Liposarcoma in the bone marrow: a terminal event

We report a case of metastatic liposarcoma in the bone marrow with a rapidly fatal course. In view of the poor prognosis and paucity of clinical and imaging findings in patients with high-grade liposarcoma that is metastatic to bone marrow, we propose that bone marrow examination should be performed during the patient's initial evaluation as well as follow-up examinations.

Gene expression patterns of paired bronchioloalveolar carcinoma and benign lung tissue

A variant of adenocarcinoma, bronchioloalveolar carcinoma (BAC), has increased in incidence since 1950 and now represents 2-14% of all lung cancers. There has been concomitant diminution in the proportion of squamous cell carcinoma, the most common form of primary lung cancer. The BAC form of adenocarcinoma occurs disproportionately in women, has an earlier age of onset than conventional pulmonary carcinoma, and is not linked to smoking. The increased incidence of BAC in both smokers and non-smokers suggests that BAC may have an environmental etiology other than smoking. To explore this possibility, we compared the patterns of gene expression in paired samples of tumor and normal lung tissue from 3 patients with a pathologic diagnosis of BAC. Characterization of the gene expression patterns of the paired tissue samples was performed by oligonucleotide microarray analysis of 12,000 known genes and expressed sequence tags (ESTs). We identified 12 genes that were up-regulated > or = 2-fold in all 3 tumors and 6 genes that were down-regulated in all 3 tumors to < or = 0.20 times the baseline. These findings suggest that large scale transcriptional profiling of BAC tumors may disclose a pattern of altered cellular expression in response to genetic changes, diseases, and environmental insult; such transcriptional profiling may aid in diagnosis and therapy.

Ultrastructure of the periductal area of comedo carcinoma in situ of the breast

We have previously shown that the different biological natures of comedo ductal carcinoma in situ (DCIS) and non-comedo DCIS may, in part, be explained by the different expression patterns of tenascin, a large extracellular matrix protein, as observed by immunohistochemical studies. In the present study, we compared 8 cases of comedo DCIS with 5 cases of non-comedo DCIS by ultrastructural analysis, focusing on the myoepithelium, basal lamina, and tenascin-positive extracellular periductal stromal matrix. Our observations show that the comedo type DCIS frequently has an altered basal lamina, a looser and more disorganized collagenous matrix, and a general increase in stromal cellularity, including fibroblasts, lymphocytes, histiocytes and small blood vessels. In addition, in comedo DCIS, the lateral intercellular spaces between large myoepithelial cells that border the basal lamina are often expanded, compared to those of non-comedo DCIS. These results identify structural characteristics of comedo DCIS that may play a role in its greater preinvasive potential. They may also provide a structural basis for the different strategies that are needed for for clinical management of comedo DCIS, compared to non-comedo DCIS.

Adenocarcinoid tumor of the ovary diagnosed during pregnancy. A case report

BACKGROUND

Adenocarcinoid tumors are uncommon neoplasms with dual morphology, showing components of a neuroendocrine tumor with carcinoid features and an adenocarcinomatous component composed of glands lined with mucin-containing cells, some of which are goblet type.

CASE

A 36-year-old woman had a left adnexal mass found during the second week of pregnancy. Sonography showed it to be increasing in size and eventually to become associated with pelvic pain. During the 20th week of gestation, an exploratory laparotomy was performed, and the left ovary and fallopian tube were excised. A diagnosis of adenocarcinoma was rendered by intraoperative frozen section. A staging procedure was then performed that included removal of the contralateral adenexa, pelvic lymph node sampling, peritoneal biopsies and partial omentectomy. The vermiform appendix and gastrointestinal tract appeared unremarkable. The patient was discharged. Permanent sections of the left ovary revealed an adenocarcinoid tumor.

CONCLUSION

While reports detail ovarian metastases of adenocarcinoid neoplasms from primary appendiceal and other gastrointestinal sites, this case, in the setting of a normal appendix and negative workup for an extraovarian origin, is the fourth documented one of a primary ovarian adenocarcinoid tumor and first diagnosed during pregnancy.

Biliary tract brush cytology

OBJECTIVE

To prospectively review brush smears obtained during endoscopic retrograde cholangiopancreatography (ERCP) primarily from the biliary tree.

STUDY DESIGN

A total of 175 specimens from 147 patients were included in the study. The smears, prepared directly from the endoscopic brush, were stained by the Papanicolaou technique and analyzed for standard cytologic features.

RESULTS

The smears were categorized into benign/reactive, significant atypia and suspicious/positive. The consistent features seen in suspicious or positive smears were tightly cohesive, small, three-dimensional cell clusters that formed cell balls. The cells in the clusters displayed features of malignant cells.

CONCLUSION

ERCP-guided brushing is a safe diagnostic procedure for the evaluation of biliary tree lesions. Small, three-dimensional epithelial clusters with marked atypia signify malignancy and warrant the diagnosis of a malignant neoplasm even when only one or two such clusters are seen in the smears. Single cells, cytoplasmic vacuoles and prominent nucleoli are not essential for a diagnosis of malignancy.

Tenascin patterns of expression in duct carcinoma in situ of the breast

Immunohistochemical methods were used to study tenascin (TN) expression in duct carcinoma in situ (DCIS) of the breast of different histologic types. We evaluated 82 lumpectomy specimens of DCIS. There were 5 cases of comedo type, 19 cases of noncomedo type, and 58 cases of mixed comedo and noncomedo type. In 44 cases, the intraductal carcinomas were associated with infiltrating (invasive) duct carcinoma. TN expression was studied by immunohistochemical methods using monoclonal mouse anti-human tenascin (DAKO-TN2M636; 1:50 dilution). Positivity was recorded on a scale of 0 to 2+ for presence of TN staining around tumor ducts and thickness of TN-stained fibrous bands. TN showed positive correlation between thick bands around comedo DCIS and thin bands around noncomedo DCIS. The TN score had statistically significant positive association with high nuclear grade (p 0.004), periductal inflammatory infiltrate of DCIS (p 0.0006), associated extensive central necrosis of DCIS (p 0.0005), and comedo DCIS (p 0.0004). TN expression in the stroma was positively associated with tumor size (p 0.00002), extensive central necrosis (p 0.02), comedo DCIS (p 0.0005), and associated invasive carcinoma (p 0.006). The TN score did not correlate with duct size, multicentric carcinoma, or associated microcalcification. These results demonstrate the different biological nature of DCIS comedo type and suggest its preinvasive potential.

Pleomorphic large cell sarcoma of the spleen with rhabdomyosarcomatous differentiation

An unusual case is reported of pleomorphic large cell sarcoma of the spleen with rhabdomyosarcomatous differentiation in a 34-year old male. According to our knowledge, such a neoplasm has never been reported in the literature.

Multifactorial analysis of long-term follow-up (more than 5 years) of primary extremity sarcoma

BACKGROUND

The majority of survival studies in patients with extremity soft tissue sarcoma have focused on early recurrence and mortality. There are few data addressing long-term follow-up and survival.

OBJECTIVE

To analyze survival and recurrence in patients with extremity soft tissue sarcoma who survive for more than 5 years.

METHODS

Patients who underwent treatment for primary tumors (July 1982 to July 1994) and were followed up for more than 5 years were the subject of study. Disease-specific and disease-free survival were determined actuarially. Significance was evaluated using log-rank testing for univariate analysis and Cox model stepwise regression for multivariate analysis.

RESULTS

A total of 495 patients with primary extremity tumors were treated before July 1989 and eligible for 5-year follow-up. Of these, 282 have been followed up for more than 5 years (median follow-up, 84.4 months). Actuarial disease-specific survival of patients who survive for longer than 5 years was 79%+/-7% (+/-SEM) at 10 years, and of those who were metastasis free at 5 years was 91%+/-4% at 10 years. On univariate analysis, post-5-year disease-specific survival was influenced by positive microscopic margin and initial tumor size of 5 cm or greater. On multivariate analysis, post-5-year disease-specific survival was influenced only by positive margins.

CONCLUSIONS

Based on these analyses, 21% of patients with primary extremity sarcoma who survive for 5 years will die of disease within 5 years. Even of those who are metastasis free at 5 years, 9% will die of disease within 5 years. In contrast to early mortality, tumor grade has no influence on post-5-year prognosis. Patients with positive microscopic margins are at risk for post-5-year disease-specific mortality and therefore require long-term follow-up and consideration for investigational therapy.

Malignant hemangioendothelioma presenting as multifocal intraskeletal lesions during pregnancy. A case report

BACKGROUND

Malignant hemangioendothelioma is a neoplasm of vascular origin characterized by irregular vascular channels lined with atypical endothelial cells.

CASE

A gravida at 32 weeks' gestation presented with diffuse back and lower leg pain and was diagnosed with multifocal malignant hemangioendothelioma of bone. Computed tomography of the chest also demonstrated a small right atrial density. Three weeks later the patient became septic, and cesarean section was performed. After several cycles of chemotherapy, clinical improvement was noted. However, disease progression was noted thereafter, and the patient died one and a half years after the diagnosis.

CONCLUSION

Our case was a primary multifocal malignant hemangioendothelioma of bone arising during pregnancy. Considering the absence of pulmonary involvement, it is unlikely that the skeletal lesions represented metastatic deposits from a cardiac primary. With such extensive skeletal disease, the right atrial density probably was a metastatic deposit.

Primary subcutaneous mucormycosis (zygomycosis): a case report

A case of mycormycosis presenting primarily as a subcutaneous mass of the left leg in an immunocompetent individual is described. The mass that was diagnosed initially as a non-specific foreign body granulomatous process recurred a year later. Histopathological examination of the primary and recurrent lesions revealed partly degenerated hyphae associated with acute necrotizing and chronic granulomatous inflammation. Histomorphological features of primary subcutaneous mucormycosis without predisposing factors have not been previously reported.

Synchronous Paget's disease of the vulva and breast

We report the first case of synchronous Paget's disease of the vulva and breast diagnosed within a period of 7 months. This is the fourth case of mammary Paget's disease associated with either preceding or following vulvar Paget's disease documented in the literature. With consideration of increasing age of the population, and the fact that vulvar Paget's disease affects elderly women and that breast cancer is the most common malignancy of women in the United States, one can anticipate the occurrence of these two conditions to be more prevalent in the future.

Lipoma of the mitral valve in a child

Echocardiographic examination, performed in an asymptomatic 5 year old boy for a perimembranous ventricular septal defect (VSD), revealed a 6 x 6 mm tumor on the anterior leaflet of the mitral valve. Clinically, it was diagnosed as a benign myxoma. Histopathologic diagnosis of the excised mitral valve tumor was benign lipoma. The third case of mitral valve lipoma in the pediatric age group is reported along with a review of the literature. Echocardiogram remains the most sensitive diagnostic modality in the early detection of such neoplasms.

Intraoral tumor of Chievitz in a child

Juxtaoral organs known as organs of Chievitz are intramuscular embryonic structures found close to the angle of the mandible near the insertion of the pterygomandibular raphae. They are considered of neuroepithelial origin with no known function. We describe the first tumor of the organ of Chievitz which presented intraorally in a child. Immunohistochemically, the Chievitz nests showed positive reaction for vimentin, cytokeratins, and epithelial membrane antigen and ultrastructurally demonstrated cytoplasmic processes and intermediate filament bundles. These observations, together with light microscopic features, suggest that the epithelial nests of the organ of Chievitz are meningothelial rather than neuroepithelial.

Primary sarcomas of the mediastinum: results of therapy

Primary sarcomas of the mediastinum are rare, and data concerning treatment and results of therapy are sparse.

OBJECTIVE

To assess presentation, management, prognostic factors, and survival in mediastinal sarcomas.

METHODS

We reviewed our experience with 47 patients with the diagnosis of primary sarcoma of the mediastinum. Data were collected from a computerized institutional database and medical records. Survival was analyzed by Kaplan-Meier method and comparisons of survival by log rank test.

RESULTS

The median age of 47 patients with mediastinal sarcoma was 39 years (range 2.5 to 69 years), with a male/female ratio of 1.6. The most common complaints were chest/shoulder pain (38%) and dyspnea (23%). The most common tumor types were malignant peripheral nerve tumor (26%), spindle cell sarcoma (15%), leiomyosarcoma (9%), and liposarcoma (9%). Operation was the primary treatment modality in 72% of cases (n = 34); 22 sarcomas (47%) were completely resected. The overall 5-year survival was 32%. High-grade lesions had a significantly decreased survival (5-year survival = 27%) compared with low-grade tumors (5-year survival = 66%) (p = 0.05). The overwhelming factor determining survival was the ability to completely resect the tumors (5-year survival 49% for complete resection; 3-year survival 18% for incomplete or no resection) (p = 0.0016). Despite complete resection, local recurrence occurred in 64% of cases.

CONCLUSION

Because the overall survival for patients with mediastinal sarcomas is 32% and the local recurrence is 64% for tumors completely resected, aggressive adjuvant therapy should continue to be systematically explored.

Cytodiagnosis of a primary effusion lymphoma. A case report

BACKGROUND

Primary effusion lymphoma (PEL), commonly described in AIDS patients, is a unique subset of lymphoma in which the neoplastic lymphocytes proliferate exclusively in serous cavities.

CASE

A 27-year-old male, HIV positive for five years and with multiple opportunistic infections in the past, was admitted for sudden-onset shortness of breath caused by a pleural effusion. Cytologic examination of the pleural fluid revealed medium to large atypical lymphocytes with a high mitosis rate, suspicious for lymphoma. Further diagnostic tests, such as immunophenotypic analysis and cytogenetic and molecular studies, confirmed the diagnosis of PEL.

CONCLUSION

Cytopathologists and cytotechnologists should be aware of this new entity since additional studies are required for a definitive diagnosis.

Histiocyte-rich B-cell lymphoma

This is the second report of histiocyte-rich B-cell lymphoma and the first case analyzed by flow cytometry and cytogenetic study. The immunophenotype determined by flow cytometry was that of a B-cell antigen-positive, surface immunoglobulin-negative B-cell lymphoma with 79% CD11c positive histiocytes. The lymphoid cells were composed of 76% neoplastic B-cells and 24% reactive T-cells. Immunohistochemical staining showed large numbers of histiocytes positive for CD68 and lysozyme in the lymph node and the bone marrow. Neoplastic lymphoid cells were positive for CD20, CD45, CD74 and CDw75. The monoclonality of the tumor cells was established by the evidence of rearrangements of the heavy chain and kappa light chain genes and a complex clonal cytogenetic abnormalities including t(8;14)(q11;q32). The tumor cells were large, pleomorphic lymphoid cells and showed no features resembling those of the L/H cells of Hodgkin's disease as previously reported. The rapidly progressive clinical course in the present case is consistent with the clinical features shown in the original study. The histiocytic component in this tumor is presumably recruited by a lymphokine with the nature of a growth factor from the tumor cells that may also be responsible for the rapid proliferation of the tumor cells and the aggressive clinical course. This entity merits special recognition because it leads to a predictable poor prognosis and because of its potential of being misdiagnosed as true histiocytic lymphoma.

Malignant fibrous histiocytoma at the site of a total hip replacement: review of the literature and case report

Tumors developing in association with metallic implants are being reported with increasing frequency in the orthopedic literature. The authors report the tenth case of malignant fibrous histiocytoma associated with a total hip replacement. The diagnosis was made during an evaluation for rapid radiographic osteolysis surrounding the femoral component detected less than 1 year after revision of a hemiarthroplasty to a total hip replacement. The short latency period and aggressiveness of this tumor mimicking rapid osteolysis prompted a review of the literature, etiology and significance of implant-associated malignant fibrous histiocytoma.

Diagnosis and treatment of disseminated struma ovarii with malignant transformation

Struma ovarii are specialized teratomas consisting of thyroid tissue. They may demonstrate all pathologic features seen in the thyroid gland. Malignant transformation of thyroid tissue in struma ovarii is uncommon and is rarely recurrent or metastatic. We report the diagnosis and treatment of a recurrent struma ovarii with malignant transformation, and intraperitoneal, retroperitoneal, and hepatic metastases.

Mesenchymal chondrosarcoma of the cerebellum

Mesenchymal chondrosarcoma is a rare malignant neoplasm of bone and soft tissues. An unique case is described of an 8-year-old child with a midline cerebellar lesion. Pertinent clinical and radiologic findings along with histopathologic features are described. To our knowledge, this is the first case of mesenchymal chondrosarcoma arising in the cerebellar parenchyma of a child.

Prostatic tissue in benign cystic ovarian teratomas

Benign prostatic tissue was found in three of 25 benign cystic teratomas of the ovary. Our finding may indicate that prostatic tissue in mature ovarian teratomas is more common than currently reflected in literature.

Intrathoracic pleomorphic liposarcoma in a child: study of an unusual case

Primary intrathoracic liposarcoma is an extremely rare neoplasm in the pediatric age group. We report an unusual case of a 3-year-old boy who presented with a large intrathoracic tumor arising from the right chest wall. Biopsy showed a pleomorphic sarcoma with histological, immunohistochemical, and ultrastructural features of pleomorphic liposarcoma. The tumor displayed an aggressive clinical behavior, and the patient continued to have recurrences despite rigorous chemotherapy and radiation treatment. He subsequently died 2 years after the initial diagnosis.

Pediatric desmoid tumor: retrospective analysis of 63 cases

PURPOSE

This study was conducted to evaluate clinical prognostic factors predictive of the probability of recurrence of desmoid tumor (DT).

PATIENTS AND METHODS

Sixty-three patients with histologically confirmed diagnosis of DT were retrospectively studied. Median age at diagnosis was 13 years. Patient distribution by site was as follows: 61% extremities, 18% head and neck, 13% trunk (including 5% intraabdominal), and 8% multicentric lesions. All patients had partial or complete resections; 20 patients also received radiotherapy and/or chemotherapy.

RESULTS

At a median follow-up time of 6 years since first treatment, the overall actuarial probability of having one or more recurrences was 75%. Age, sex, site, size, or number of previous recurrences had no significant impact on the likelihood of recurrence. The only factor associated with an increased proportion of recurrence-free patients was a negative margin of resection (70% v 15% with positive margins; P = .006). Of the four patients with more than 3 years follow-up since chemotherapy, two recurred, and of the 11 patients with the same follow-up after radiotherapy, four recurred, including two of five patients who received a dose of 50 Gy or more. No deaths directly related to tumor invasion were observed.

CONCLUSION

A surgical approach aiming at clear margins is presently the best treatment option. When this cannot be accomplished without severe disfigurement or function impairment, partial resection is an acceptable alternative, but one associated with a high risk of regrowth. Whether adjuvant strategies should be used in this situation remains to be addressed.

Pleomorphic rhabdomyosarcoma of the heart metastatic to bone. Report of a case with fine needle aspiration biopsy findings

Pleomorphic rhabdomyosarcoma is an extremely rare and highly malignant neoplasm. We report an unusual case of a 14-year-old boy with skeletal metastases from a primary cardiac tumor. Fine needle aspiration biopsy of a lytic lesion in the right iliac wing showed a pleomorphic population of clusters and single cells with hyperchromatic nuclei; granular, pink cytoplasm; and isolated, large cells with whiplike or globoid cytoplasmic processes and occasional striations. Histologic, ultrastructural and radiologic features are also presented.

Intracardiac teratoma in a child simulating an atrioventricular nodal tumor

Intracardiac teratoma is an extremely rare pediatric neoplasm. We studied the case of a 6-year-old girl with a right intraventricular cardiac mass. The tumor consisted of clusters of monotonous round epithelial cells scattered in a dense fibrotic stroma and was thought to represent an atrioventricular nodal tumor. Three years later the tumor recurred, with multiple mature elements derived from all three germ layers, and was diagnosed as mature cystic teratoma. Still present, however, were multiple areas that were histologically similar to the earlier lesion. Immunostaining revealed strong positivity for insulin, glucagon, somatostatin, and chromogranin consistent with overgrown pancreatic islets of Langerhans within a mature teratoma.

Prognostic factors for recurrence and survival in head and neck soft tissue sarcomas

BACKGROUND

Soft tissue sarcomas of the head and neck represent uncommon malignant neoplasms. With the exception of orbital and parameningeal sites, the treatment of sarcomas in the head and neck has not been standardized. The authors used a prospectively collected database of adult soft tissue sarcomas to identify prognostic factors for local control and survival.

METHODS

A prospectively collected database of adult soft tissue sarcoma from 1982 to 1989 was analyzed for the impact of prognostic factors on local control and survival. Factors examined included histologic type, tumor grade, size, and resection margins.

RESULTS

The overall and disease free survival at 5 years was 71 and 60%, respectively. Local control was 70% at 5 years. On univariate analysis, grade and margin status were predictors for local control. Analysis based on the Cox proportional hazard model revealed that margin status was the only significant factor in predicting local control. Grade and margin status were significant prognostic indicators for survival both on univariate analysis and in the Cox proportional hazard model.

CONCLUSION

Patients with head and neck sarcomas should undergo wide excision with the removal of all gross disease and the acquisition of negative, microscopic surgical margins. Patients with positive margins should receive adjuvant radiotherapy for local control. High grade lesions place patients at risk for local recurrence and distant dissemination. Investigational regimens designed to prevent metastatic disease should be performed.

Preoperative and postoperative adjuvant combination chemotherapy for adults with high grade soft tissue sarcoma

BACKGROUND

Patients with high grade soft tissue sarcoma greater than or equal to 10 cm have a 3-year disease-free survival of approximately 30%. There is no convincing evidence, however, that postoperative adjuvant chemotherapy is beneficial. Preoperative chemotherapy has theoretical advantages over postoperative chemotherapy.

METHODS

Twenty-nine evaluable patients with primary or recurrent high grade, nonmetastatic, soft tissue sarcoma were treated with two preoperative cycles of cyclophosphamide 500 mg/m2, doxorubicin 60 mg/m2, and DTIC 1000 mg/m2 before definitive surgery and radiation. Clinical and radiologic assessment of response to chemotherapy was performed preoperatively, and the resected specimen was examined for treatment effects. Patients who did not progress during preoperative therapy were eligible to receive four additional cycles of chemotherapy. Disease-free and overall survival rates of study patients were compared with two cohorts of historic controls.

RESULTS

Although subjective changes in the firmness of some tumors were observed, only one patient met the criteria for partial response (3%, 2-sided 95% confidence interval = < 1-17%). Intratumoral hemorrhage, cystic necrosis, and liquefaction were observed regularly, and three tumors were more than 90% necrotic. Toxicity of the chemotherapy was acceptable, but patients were reluctant to receive postoperative therapy. The median time free from distant metastasis was 28 months; median survival was 35 months. These results were not superior to the experience with no chemotherapy, or with postoperative doxorubicin.

CONCLUSIONS

Adjuvant chemotherapy for patients with soft tissue sarcoma remains investigational. There is a strong rationale, however, for continued investigation of preoperative chemotherapy for high risk patients using doxorubicin and ifosfamide with colony stimulating factor support. Development of sensitive and specific methods to assess response to preoperative chemotherapy is needed.

Biological study of R24 mouse monoclonal antibody in patients undergoing thoracotomy for pulmonary metastases from soft tissue sarcoma

The disialoganglioside GD3 is expressed on the surface of soft tissue sarcoma, malignant melanoma, and other malignant cells and is, therefore, a potential target for therapeutic monoclonal antibodies. Intravenously administered R24, a murine IgG3 monoclonal antibody to GD3, induces inflammation and tumor regression at sites of metastatic malignant melanoma. R24 5 mg/m2 was given intravenously every other day for six doses to 10 patients with pulmonary metastases from a primary soft tissue sarcoma of the extremity for whom thoracotomy was planned. Resected tissue was available from 7 patients. All metastases expressed GD3; however, expression was heterogeneous within tumors, and in no tumor were more than 80% of the cells GD3 positive. A mild to moderate infiltrate consisting of mononuclear cells with T-cell markers was identified around or within pulmonary metastases in 6 patients. Tolerable acute allergic reactions occurred in all patients, but 3 patients had severe chest tightness and bronchospasm that limited the planned therapy. The setting of thoracotomy for metastatic disease provides an ideal system for studies on the pharmacology and biological effects of monoclonal antibodies that target soft tissue sarcoma antigens.

Aggressive natural killer cell lymphoma/leukemia. A recently recognized clinicopathologic entity

We report a comprehensive study of a case of aggressive natural killer cell lymphoma/leukemia, which is characterized by young male predominance, rapidly progressive clinical course, and presence of lymphadenopathy, hepatosplenomegaly, and bone marrow involvement. The leukemic phase is frequently preceded by pancytopenia. The diagnostic clues are the detection of cytoplasmic granules in tumor cells on Wright-Giemsa-stained tissue imprints or smears and a selective loss of T-cell antigens. Immunophenotyping is decisive in making the final diagnosis by showing positive natural killer cell markers (CD16, CD56, and/or CD57), CD2, CD11c, and Ia, but negative CD3, T-cell receptor heterodimers, terminal deoxynucleotidyl transferase, and B-cell markers. Genotyping always shows germline configuration in both immunoglobulin and T-cell receptor genes. The unique feature in this case is its presentation as a testicular lymphoma, which has not been previously reported. Polymerase chain reaction was performed in this case but failed to detect human T-cell leukemia virus type I/II provirus. It is important to recognize this new entity as it is a highly aggressive disease with a rapidly progressive clinical course and fails to respond to any chemotherapeutic regimen available.

Liposarcoma in patients younger than or equal to 22 years of age

BACKGROUND

There have been few reported series of liposarcomas in patients younger than or equal to 22 years of age.

METHODS

A retrospective analysis of all patients presenting with liposarcoma between 1949-1990 at Memorial Sloan-Kettering Cancer Center with age at diagnosis younger than or equal to 22 years was performed. Variables evaluated for their predictive effect on survival included anatomic location of the primary, size, and completeness of surgical resection.

RESULTS

Eighteen patients were identified. Only 1 patient (6%) presented with a high-grade lesion, and in 13 patients (72%), the myxoid subtype was observed. All but one patient undergoing complete resection remain disease-free 1.3-29.1 years after treatment, while all patients with gross residual tumor have died from disease. Two of three patients with microscopic residual at resection are disease-free 2 and 11.8 years after diagnosis with the addition of external beam radiation therapy.

CONCLUSIONS

The authors conclude that complete surgical resection is crucial for survival in young patients with liposarcoma and the external beam radiation therapy may be effective against microscopic residual.

The changing role of amputation for soft tissue sarcoma of the extremity in adults

The role of amputation in soft tissue sarcoma of the extremity has decreased at Memorial Sloan-Kettering Cancer Center during the last 20 years. In an attempt to determine the reasons for this change in therapy, an analysis of two separate databases involving 1,057 patients compiled during the periods of 1968 to 1978 and 1982 to 1990 was performed. The patients requiring amputation for soft tissue sarcoma of the extremity in the two databases (n = 233) were compared in an attempt to determine any significant differences between the two time periods. The groups were specifically compared for differences in risk factors, indications for amputations and the effect a decreasing incidence of amputation in the 1982 to 1990 group had on local recurrence and overall survival between the two groups. Despite similarity of risk factors and indications for amputation, the decreased incidence of amputation during the 1982 to 1990 period was associated with a significant decrease in local recurrence after amputation and no significant change in overall survival compared with the 1968 to 1978 group. Absence of local recurrence was associated with significant improvement in survival. Possible reasons for the shift in therapy, as well as the present and future role of amputation in soft tissue sarcoma of the extremity, are discussed.

Desmoid tumors of the chest wall. A locally recurrent problem

Desmoid tumors, in general, are known for their propensity to recur. To evaluate treatment and results, we reviewed the records of 32 patients admitted to our institution with a chest wall desmoid tumor from 1948 to 1988. There were 13 men and 19 women whose ages ranged from 12 to 67 years (median 36 years). Four patients had Gardner's syndrome. Treatment was wide resection. Median follow-up was 110 months. The overall 5-year survival was 93%; 5-year disease-free survival was 71%. The 5-year local recurrence rate was 29%. Since death from disease is uncommon after resection, but local recurrence is common, we recommend aggressive wide resection in patients who have desmoid tumors of the chest wall when seen initially.

Refinement of clinicopathologic staging for localized soft tissue sarcoma of the extremity: a study of 423 adults

PURPOSE

The prognostic value of factors used in clinicopathologic staging of localized soft tissue sarcoma (STS) of the extremity were analyzed comprehensively.

PATIENTS AND METHODS

Four hundred twenty-three patients with STS that was confined to the extremity were admitted to Memorial Sloan-Kettering Cancer Center from 1968 to 1978. Cox models for the hazards rates of tumor mortality, development of a distant metastasis, strictly local recurrence, and postmetastasis survival were developed. Tests of changes in the prognostic value of the important variables over time were performed, as well as an analysis of the effect of a local recurrence on the hazard rate of distant metastasis.

RESULTS

Three unfavorable characteristics contained independent prognostic value for the rates of distant metastasis and tumor mortality: high grade (P less than .00001), deep location (P less than .0002), and size greater than or equal to 5 cm (P less than .007). Their Cox model coefficients did not differ significantly (P greater than or equal to .65); thus, a staging scheme based on the risk of ever developing a distant metastasis would assign equal prognostic weights to grade, depth, and size. The tumor grade effect during the initial 18 months was much larger in magnitude than those for depth and size, and its effect disappeared beyond that time (P = .0003). Thus, a staging scheme based on the risk of early metastatic spread would assign a distinctly larger prognostic weight to grade and lesser but equal weights to depth and size. There was no local recurrence effect on the rate of distant metastasis in the high-risk group (high grade, deep, and greater than or equal to 5 cm; P = .75), but there was a significant association among the remaining groups combined (P = .0039). The magnitude of this association actually increased according to the number of favorable characteristics presented (P = .0024).

CONCLUSIONS

The refinement of clinicopathologic staging may depend on the choice of outcome variable: ultimate prognosis versus early metastatic spread. Additionally, the observed local recurrence effect may be explained by a tendency for some patients to acquire one or more unfavorable risk factors at the time of local recurrence.

Tendosynovial sarcoma. Clinicopathologic features, treatment, and prognosis

BACKGROUND

Clinicopathologic features, treatment, and results are reported for 95 tendosynovial sarcomas identified from a prospective sarcoma data base established at Memorial Sloan-Kettering Cancer Center (MSKCC) in 1982.

METHODS

Eighty-five patients had definitive treatment of the primary tumor at MSKCC: Epithelial sarcomas were excluded.

RESULTS

The local recurrence rate was 18%. Survival rates were not influenced by either the method of local treatment or the use of chemotherapy. The overall actuarial survival rate was 59% at 5 years (median, 92 months). For 25 patients who had resection of pulmonary metastases, the 5-year actuarial survival rate was 43% (median, 22 months) from the time of first thoracotomy. Sex, age, tumor site, and histologic subtype (monophasic versus biphasic) were not significant predictors of survival rates. Regional lymph node metastasis occurred in 3%. The incidence of distant metastasis was 49%, with an associated 5-year survival rate of 31% (median, 33 months). Tumor size was a highly significant prognostic feature, with 5-year survival rates of 86% for patients with tumors smaller than 5 cm and 22% for those with tumors larger than 10 cm (P less than 0.00001).

CONCLUSIONS

Improvement of treatment results for tendosynovial sarcoma will require effective new systemic adjuvant therapeutic strategies.

Immunoperoxidase staining of cervicovaginal smears after radiotherapy

Cervicovaginal smears from 2 women with postirradiation dysplasia, 4 women with postirradiation squamous cell carcinoma of the cervix, 30 women with irradiation atypia and 5 healthy, nonirradiated women were stained immunohistochemically with six keratin antibodies. For four of the antibodies--CK19 (BA17), EMA, PKK-1 and CAM 5.2--squamous cells showing irradiation atypia, postirradiation dysplasia or postirradiation squamous cell carcinoma were more likely to stain positively than were nonirradiated squamous cells. For three of the antibodies in which multiple squamous cells stained positively, the proportion of squamous cells showing postirradiation dysplasia or postirradiation squamous cell carcinoma staining strongly was equal to or greater than the corresponding overall proportion for squamous cells showing irradiation atypia. This was statistically significant with only one antibody, PKK-1. No statistically significant differences were seen in staining of irradiated and nonirradiated squamous cells by MAK-6 and AE1:AE3. The data show that some keratin antigens are more often expressed in the irradiated groups and that there may be differences in the degree of antigen expression between squamous cells showing postirradiation dysplasia or postirradiation squamous cell carcinoma and squamous cells showing irradiation atypia.

Adult urological sarcoma

From July 1982 to December 1989, 43 of 1,583 adults (2.7%) with soft tissue sarcoma admitted to the Memorial Sloan-Kettering Cancer Center (MSKCC) had tumors arising from the urinary tract and male genital tract (urological sarcoma). The most common site of origin of the tumor was paratesticular (14 patients), followed by the prostate/seminal vesicle (12), bladder (10) and kidney (7). The most common histological type was leiomyosarcoma (19 patients), followed by rhabdomyosarcoma (14), liposarcoma (5) and 5 other histological sarcoma categories (angiosarcoma, malignant fibrous histiocytoma, mesenchymoma and 2 undifferentiated sarcomas). Most of the tumors were high grade (86%) and more than half (56%) were greater than 5 cm. in diameter. A total of 9 patients (21%) presented with metastatic disease, 8 of whom had rhabdomyosarcoma. Complete resection with negative microscopic margins was possible in 58% of the patients. Actuarial relapse-free survival for all patients at 3 and 5 years was 55% and 40%, respectively. There were no significant differences in survival based on patient age, sex or histological tumor type. Favorable prognostic variables by univariate analysis included tumor diameter less than 5 cm., low histological grade, paratesticular or bladder tumor site and complete surgical resection. Application of the MSKCC sarcoma staging system, which is based on grade, size, depth and presence or absence of metastasis, was useful to predict survival. In our experience patients with stage 3 (high grade, greater than 5 cm., 15 patients) or stage 4 (metastatic disease, 9 patients) had a combined 3-year relapse-free survival rate of only 26% and they should be considered candidates for adjuvant treatment protocols.