Incidence patterns of soft tissue sarcomas, regardless of primary site, in the surveillance, epidemiology and end results program, 1978-2001: An analysis of 26,758 cases

Soft tissue sarcomas (STS) are a heterogeneous group of uncommon tumors that show a broad range of differentiation that may reflect etiologic distinction. Routine tabulations of STS are not morphology-specific. Further, the lack of inclusion of sarcomas arising in all organs in most standard evaluations underestimates the true rates. We analyzed the 1978-2001 Surveillance, Epidemiology and End Results program incidence rates of STS regardless of primary site, except bones and joints, using the 2002 criteria of the WHO classification. There were 26,758 cases available for analysis. Leiomyosarcomas accounted for 23.9%, malignant fibrous histiocytomas 17.1%, liposarcomas 11.5%, dermatofibrosarcomas 10.5%, rhabdomyosarcomas 4.6% and angiosarcomas 4.1%. Almost half (47.9%) of the sarcomas arose in the soft tissues, 14.0% in the skin and 7.0% in the uterus. Overall, incidence rates were highest among black women (6.26/100,000 woman-years) and the lowest among white women (4.60/100,000). Age-adjusted rates increased at 1.2% and 0.8% per year among white males and females, respectively, both trends statistically significant, while rates among blacks declined slightly. About 40% of leiomyosarcomas among women were uterine in origin, with a black/white rate ratio of 1.7. This rate ratio increased to 2.0 when we accounted for the lower prevalence of intact uteri among black compared to white women. Total STS rates rose exponentially with age. Rates for both uterine leiomyosarcoma and dermatofibrosarcoma increased rapidly during the childbearing years, peaking at about age 40 and 50, respectively. Incidence patterns of STS varied markedly by histologic type, supporting the notion that these tumors may be etiologically distinct.

Sarcomas of the oral and maxillofacial region: a review of 32 cases in 25�years

Thirty-two cases of sarcomas involving the oral and maxillofacial region over a period of 25 years were reviewed. The age range was from 5 months to 77 years with a mean age of 42. The male to female ratio was 3:1. The sarcomas were located in the maxilla including the maxillary sinus (n= 13), mandible (n= 13), buccal mucosa (n= 3), temporomandibular fossa (n= 2), and submandibular region (n= 1). Histologically sarcomas were classified as osteosarcoma (n= 9), malignant fibrous histiocytoma (n= 7), rhabdomyosarcoma (n= 5), fibrosarcoma (n= 3), plasmacytoma (n= 2), leiomyosarcoma (n= 2), angiosarcoma (n= 2), liposarcoma (n= 1), and ameloblastic fibrosarcoma (n= 1). Surgical resection was performed in 29 cases. Local recurrence was found in 10 patients and metastasis in 11 patients. Metastases included five regional lymph node metastases and eight distant metastases. The survival of patients with local recurrence or metastasis was poor. Surgery is the most reliable treatment for sarcomas of the oral and maxillofacial region. Adequate excision with safety surgical margin as the initial therapy is important for better survival. The value of radiation therapy and/or chemotherapy is uncertain. The 5-year survival rate of primary cases was 61%.

[Frequency of genetic diseases and cancer antecedents in 493 adults with visceral or soft tissue sarcomas]

Little is known about epidemiology of adults soft tissue and visceral sarcomas (ASTS). The frequency of previous cancers and associated genetic diseases has been analyzed out of 493 ASTS, treated between 1997 and 2002 at Oscar Lambret Cancer Center. Median age is 51, sex ratio is close to 1. Liposarcomas and malignant fibrous histiocytofibromas are the two main types (respectively 104 and 86 cases). Upper and lower limbs are the two main locations (respectively 176 and 75 cases). Fifteen patients had associated genetic disease, including 12 cases of Recklinghausen diseases. 7 out of those 15 patients have neurosarcoma. 30 patients have previous cancers, including 7 breast cancers, 3 lymphomas and 3 chronic lymphocytic leukemias. Four out of those 30 patients have two different previous cancers. 13 patients have radiation-induced sarcomas, after an average 10-year-period, and an average dose of 53 Gy. Undifferenciated sarcomas are the main histologic type (8/13), followed by angiosarcomas (2/13). Radiation-induced sarcomas are located in the chest wall (7/13), in pelvis (2/13) and head and neck (2/13). Those sarcomas are high grade (10 grade III tumours). ASTS epidemiology is complex with different risk factors depending on histologic type.

Sclerosing haemangioma of the lung in a 4-year-old child

Sclerosing haemangioma of the lung (SHL) should be recognised as a distinct clinicopathological entity. It is a benign neoplasm, probably of epithelial origin. Clinically, the tumour is asymptomatic and shows a striking preponderance in middle-aged women. SHL is often detected incidentally, as a round, well-defined homogeneous mass on routine chest radiograms. The diagnosis is based on pathohistologic examination of the biopsy material, therapy is surgical, and prognosis is excellent. We report a case of a 4-year-old boy with SHL, which is extremely rare in childhood.

Fibrous histiocytoma of tendon sheath of the hand

The hand is not uncommonly afflicted by Fibrous histiocytoma/Giant Cell tumour of tendon sheath, an enigmatic and loosely-defined clinical entity only occasionally entering into the literature. The 26 cases in this clinico-pathologic review were obtained by a computerised search of histological files at the Dept. of Pathology, UCHG. Twice as many of these were female, more often in their fourth decade of life. The condition has a propensity for the long digits, more often the volar aspect and roughly evenly distibuted over each of the joints. Resection of these neoplasia is tedious due to it's propensity to grow between local anatomical structures contributing to a high recurrence rate. Interestingly it rarely figures in guesses at pre-operative diagnosis although the second commonest cause of a benign superficial hand mass after ganglion. We suggest that if this condition is suspected, referral to a specialist hand surgeon in the first instance is wise.

Histopathological survey of neoplasms in flat-coated retrievers, 1990 to 1998

Over the period from March 1990 to December 1998, veterinary surgeons in general practice were invited to submit tissues suspected of being neoplastic which had been removed from flat-coated retrievers. When possible, pedigree details were obtained from the owners. In addition, data were collected from flat-coated retrievers known to have suffered from a neoplastic condition and for which a histopathological report was available. A total of 1023 submissions was obtained from 782 dogs. These included 165 non-neoplastic lesions (16 per cent), 447 benign samples (44 per cent) and 411 malignant samples (40 per cent). Soft tissue sarcomas accounted for 55 per cent of the malignant samples (26 per cent of all tumour samples and 22 per cent of all submissions) with 63 per cent of them being diagnosed as undifferentiated. Carcinomas accounted for 20 per cent of malignant samples (8 per cent of all submissions). Of the benign tumours, cutaneous histiocytoma was the most common diagnosis (48 per cent of benign tumours, 25 per cent of all tumours and 21 per cent of all submissions).

Primary renal malignant fibrous histiocytoma. A case report and review of the literature

Primary renal malignant fibrous histiocytoma is a rare tumor of the kidney. We report an additional case noting, as other authors have, the similarity in clinical presentation with renal cell carcinoma. We also review the 23 documented cases of the international literature, emphasizing the current diagnostic approaches and therapeutic management.

Locally recurrent malignant fibrous histiocytoma: a rare and aggressive genitourinary malignancy

OBJECTIVE

In this study, 22 cases of locally recurrent urological malignant fibrous histiocytoma were reviewed considering therapeutic options, follow-up and prognosis.

PATIENTS AND METHODS

In the available literature on this topic we identified 19 cases of locally recurrent genitourinary malignant fibrous histiocytoma. Three additional cases are discussed, primarily arising from the kidney, the bladder and the paratesticular region.

RESULTS

The prognosis of locally recurrent urological malignant fibrous histiocytoma was found to be extraordinarily poor. Only 2 of 22 patients have survived for longer than 3.5 years. One of them reported herein is still alive 10 years after extensive lymphatic spread accompanying the first local recurrence. In this case, late local recurrence occurred after an 8-year interval free of disease.

CONCLUSION

Malignant fibrous histiocytoma is an unusual urological malignancy with a high rate of local recurrence. The latter is frequently accompanied by metastatic disease and unrelenting progression. Despite the poor prognosis early detection of local failure and aggressive salvage therapy might offer the chance of long-term survival in selected cases. Close and life-long follow-up is advisable for patients once treated for recurrent urological malignant fibrous histiocytoma.

The risk of angiosarcoma following primary breast cancer

Lymphangiosarcoma of the upper extremity is a rare and aggressive tumour reported to occur following post-mastectomy lymphoedema (Stewart-Treves syndrome). Haemangiosarcoma, a related rare tumour, has occasionally been reported to occur in the breast following irradiation. We conducted a case-control study using the University of Southern California-Cancer Surveillance Program, the population-based cancer registry for Los Angeles County, to evaluate the relationship between invasive female breast cancer and subsequent upper extremity or chest lymphangiosarcoma and haemangiosarcoma together referred to as angiosarcoma. Cases were females diagnosed between 1972 and 1995 with angiosarcoma of the upper extremity (n = 20) or chest (n = 48) who were 25 years of age or older and residing in Los Angeles County when diagnosed. Other sarcomas at the same anatomic sites were also studied. Controls were females diagnosed with cancers other than sarcoma during the same time period (n = 266,444). Cases and controls were then compared with respect to history of a prior invasive epithelial breast cancer. A history of breast cancer increased the risk of upper extremity angiosarcoma by more than 59-fold (odds ratio [OR] = 59.3, 95% confidence interval [95% CI] = 21.9-152.8). A strong increase in risk after breast cancer was also observed for angiosarcoma of the chest and breast (OR = 11.6, 95% CI = 4.3-26.1) and for other sarcomas of the chest and breast (OR = 3.3, 95% CI = 1.1-1.7).

Soft tissue sarcoma of the upper extremity: descriptive data and outcome in a population-based series of 108 adult patients

We report a population-based, 29-year review of 108 adult patients with soft tissue sarcoma of the upper extremity who had a minimum follow-up period of 3 years. Fifty tumors were localized in the upper arm, 8 in the elbow, 40 in the forearm, and 10 in the hand. Thirty-four tumors were subcutaneous and 74 were deep-seated. The median tumor size was 6 cm. Malignant fibrous histiocytoma was the most common histotype (n = 43), and grade IV (on a 4-grade scale) was the most common malignancy grade (n = 54). All but 6 patients underwent surgery; limb-sparing surgery of the primary tumor was performed in 89 patients. Twenty-four patients were given adjuvant radiotherapy; 11 received adjuvant chemotherapy. Inadequate local treatment was more common in patients treated outside the tumor center. Local recurrence occurred in 15 of 28 with inadequate local treatment and in 16 of 74 patients with adequate local treatment (20 of the 39 patients treated outside the center and 11 of the 63 patients treated at the center). At the latest follow-up visit, 32 patients had developed metastases, giving a 5-year metastasis-free survival rate of 0.72. In a multivariate analysis, tumor size larger than 5 cm and vascular invasion emerged as independent prognostic factors. Patients without these 2 factors had excellent survival. When compared with soft tissue sarcoma of the lower extremity or trunk wall, tumors in the upper extremity were smaller at the time of diagnosis and had a higher 5-year metastasis-free survival rate.

Tumours and tumour-like lesions of bone. The UHWI experience. University Hospital of the West Indies

A review of all primary tumours and tumour-like lesions of bone diagnosed in patients who attended the University Hospital of the West Indies over a 10-year period revealed 136 cases comprising 69 benign and 54 malignant tumours, and 13 cases of tumour-like lesions. The prevalence and clinical characteristics of the various lesions are discussed and compared with the findings in other series. The results of this analysis provide demographic data useful in the differential diagnosis of bone lesions locally.

Hereditary multifocal renal cystadenocarcinomas and nodular dermatofibrosis in 51 German shepherd dogs

The clinical findings in German shepherd dogs with hereditary multifocal renal cystadenocarcinomas and nodular dermatofibrosis are presented. Between 1978 and 1996, 51 cases were examined. Eight cases were detected after being offered a clinical examination because the disease was present in a parent. The remaining 43 dogs were diagnosed after an unsolicited visit to a clinic because of a specific problem. Skin lesions were the main reason (37 per cent) the owners presented their dog for examination. The mean age at diagnosis of renal cystadenocarcinomas and nodular dermatofibrosis was 8.2 years. The male-to-female ratio was 1.1, while the corresponding figure for a reference population was 1.25. Enlarged and abnormally shaped kidneys were palpated in 60 per cent of the dogs and were detected by radiography in 86 per cent of cases. The renal lesions, including metastases, were the main reason for euthanasia and death. The mean age at death was 9.3 years, and the mean age at the first detection of nodular dermatofibrosis was 6.4 years.

Follicular basal cell hyperplasia overlying dermatofibroma

Follicular basal cell hyperplasia (FBCH) overlying dermatofibroma represents aborted or impeded pilar differentiation. Historically, this hyperplasia has been misinterpreted as basal cell carcinoma. In a large series of dermatofibroma (258 cases), those that contained primitive or malformed follicular structures over the lesion (59 cases) were compared with those without such elements (199 cases). Statistical analysis of various clinicopathologic features showed that FBCH was significantly associated with younger age, trunk location, hypercellular dermatofibroma, loss of a Grenz zone, clear cell hyperplasia, and seborrheic keratosis-like change. There was an inverse correlation between epidermal atrophy, lichen simplex chronicus-like change, and lower extremity location with FBCH. Histologic features favoring a diagnosis of FBCH over basal cell carcinoma are the focal nature and superficial location of the lesion, lack of cytologic atypia and mitoses, recognizable components of hair follicle differentiation, focal condensation of mesenchymal cells around basal cell proliferation, and the association of epidermal hyperplasia. Our findings suggest that FBCH, clear cell hyperplasia, and seborrheic keratosis-like change all represent an expression of follicular differentiation overlying dermatofibroma.

A comparison of Mohs micrographic surgery and wide excision for the treatment of atypical fibroxanthoma

BACKGROUND

Atypical fibroxanthoma (AFX) is an uncommon spindle cell neoplasm occurring most often in actinically damaged skin of elderly patients. This tumor has invasive potential, may recur locally after excision, and rarely metastasizes. To conserve tissue and improve the likelihood of cure, Mohs micrographic surgery (MMS) has been used for treatment.

OBJECTIVE

We review and discuss the Mayo Clinic experience treating AFX with MMS and retrospectively compare the clinical outcome with that in a similar cohort of patients treated with wide local excision (WE).

METHODS

The medical records of 45 patients were reviewed at three Mayo Clinic practices. Follow-up data were available for 44 patients: 19 treated with MMS and 25 with WE.

RESULTS

In patients treated with MMS, there were no recurrences after a mean follow-up of 29.6 months. There were three first recurrences in 25 patients (12%) treated with WE after a mean follow-up of 73.6 months. One patient had a single local recurrence, and two patients each had two local recurrences. Parotid node metastasis eventually developed in one of the patients with two local recurrences, so that the regional metastatic rate in this series was 4% (1 in 25 patients).

CONCLUSION

Microscopic control of the surgical margins with MMS in the treatment of AFX results in a lower recurrence rate than that with WE and conserves normal tissue.

Primary lung neoplasia in a beagle colony

As part of long-term pulmonary carcinogenesis studies in dogs, it is important to analyze the incidence of spontaneous lung neoplasia. Primary lung carcinoma incidence was determined in two control populations of Beagle dogs observed for their life spans. One population comprised 216 dogs (112 males and 104 females) that were controls for life span studies, and another comprised 182 dogs (50 males and 132 females) that were retirees from a breeding colony. Forty lung neoplasms were noted in the 398 dogs; 35 neoplasms were carcinomas classified as papillary adenocarcinoma (20), bronchioloalveolar carcinoma (9), adenosquamous carcinoma (5), or bronchial gland carcinoma (1). The other five neoplasms were a malignant fibrous histiocytoma, three adenomas, and a fibroma. The crude incidence of lung carcinomas averaged for both populations was 8.8% (35/398) and was dominated by a relatively high incidence of lung neoplasia in aged dogs, those dying after the median life span of 13.6 years.

[Immunohistochemical study on the histogenesis of malignant fibrous histiocytoma]

Forty cases of malignant fibrous histiocytomas (MFHs) consisting of 33 cases of storiform-pleomorphic subtype MFH and 7 cases of myxoid subtype MFH, were studied immunohistochemically. Immunohistochemical stains were performed by the labelled streptavidin biotin method. The primary antibodies used in this study were classified into 4 groups according to their main specificities: 1) epithelial and non-epithelial (mesenchymal) markers, 2) histiocytic markers, 3) myogenic markers, 4) and that considered as possible lipogenic marker. In addition to these markers, alcian-blue stain, periodic acid-Schiff stain, Masson-trichrome stain, silver impregnation stain, oil red O stain, and Sudan III stain were performed in some cases at the same time. Over 85% of the cases were positive for mesenchymal and histiocytic markers, and no cases were positive for epithelial markers. About 40% of MFH were positive for some myogenic markers, but none of these cases were positive for any skeletal muscle markers. S-100 protein, considered as a possible lipogenic marker through the results of other special stains, was positive in about 10% of the MFHs. The immunohistochemical results of myogenic and lipogenic markers were parallel to the histological subtype; the positive percentages for myogenic markers were about 50% in the cases of storiform-pleomorphic subtype, but were 17% in the cases of myxoid subtype. On the other hand, the positive percentage for lipogenic marker was only 4% in the cases of storiform-pleomorphic subtype, but was 50% in the cases of myxoid subtype. These were supposed to be additional and occult characteristics of MFH. Therefore, the interrelation between the immunohistochemical results and histological subtype of MFH interestingly suggested a new entity of MFH concerning the histogenesis of MFH: MFH was suspected to contain some groups of very poorly differentiated and/or dedifferentiated sarcomas and to be the precondition of some sarcomas.

Malignant fibrous histiocytoma of the larynx--a rare case in an adolescent. A case report

Malignant fibrous histiocytoma is a rare lesion, most often occurring in the elderly. A very unusual case in a 15-year-old boy diagnosed by CT and confirmed at histopathology is presented.

Prosthetic survival and clinical results with use of large-segment replacements in the treatment of high-grade bone sarcomas

We evaluated the long-term clinical results and the survival of the prostheses in eighty-two patients who had had a limb-sparing procedure by means of the implantation of a large-segment prosthesis. All patients had had a high-grade bone sarcoma of the distal, middle, or proximal part of the femur; the proximal part of the humerus; the proximal part of the tibia; or the pelvis. The duration of follow-up ranged from two to twelve years (median, three and one-half years). Function was evaluated with the revised 30-point classification system of the Musculoskeletal Tumor Society. The survival of the prostheses was analyzed with regard to several variables with use of Kaplan-Meier survival estimates. Sixty-eight patients were alive at the latest follow-up evaluation. The survival rate of the prostheses was 83 per cent at five years and 67 per cent at ten years. Twelve prostheses were revised, and eleven revisions were successful. The rate of revision was highest (six of thirteen) in the patients who had had a tumor of the proximal part of the tibia. In contrast, only three (10 per cent) of the thirty-one patients who had had a tumor of the distal part of the femur and three (10 per cent) of the twenty-nine who had had a tumor of the proximal part of the humerus had a revision. Eleven patients (13 per cent) had an infection, which necessitated an amputation in six. Five patients (6 per cent) had a local recurrence, and nine patients (11 per cent), including the six already mentioned, ultimately needed an amputation. Patients who had had a tumor of the proximal part of the humerus had the highest functional scores, while those who had had a tumor of the proximal part of the tibia had the lowest scores. Large-segment prostheses were a good reconstructive option for the treatment of high-grade bone sarcomas in our patients. The rates of long-term survival of the prostheses were acceptable and the functional results were good or excellent after this form of treatment at most of the anatomical sites at which they were used.

[Malignant nictitating membrane tumors in dogs and cats]

Tumours of the third eyelid in 47 dogs and five cats were examined histopathologically. The clinical observations leading to the tumour diagnosis are presented. The tumours were seen more frequently in the dachshund breed, the affected cats belonged to the European Short-hair breed. The diagnosed tumours of the third eyelid could be histologically classified as adenomas and adenocarcinomas of the gland of the third eyelid, malignant melanomas, squamous cell papillomas and carcinomas of the nictitating membrane, several soft tissue tumours and some cases of pseudoneoplastic hypertrophy of the gland of the third eyelid. Local recurrence of tumour occurred in eight dogs and two cats after resection. Tumour metastasis was confirmed in three dogs. The clinical procedure recommended for avoidance of recurrence is discussed. The differential diagnosis of the malignancies of the third eyelid is described. Questionnaires were designed for the animal owners in an attempt to identify etiopathogenetically important factors, the results of which are discussed.

Incidence and morphology of concurrent primary carcinomas of the urinary bladder and prostate in transurethral resection specimens

A retrospective morphologic investigation was conducted to determine the incidence of concurrent primary carcinomas of the urinary bladder and prostate gland and to identify their patho-histologic features using transurethral resection specimens. The study was based upon 1281 cases with the initial diagnosis of a benign or malignant epithelial or mesenchymal tumor of the bladder. In 294 of the patients (23.0%), transurethral resection specimens were also available from the prostate. The incidence of double carcinomas (n = 52) was found to be 4.2% of all vesical carcinomas reviewed (n = 1228) and 17.7% of only those cases with biopsies available from both organs. Of the coexisting bladder carcinomas, 81% represented papillary transitional cell carcinomas grades 1 and 2. These were associated in 78.6% of the cases with well and moderately differentiated carcinomas (grades 1 and 2) of the prostate gland, showing either a uniform glandular or a pluriform glandular and cribriform pattern of growth. Half of the concurrent cancers of the bladder were noninvasive and 19.2% had infiltrated only the lamina propria. Thus, the great majority of coincidental vesical and prostatic carcinomas proved to be well and moderately differentiated and by far the majority of the bladder carcinomas exhibited a low stage. Since there was no typical association of particular histologic carcinoma types coexisting with each other and because the extent of local spread was unremarkable, it is impossible to predict the occurrence of double carcinomas of the urinary bladder and prostate on morphologic grounds.

Chromium-induced carcinoma in the nasal region. A report of four cases

The carcinogenicity of chromium is well established in chromium-induced lung cancer. As of yet, however, there have been only few reports of head-and-neck cancer induced by chromium. We report four cases of carcinoma in the nasal region which seemed to be induced by chromium. All patients have worked at the same chromate factory for 19 to 32 years. The first patient has suffered from squamous cell carcinoma of the left nasal cavity, starting 11 years after his retirement. He received radiotherapy followed by surgery. A malignant fibrous histiocytoma occurred in his left upper gingiva in a previously irradiated region, 7 years after the previous treatment. Surgery and chemotherapy for palliation failed to control the tumour, and he eventually expired. The other three patients underwent lobectomy for lung cancer. In cases 2 and 3, the tumour occurred in the left nasal cavity six and ten years, respectively, each after the lobectomy. In case 4, the tumour arose from the nasopharynx 15 years after the lobectomy. These patients are alive and well without any sign of tumour. The presented cases seem to be induced by long-term exposure to chromium. We conclude that regular physical examination of chromate workers is mandatory for the early detection not only of lung cancer but also of head-and-neck cancer.

[Computed tomography in malignant primary soft tissue tumors]

The results of CT examinations in 36 patients suffering from histologically confirmed malignant primary tumours of the soft tissues are presented (6 rhabdomyosarcomas, 4 leiomyosarcomas, 6 liposarcomas, 4 malignant schwannomas, 5 malignant fibrous histiocytomas, 4 malignant haemangiopericytomas, 3 angiosarcomas, 1 fibrosarcoma, 1 renal sarcoma, 2 malignant mesenchymal tumours without histologically clear classification). The CT image alone will not yield information on the type of tumour or on the tumour status. However, CT continues to rank in the diagnosis of tumours of the soft tissues and is even superior to MR especially in the identification of gas accumulations due to infection in a tumour of the soft tissues that is otherwise unclear. Comparing the literature conclude that MR is now the imaging method of choice in the diagnosis of soft tissue tumours.

[Methodology, technical prerequisites and postoperative morbidity of intraoperative radiotherapy (IORT) of soft tissue sarcomas. Heidelberg Krankengut 6/91-9/92]

Since June 1991 the IORT facility has operated a dedicated linear accelerator, which was installed within the central operating theater of the Department of Surgery. As of 9/92 a total of 28 patients suffering from peripheral (n = 20) or centrally (n = 8) located soft tissue sarcomas had been were treated. Thirteen patients revealed a primary and 15 patients a recurrent tumor. Tumor resection with negative margins was performed in 20 patients, positive margins remained in 5 patients, and gross macroscopic residual disease in 3 patients. Combined intraoperative and external beam radiotherapy was applied in 22 patients, using IORT doses of 10-20 Gy and an external beam dose of 26-50 Gy. Three patients were irradiated intraoperatively twice with a time interval of 24 h. After a median follow-up of 9.9 months, 20 patients are disease free. Two patients died 4 and 5 months after the end of therapy with rapidly progressive distant metastases. An infield failure within the external beam target volume was seen in 1 patient and local failure at the field margin of the external field in 3 patients. So far, there have been no IORT infield failures. Follow-up is performed with magnetic resonance imaging. In 3 patients a second operation was necessary because of a severe wound infection, including one patient suffering from osteomyelitis of a neighboring bone. Mild sensory neuropathy occurred in 1 patient 7 months after treatment. Overall only mild and reversible postoperative and posttherapeutic complications were seen.(ABSTRACT TRUNCATED AT 250 WORDS)

A case of inflammatory malignant fibrous histiocytoma of the colon

Primary malignant fibrous histiocytoma seldom occurs in the alimentary tract. This report documents a case in which a 50-year-old man presented with abdominal fullness and anorexia, together with inflammatory reactions such as fever, leukocytosis, an elevated erythrocyte sedimentation rate and positive CRP. Radiologic and endoscopic studies revealed a large mass in the ascending colon. The histology of the resected tumor revealed inflammatory malignant fibrous histiocytoma, a histologic subtype which is rare among not only soft tissue fibrous but also as gastrointestinal histiocytomas. The inflammatory reactions disappeared following resection of the tumor. Although we suspected that the tumor produced granulocyte colony-stimulating factor because of the slightly elevated serum level and the characteristics of the tumor histology, an immunohistochemical study failed to show the G-CSF production by the tumor cells.

Atypical fibroxanthoma: DNA ploidy analysis of 14 cases with possible histogenetic implications

The histogenesis of atypical fibroxanthoma (AFX) and its relationship to malignant fibrous histiocytoma (MFH) are a subject of controversy. Many investigators have proposed that AFX may represent a reactive process, while others contend that it is a true fibrohistiocytic neoplasm, closely related to MFH. In an attempt to determine whether biologic differences between AFX and MFH may be accounted for at the cellular DNA level, we performed ploidy analysis on 14 cases of AFX by flow cytometry and compared our results with previously reported DNA analyses of MFH. Thirteen of the 14 lesions demonstrated diploid distribution of nuclear DNA, and only 1 case had an aneuploid population. This contrasts with prior data on MFH, the vast majority of which are aneuploid. Our results suggest that, despite histologic similarities, AFX may be distinguished from MFH on the basis of DNA content. These findings may be significant in understanding the biologic behavior of AFX.

Malignant fibrous histiocytoma of the soft tissues of the trunk and extremities

Malignant fibrous histiocytoma (MFH) is the most commonly diagnosed soft-tissue sarcoma. Of 408 retrospectively reviewed patients with MFH, 220 patients had primary, localized, previously untreated tumors involving the extremities or limb girdles. Univariate statistical analysis of results revealed five prognostic factors that were significantly related to poor outcome: old age, deeply seated lesions, surgical grade, large size, and marginal or intralesional surgery. Multivariate analysis revealed only three factors that were significantly related to poor prognosis: old age, deeply seated lesions, and inadequate surgery.

Intraarterial chemotherapy with limb-sparing resection of large soft-tissue sarcomas of the extremities

Fifteen patients with large (average, 15-cm), high-grade soft-tissue sarcomas of the extremities received prolonged selective intraarterial infusions of chemotherapeutic agents in an attempt to permit limb-sparing resection of these tumors, which would otherwise have required amputation. There were seven malignant fibrous histiocytomas, four liposarcomas, two fibrosarcomas, one leiomyosarcoma, and one rhabdomyosarcoma; 73% were grade III. Seven patients underwent two catheterizations, for a total of 22 infusions, which averaged 11.3 days each. There were four catheterization-related complications, including catheter occlusion or dislodgement in one patient each and two cases of arterial thromboembolism in patients in whom anticoagulant dose was not adequate. Both of the latter patients required thrombectomy; one developed gangrene, which precluded limb-sparing surgery. Thirteen of the 15 patients underwent limb-sparing resections, and two underwent amputations. No wound complications occurred. With a median follow-up of 36 months (mean, 34 months), life-table analysis indicates overall and disease-free survivals of 72% and 59%, respectively, at 2 years and 64% and 59% at 3 years. In comparison to other reported therapies, this technique permits limb salvage in most patients without the high wound complication rate associated with preoperative radiation therapy, with equivalent local disease control and survival.

Necrosis observed on CT enhancement is of prognostic value in soft tissue sarcoma

Fifty-one patients with deep-seated soft tissue sarcoma of the extremities and trunk wall were examined with contrast-enhanced CT for presence of nonenhanced tumor areas (CT necrosis). After a median follow-up time of 3 years, 19 of the 41 patients with CT necrosis had developed metastases, compared to none of the 10 patients who had tumors without CT necrosis. Tumors with CT necrosis were larger than tumors without, but in tumors of similar size, absence of CT necrosis was a favorable prognostic sign.

Atypical fibrous histiocytoma of the skin and subcutis in childhood and adolescence

The authors have observed 15 examples of a distinctive fibrohistiocytic lesion in children and adolescents which they chose to designate as "atypical fibrous histiocytoma" (AFH). Patient ages ranged from 1 to 19 years (mean 9.3 yr.). Only two cases were encountered in the first year of life, but 7 were seen in children under the age of 10 yr. The anatomic distribution of AFH showed a tendency for a truncal origin (66%), and none was located in the skin of the face, neck, or scalp. Tumor sizes ranged from 1 to 3 cm, and one-third were 2 cm or greater in maximum dimension. Histologically, AFH was characterized by a multinodular, dermal or dermal-subcuticular proliferation of spindle cells, with tapered, cytologically bland nuclei. However, nucleocytoplasmic ratios were increased when compared with those of normal fibroblasts. Nuclear chromatin was dispersed or vesicular; nucleoli were seen in a minority of cases, but mitotic activity was regularly present. Admixed giant cells were present but infrequent, cellularity was dense, and a storiform growth pattern was consistently seen. Mean followup in this group of cases averaged 75 mo. Seven patients (47%) had tumor recurrences after initial excision; in two of these, tissue margins had been free of involvement. The authors conclude that AFH of childhood is analogous to a lesion that has previously been reported as "benign fibrous histiocytoma" in adults. Complete excision and regular postoperative surveillance are recommended for these tumors.

Fibrous histiocytomas in the tropics

Sixty patients with fibrous histiocytomas - malignant fibrous histiocytomas and benign histiocytomas - presenting at University College Hospital, Ibadan over a 10-year period have been evaluated retrospectively. A malignant:benign tumour ratio of 2.8:1, a male:female ratio of 1:1, and a predilection for malignant histiocytomas to occur early (16-25 years) in contrast to benign histiocytomas (26-35 years) were noted. While the trunk accounted for one-third of cases, the extremities accounted for two-thirds of all patients. A long history of slow growth (from 6 months to 11 years) of a large bossellated tumour anywhere in the body, with a tendency to recurrence after excision and potential for metastasis, constitute the main characteristics of this tumour.

Staging of malignant tumours of the foot

Tumours of the foot in general, and malignant tumours in particular, are extremely rare. In the absence of a large series it is necessary to resort to surgery based on "principles" and not on experience or on data drawn from retrospective clinical studies. Enneking's "Surgical Staging System" (S.S.S) is a method of staging musculo-skeletal tumours which has been universally adopted-for several years and which is based, as already known, on the concept of anatomo-surgical "compartments". In the particular case of the foot, the S.S.S. suggests the surgical criteria specific to each anatomical region. The authors illustrate the principles with some examples taken from their experience, evaluating the surgical, oncological and functional aspects.

Sarcomas in north west England: II. Incidence

Incidence data on a population-based series of bone, soft tissue and visceral sarcomas from the North West of England are presented. The data are derived mainly from a total of 429 cases registered with the North Western Regional Cancer Registry and diagnosed during the period 1982-84, 76% of which were confirmed as sarcomas by a panel of five pathologists. Overall incidence of confirmed sarcomas per million person years was slightly higher in females (26.81) than in males (24.71) but there was no sex difference when 38 non-reviewed cases were taken into consideration (females 29.07, males (28.83). After exclusion of tumours of female genital tract, incidence of soft tissue tumours was very similar in both sexes (females 18.25, males 18.70). Bone tumours were almost twice as frequent in males (6.01) as in females (3.55).

Long-term scintigraphic appearance of extremities following bone tumor resection and allograft reconstruction

The authors retrospectively reviewed the Tc-99m medronate scan findings in six patients who had no evidence of metastatic disease following en bloc resection of a primary osteosarcoma and subsequent limb reconstruction using allograft bone. Persistently increased radionuclide uptake was noted at the junction between the host bone and the graft, while the graft cortical bone showed persistently decreased activity. Radionuclide uptake at the periphery of the graft varied. Over time the youngest patient in the series had increasingly normal scan findings.

Accumulation of leucocytes labelled with technetium-99m hexamethylpropylene amine oxime in malignant abdominal tumours

A total of 343 leucocyte scans labelled with technetium-99m hexamethylpropylene amine oxime were reviewed that had been performed in 338 patients suspected of having abdominal infection or inflammation. There was uptake by malignant abdominal tumours in 10 cases (2.9%), which represents 62.5% of known malignancies at the time of the scintigram. Accumulation was seen in 8 patients with adenocarcinoma of the colon associated with a secondary infection in the tumour or pericolic inflammation. A large tumour that had spread beyond the bowel wall was related to a positive scintigram. Accumulation was also found twice in a malignant fibrous histiocytoma in which bleeding and an inflammatory reaction to necrosis were probably responsible for the uptake. The relevant treatment was delayed for 2 weeks-2 months in 4 patients with adenocarcinoma of the colon in whom the positive uptake was regarded as confirmation of the clinically suspected acute diverticulitis.

Cytometry and morphometry of malignant fibrous histiocytoma of the extremities. Prediction of metastasis and mortality

Flow cytometry and nuclear morphometry were compared with traditional pathologic grading techniques for predicting the course of malignant fibrous histiocytoma of the extremities. Clinical, pathologic, and flow/morphometric variables from 53 cases were tested by Cox regression for prediction of distant recurrence and mortality. Tumor grading based on extent of tumor necrosis was a significant predictor for both disease-free survival (p = .014) and overall survival (p = .003). The fraction of nuclei in the S + G2M segment of DNA histograms was significant for disease-free survival (p = .007), and remained significant (p = .033) in a joint Cox model with necrosis-based grade (p = .004 for the bivariate model). Relative risk for recurrence varied nearly 10x between the 10th and 90th percentiles of grade and (S + G2M)1/2. Overall survival was predicted by a nuclear shape feature termed "R" (p = .000008), the casewise difference (residual) between expected and observed nuclear perimeter as a function of average Feret diameter. In a bivariate Cox model, relative risk of mortality varied 35x between the 10th and 90th percentiles of grade and R. Cytometric and morphometric data contain information about recurrence-free and overall survival beyond that available from more usual clinical and pathologic features. It seems likely that nuclear morphometry, in particular, will prove to be a useful aid for estimating the prognosis of patients with malignant fibrous histiocytoma of the extremities.

Long-term risk of sarcoma following radiation treatment for breast cancer

Between 1954 and 1983, 7620 patients were treated for breast carcinoma at Institut Gustave Roussy (France). Of these patients, 6919 were followed for at least 1 year. Out of these, 11 presented with sarcomas thought to be induced by irradiation, 2 of which were Steward-Treves Syndrome, and 9 of which were sarcomas within the irradiated fields. All histological slides were reviewed and a comparison with those of breast cancer was done. The sites of these sarcomas were: parietal wall, 1 case; second costal cartilage, 1 case; infraclavicular region, 1 case; supraclavicular region, 2 cases; internal third of the clavicle, 2 cases; axillary region 2 cases; and the internal side of the upper arm (Stewart-Treves syndrome), 2 cases. The median age of these 11 patients at the diagnosis of sarcomas was 65.8 (49-83). The mean latent period was 9.5 years (4-24). Three patients underwent radical mastectomy and nine modified radical mastectomy. Only one patient received chemotherapy. The radiation doses received at the site of the sarcoma were 45 Gy/18 fr. for 10 cases and 90-100 Gy for 1 case (due to overlapping between two fields). The histology was as follows: malignant fibrous histiocytoma, 5 cases; fibrosarcoma, 3 cases; lymphangiosarcoma, 2 cases; and osteochondrosarcoma, 1 case. The median survival following diagnosis of sarcoma was 2.4 years (4 months-9 years). Two patients are still alive: one with recurrence of her breast cancer, the other in complete remission, with 7 and 3 years follow-up, respectively. All other patients died from their sarcomas. The cumulative incidence of sarcoma following irradiation of breast cancer was 0.2% (0.09-0.47) at 10 years. The standardized incidence ratio (SIR) of sarcoma (observed n# of cases (Obs)/expected n# of cases (Exp) computed from the Danish Cancer Registry for the same period) was 1.81 (CI 0.91-3.23). This is significantly higher than one, with a p = 0.03 (One Tailed Exact Test). The mean annual excess (Obs-Exp)/100.000 person-years at risk during the same period/(100,000) was 9.92. This study suggests that patients treated by radiation for breast cancer have a risk of subsequent sarcomas that is higher than the general population. However, the benefit from adjuvant radiation therapy in the treatment of breast cancer exceeds the risk of second cancer; therefore, the potential of radiation-induced sarcomas should not be a factor in the selection of treatment for patients with breast cancer.

Malignant fibrous histiocytoma of soft tissue. A population-based epidemiologic and prognostic study of 137 patients

Epidemiology and prognosis were analyzed in a consecutive, population-based series of 137 patients with malignant fibrous histiocytoma of soft tissue in the extremities and trunk wall, with a complete follow-up of minimum 3 years. All but one patient were treated by surgery in 28 cases combined with adjuvant radiotherapy or chemotherapy. The annual incidence was 0.42/10(5). The ratio men to women was 1.1. The median age was 64 years (range, 22 to 87 years). The thigh was the most common location. The median size was 6 cm. Superficial tumors constituted 43% and were smaller than deep-seated tumors. Eighty-three tumors were storiform-pleomorphic, 53 were myxoid, and one was of inflammatory type. The myxoid tumors were smaller and more often superficial. The cumulative 5-year survival rate for all patients was 0.7, but differed markedly between the histologic types; it was 1.0 in patients with myxoid tumors and 0.5 in patients with storiform-pleomorphic tumors. In the 77 patients with storiform-pleomorphic tumors without metastases at presentation, only tumor size larger than 10 cm and tumor necrosis independently impaired survival. The 23 patients who had none of these risk factors had a 5-year survival rate of 0.8.

Angiomatoid malignant fibrous histiocytoma. A follow-up study of 108 cases with evaluation of possible histologic predictors of outcome

Described by Enzinger in 1979, angiomatoid malignant fibrous histiocytoma is a distinctive tumor of adolescence and early adult life characterized by sheets of relatively bland rounded or spindled cells separated by areas of cystic hemorrhage and surrounded by a prominent inflammatory infiltrate and often a fibrous pseudocapsule. On the basis of the original 41 cases, the tumor has been considered a low-grade malignancy. We are reporting the clinicopathologic findings and follow-up information of 108 new cases of angiomatoid malignant fibrous histiocytoma to determine the long-term behavior of this tumor and whether various histologic features (atypia, mitoses, infiltrative borders, and inflammatory infiltrate) are useful in predicting outcome. Follow-up information was obtained in 94 (87%) cases. Local recurrences developed in 11 patients (12%), all of whom were cured by re-excision. The initial excision in all patients developing local recurrence appeared to be incomplete. Local recurrence was statistically associated with irregular tumor border and head and neck location. Five patients developed metastases. Four had only local metastases, which responded to surgery, whereas the fifth patient developed presumed pulmonary and cerebral metastases and died. The development of both local and distant metastases was correlated with invasion into the deep fascia or muscle but not to various histologic parameters such as mitotic rate and pleomorphism. We conclude that angiomatoid malignant fibrous histiocytoma is intrinsically a low-grade tumor, and assessment of various histologic parameters or grading provides little or no additional prognostic information. Because death from disease occurred in only one patient (1%) in our series, it seems reasonable to reclassify angiomatoid malignant fibrous histiocytoma with fibrohistiocytic tumors of intermediate malignancy rather than with the conventional malignant fibrous histocytoma, the majority of which are high-grade sarcomas.

Wallace P. Rowe lecture. Poxviruses of laboratory animals

Currently the subfamily Chordopoxvirinae, the poxviruses of vertebrates, is subdivided into eight genera, containing some 20-30 species; an inexact figure because the birdpox viruses have not yet been properly investigated taxonomically. I have discussed seven species belonging to three genera, all of which have caused infection and usually disease in mammals commonly used in the laboratory. The list could have been extended had I included chickens and swine as laboratory animals, for that would have meant that I would have spoken about the birdpox viruses and swinepox virus as well. However, I think I have said enough to remind you of the importance of this family of viruses to those of you concerned with laboratory animal medicine. I believe that Wally Rowe would have been interested, for every case I have described presents problems in the ecology of viruses, and like my mentor Macfarlane Burnet, Wally approached virology from an ecological point of view, whether he was thinking about the DNA provirus of retroviruses and the host chromosome, the pathogenesis of disease, or the spread of viruses in animal populations, all topics to which he made major contributions.

Fibrosarcoma of the head and neck

A review of 118 archival cases originally diagnosed as fibrosarcoma of the head and neck is presented. Sites of involvement were the sinonasal region, upper aerodigestive tract, skin, and soft tissues. Review of the pathologic specimens applying strict histopathologic criteria including immunohistochemical techniques reclassified many of the tumors as malignant fibrous histiocytoma, monophasic synovial sarcoma-like neoplasm, or dermatofibrosarcoma protuberans. Improved clinical outcome correlated significantly with lesser tumor size, lower histologic grade, and negative surgical margins. Location in the skin or soft tissue tended to convey improved survival, although not to a level of statistical significance.

Recurrence in juvenile angiofibroma

A potential for recurrence of juvenile angiofibroma exists after all treatment modalities, both surgical and medical but the methods of defining recurrence and failure to cure varies considerably from series to series. To evaluate factors which might influence successful treatment, a series of 33 patients have been reviewed retrospectively. All patients were treated by simple or extended lateral rhinotomy as a primary or secondary procedure. The final long-term disease control rate was 97% but during the treatment period the overall symptomatic recurrence rate was 50%. However, amongst those treated primarily the recurrence rate was 34%. Of the factors examined, the strongest predictor of recurrence was preoperative embolisation. This group exhibited both early and multiple recurrence when compared with the non-embolised group and the possible reasons for this are examined.

Malignant fibrous histiocytoma of the hypopharynx

Malignant fibrous histiocytoma has been the most common soft-tissue sarcoma of late adult life. However, it is relatively uncommon in the head and neck. Furthermore, there has been no report of malignant fibrous histiocytoma of the hypopharynx in the literature. The first case of malignant fibrous histiocytoma of the hypopharynx is presented. The patient, a 70-year-old male, underwent extended laryngectomy and elective neck dissection with primary tracheoesophageal shunt operation and pharyngeal myotomy for voice restoration following total laryngectomy. For more than 2 years, there has been no evidence of the disease or metastasis. He has the satisfactory phonatory and swallowing function.

Juvenile nasopharyngeal angiofibroma in a static population: the implications of misdiagnosis

We present a 20-year review of juvenile angiofibroma in the relatively static population of Northern Ireland. Seventeen cases were identified and new slides were prepared from the stored paraffin blocks of all their original biopsy material, and re-examined. Five females, a 36-year-old and an 18-year-old male had their diagnoses revised. We suggest clinical criteria, which in conjunction with radiological investigations, should be strictly applied in all cases. Such application would, in retrospect, have identified those cases excluded by pathological re-examination, thus avoiding unnecessary surgery and radiotherapy. Atypical cases which do not satisfy the clinical criteria may be subjected to repeat biopsy but routine initial biopsy is not recommended.