) were diagnosed with schwannoma. Regular morphology (95.2% vs. 39.2%), cystic degeneration (71.4% vs. 27.5%), target sign on elastography (82.5% vs. 0), and polar blood supply sign (87.3% vs. 14.7%) were more common in schwannomas than in non-schwannoma lesions (all P < 0.001). Combining the four signs for diagnosis of schwannomas, the sensitivity, specificity, and accuracy were 95.24%, 96.08%, and 95.76%, respectively, with an area under the curve (AUC) of 0.987 (95% confidence interval = 0.955-0.998). Entering and exiting nerve sign was observed in 87.3% of schwannomas and in 3.0% of non-schwannoma lesions (P < 0.001), while split-fat sign was similar between the two groups (9.5% vs. 2.0%; P = 0.068).

CONCLUSION

Polar blood supply sign and target sign on elastography are specific US signs in peripheral schwannomas. The combination of two-dimensional imaging, color flow imaging, and elastography can achieve an excellent diagnostic accuracy in schwannomas.

Diagnostic accuracy of optical coherence tomography for surgical margin assessment of feline injection-site sarcoma

The invasive, locally aggressive nature of feline injection-site sarcomas (FISSs) poses a unique challenge for surgeons to obtain complete margins with surgical excision. Optical coherence tomography (OCT), an imaging technology that uses light waves to generate real-time views of tissue architecture, provides an emerging solution to this dilemma by allowing fast, high-resolution scanning of surgical margins. The purpose of this study was to use OCT to assess surgical margins of FISS and to evaluate the diagnostic accuracy of OCT for detecting residual cancer using six evaluators of varying experience. Five FISSs were imaged with OCT to create a training set of OCT images that were compared with histopathology. Next, 25 FISSs were imaged with OCT prior to histopathology. Six evaluators of varying experience participated in a training session on OCT imaging after which each of the evaluators was given a dataset that included OCT images and videos to score on a scale from cancerous to non-cancerous. Diagnostic accuracy statistics were calculated. The overall sensitivity and specificity for classification of OCT images by evaluators were 78.9% and 77.6%, respectively. Correct classification rate of OCT images was associated with experience, while individual sensitivities and specificities had more variation between experience groups. This study demonstrates the ability of evaluators to correctly classify OCT images with overall low levels of experience and training and also illustrates areas where increased training can improve accuracy of evaluators in interpretation of OCT surgical margin images.

Benign connective and soft-tissue neoplasms of the oral and maxillofacial region: Cross-sectional study of 1066 histopathological specimens

BACKGROUND

Benign connective and soft-tissue neoplasms (CSTNs) are unusual in the head and neck region. The aim of the present study was to evaluate the demographic and clinicopathological features of these neoplasms.

METHODS

A cross-sectional study was conducted of cases diagnosed as benign CSTNs, with data collected from biopsy records. The chi-square test was used. A p-value <0.05 was considered indicative of statistical significance.

RESULTS

Among the 38 119 specimens, 1066 (2.79%) were benign CSTNs: 369 fibroblastic/myofibroblastic, 250 adipocytic, 179 vascular, 130 neural, 94 osseous/cartilaginous, 19 muscular, and two fibrohistiocytic. Most patients were female (62.8%) and white-skinned (45.8%). Mean age was 42 years. The tongue (25.2%) was the most affected site for extraosseous neoplasms.

CONCLUSION

This study had the largest sample of benign oral and maxillofacial CSTNs. Although these tumors have similar clinical features, the characterization and differentiation detailed here may help clinicians with regards to the correct diagnosis.

Benign or Malignant Characterization of Soft-Tissue Tumors by Using Semiquantitative and Quantitative Parameters of Dynamic Contrast-Enhanced Magnetic Resonance Imaging

PURPOSE

To evaluate the efficacy of the semiquantitative and quantitative parameters of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) in differentiating between benign and malignant soft-tissue tumors.

METHODS

A total of 45 patients with pathologically confirmed soft-tissue tumors (15 benign and 30 malignant tumors) underwent DCE-MRI. The semiquantitative parameters assessed were as follows: time to peak (TTP), maximum concentration (MAX Conc), area under the curve of time-concentration curve (AUC-TC), and maximum rise slope (MAX Slope). Quantitative DCE-MRI was analyzed with the extended Tofts-Kety model to assess the following quantitative parameters: volume transfer constant (Ktrans), microvascular permeability reflux constant (Kep), and distribute volume per unit tissue volume (Ve). Data were evaluated using the independent t test or Mann-Whitney U test and receiver operating characteristic (ROC) curves.

RESULTS

The TTP (P = .0035), MAX Conc (P = .0018), AUC-TC (P = .0018), MAX Slope (P = .0018), Ktrans (P = .0018), and Kep (P = .0035) were significantly different between the benign and malignant soft-tissue tumors. The AUC of the ROC curve demonstrated the diagnostic potential of TTP (0.778), MAX Conc (0.849), AUC-TC (0.831), MAX Slope (0.847), Ktrans (0.836), Kep (0.778), and Ve (0.638).

CONCLUSIONS

The use of semiquantitative and quantitative parameters of DCE-MRI enabled differentiation between benign and malignant soft-tissue tumors. The values of TTP were lower, while those of MAX Conc, AUC-TC, MAX Slope, Ktrans, and Kep were higher in malignant than in benign tumors.

Superficial Acral Fibromyxoma: Literature Review

Superficial acral fibromyxoma is a benign and rare tumor of the soft tissues. It usually manifests itself through a painless mass of slow growth that affects mainly males in the fifth decade of life. It usually affects the distal region, with a polypoid or dome-shaped appearance. The histological appearance is of a dermal mass without capsule, with spindle-shaped fibroblasts in a storiform or fasciculated pattern in the myxocollagenous stroma. The immunohistochemical evaluation of superficial acral fibromyxoma is usually positive for CD34 and CD99, with variable positivity for epithelial membrane antigen. The treatment consists of complete excision of the tumor mass.

A review of the current literature on superficial acral fibromyxoma was performed, with an emphasis on the number of cases reported, location, diagnostic methods, histological characteristics, differential diagnoses and treatment.

A total of 314 reported cases of superficial acral fibromyxoma with variable locations were found in the current literature, mainly in the toes (45.8%) and fingers (39.1%). It has a slightly superior incidence in men (61%) and enormous variability in the age range of occurrence.

Superficial acral fibromyxoma is a single soft-tissue tumor that should enter the differential diagnosis of periungual and subungual acral lesions; the treatment consists of simple excision. More studies are needed to better understand this pathology, which was first described in 2001.

Mesenchymal chondrosarcoma of the right buccal region: A case report and review of the literature

Extraskeletal mesenchymal chondrosarcoma (EMCS) is a rare malignant cartilaginous tumor arising from the soft tissues. The most common areas of extraskeletal origin are the lower extremities, the orbits and the central nervous system, among others. In this study, the case of primary EMCS arising from the right buccal region in a 26-year old female is presented. Histological and immunohistochemical analysis confirmed the diagnosis of EMCS. Subseqently, the patient was treated with radical surgery, but declined chemotherapy or radiotherapy, which was recommended. One year after surgery, no recurrence had been identified in the patient. To the best of our knowledge, only one case of primary EMCS of the buccal region has been reported previously. In the current study, a case of primary EMCS of the buccal region is presented.