Lars-Gunnar Kindblom

Gastrointestinal stromal tumors: the incidence, prevalence, clinical course, and prognostication in the preimatinib mesylate era--a population-based study in western Sweden.

Recent breakthroughs regarding gastrointestinal stromal tumors (GIST) and their pathogenesis have redefined diagnostic criteria and have led to the development of molecularly targeted drug therapy. New treatment options mandate more accurate information regarding the incidence, prevalence, clinical behavior, and prognostic factors of GIST.

Prognostic factors in chordoma of the sacrum and mobile spine: a study of 39 patients.

The prognosis of patients with chordoma of the sacrum and mobile spine has been reported to be dismal and attributable in the majority of cases to intralesional surgery. The purpose of this study was to evaluate the clinical outcome of these patients using modern surgical principles aimed at complete resection and to identify prognostic factors.

Somatic mosaic IDH1 and IDH2 mutations are associated with enchondroma and spindle cell hemangioma in Ollier disease and Maffucci syndrome

Ollier disease and Maffucci syndrome are non-hereditary skeletal disorders characterized by multiple enchondromas (Ollier disease) combined with spindle cell hemangiomas (Maffucci syndrome). We report somatic heterozygous mutations in IDH1 (c.394C>T encoding an R132C substitution and c.395G>A encoding an R132H substitution) or IDH2 (c.516G>C encoding R172S) in 87% of enchondromas (benign cartilage tumors) and in 70% of spindle cell hemangiomas (benign vascular lesions). In total, 35 of 43 (81%) subjects with Ollier disease and 10 of 13 (77%) with Maffucci syndrome carried IDH1 (98%) or IDH2 (2%) mutations in their tumors. Fourteen of 16 subjects had identical mutations in separate lesions. Immunohistochemistry to detect mutant IDH1 R132H protein suggested intraneoplastic and somatic mosaicism. IDH1 mutations in cartilage tumors were associated with hypermethylation and downregulated expression of several genes. Mutations were also found in 40% of solitary central cartilaginous tumors and in four chondrosarcoma cell lines, which will enable functional studies to assess the role of IDH1 and IDH2 mutations in tumor formation.

Extraskeletal myxoid chondrosarcoma: A reappraisal of its morphologic spectrum and prognostic factors based on 117 cases

Extraskeletal myxoid chondrosarcoma (EMC), a phenotypically and genotypically distinctive entity, has generally been viewed as a low-grade sarcoma. No studies regarding clinical and morphologic prognostic factors have been performed on a large series of cases with long-term follow-up because of the rarity and protracted clinical course of EMC. The clinical, morphologic, and immunohistochemical features of 117 previously unreported cases were studied and statistically analyzed. The male-to-female ratio was 2:1. The median patient age was 52 years (range, 6-89 years), and the median tumor size was 7 cm (range, 1.1-25 cm). All tumors occurred within the deep subcutis or deeper soft tissues, with 80% occurring in the proximal extremities or limb girdles and 20% in the trunk. Most initial tumor excisions were intralesional or marginal. Follow-up information was available in 99 cases (median, 9 years: range, 2 months-22 years). Forty-eight patients were disease-free, and 41 patients had evidence of disease (18 of these had died of disease). Ten additional patients survived, but their disease status was unknown. There were local recurrences in 40 (48%) of 83 patients, 23 (58%) of whom had multiple local recurrences. Metastases occurred in 35 (46%) of 76 patients. The estimated 5-, 10-, and 15-year survival rates were 90%, 70%, and 60%, respectively. All cases had histologic features characteristic of classical EMC, at least focally. Cellular foci devoid of myxoid matrix and reminiscent of chondroblastoma, Ewings sarcoma, monophasic and poorly differentiated synovial sarcoma, fibrosarcoma, and rhabdoid tumor were identified in 29% cases. Older patient age, larger tumor size, and tumor location in the proximal extremity or limb girdle were adverse prognostic factors identified by multivariate analysis. Metastasis also adversely affected survival, although local recurrence did not. This study shows that EMC has a unique clinical course, including a high rate of local recurrence, prolonged survival after metastasis in some cases, and eventually a high rate of death due to tumor. These features distinguish EMC from low-grade sarcomas. This study shows that histologic grading is of no prognostic value in EMC because prognosis is dictated primarily by certain clinical features. Histologic recognition of classical EMC and cellular and solid, nonmyxoid variants is important, however, in view of EMCs distinctive biologic behavior.

Immunohistochemical investigations of tumors of supposed fibroblastic-histiocytic origin

The aim of this study was to localize alpha 1-antitrypsin, ferritin, and lysozyme by means of the indirect immunoperoxidase technique and to evaluate the significance of these antigens as markers of histiocytic differentiation in tumors of a supposed dual fibroblastic-histiocytic origin. The series comprised 31 malignant fibrous histiocytomas (MFH) of the pleomorphic, spindle cell, and myxoid types, four cutaneous fibrous histiocytomas, and four atypical fibroxanthomas, four dermatofibrosarcoma protuberans, and two osteoclastomas of bone. For comparison, 15 soft tissue sarcomas of various other types were examined. Of the MFHs of the pleomorphic type, 18 of 22 (82 per cent) were positively stained for alpha 1-antitrypsin and 12 of 22 (54 per cent) were positively stained for ferritin. Of the five MFHs of the spindle cell type, none was positively stained for alpha 1-antitrypsin, three were positive for ferritin, and one was positive for lysozyme. None of the myxoid variants (corresponding to grade I-II myxofibrosarcoma) was positively stained for either of the antigens. These results and the observations made on the cutaneous fibrous histiocytomas, atypical fibroxanthomas, dermatofibrosarcoma protuberans, and the various soft tissue sarcomas indicated that 1) alpha 1-antitrypsin is a valuable marker of histiocytic differentiation in both benign and malignant fibrous histiocytomas, 2) ferritin can be visualized in more than half of these fibroblastic-histiocytic tumors, and the presence of ferritin distinguishes the spindle cells of these tumors from fibroblasts of connective tissue and most fibrosarcomas, and 3) lysozyme, although a good marker of histiocytic differentiation in ordinary histiocytes and benign fibrous histiocytomas, is a poor marker of neoplastic histiocytes of malignant tumors. The results further support the concept that MFH is a tumor of a dual fibroblastic-histiocytic origin.

Clear-cell sarcoma of tendons and aponeuroses

A clinico-pathological, light microscopic and immunohistochemical study of 15 clear-cell sarcomas, with an ultrastructural analysis of 6 of the tumors, is presented. The tumors showed a strong predilection for tendons and aponeuroses of the extremities in predominantly young and middle-aged people. The clinical setting, course and light microscopic appearance agree well with the original description by Enzinger (1965). Nine of the 15 patients developed metastases, most of them including lymph nodes, and 8 of the patients had died at the time of follow-up (median follow-up time 4.8 years). Reducing pigment was demonstrated within the cells of 2 tumors. Ultrastructurally the 6 tumors studied had a uniform appearance with characteristically rounded or oval tumor cells with a single nucleus containing one or two very prominent nucleoli, a light-staining cytoplasm with a moderate amount of organelles and a variable content of glycogen. Polymorphic melanosomes were seen in the cells of one of the tumors. External laminas enclosed groups of tumor cells and invested parts of individual tumor cells. With immunoperoxidase analysis for S-100 protein positive staining was observed in the vast majority of the tumor cells of all 15 clear-cell sarcomas. Metastases appearing in 9 of the 15 cases showed positive staining for S-100 protein. There was a strong staining of the cytoplasm and generally a weak and varying staining of nuclei. The immunohistochemical and electron microscopic findings indicate that clear-cell sarcoma is a homogenous entity among soft tissue sarcomas, of probable neural crest derivation.

Prognostic factors and outcome of pelvic, sacral, and spinal chondrosarcomas: A center-based study of 69 cases

The surgical treatment of chondrosarcoma of the pelvis, sacrum, and spine is complex and technically demanding. As such, adequate surgical margins have been difficult to achieve, resulting in poor local control and survival. The objective of this study was to assess the outcome of patients with chondrosarcomas in these sites who were treated at a tumor center by using modern, aggressive surgical techniques and to identify prognostic factors.

Intermuscular and intramuscular lipomas and hibernomas. A clinical, roentgenologic, histologic, and prognostic study of 46 cases.

A series of 9 intermuscular and 34 intramuscular lipomas, and 1 intermuscular and 2 intramuscular hibernomas is presented. One intramuscular lipoma infiltrated not only muscle but also fascia and tendon. The shoulder region and the thigh were the most common sites of the lipomas. Clinically the tumor appeared in most cases as a painless, fairly soft mass. Dysfunction of the engaged muscle was apparent in only 4 patients. A characteristic change in consistency and form was shown in 14 cases: the tumor being soft and flat when the muscle was relaxed, and becoming firm and more spherical when the muscle was contracted. Some tumors, having developed in a closed fascial space, were firm on palpation even when the muscle involved was relaxed. Radiography was performed in 36 patients with lipoma. In 31 of these the tumor was clearly visible because of its radiotranslucency. Streaks of higher density caused by muscle fiber bundles were seen within the tumor area in some cases. Angiography was performed in 14 patients with lipoma. Usually the tumor appeared poor in vessels in relation to surrounding muscle, and in no patient was increased vascularity, abnormal vessel formation, or early venous filling observed. Microangiography of 2 of the lipomas demonstrated their poor vascular supply in relation to the surrounding muscle. Angiography in 2 patients with hibernoma showed that the tumor was highly vascular with irregular vessels and early venous filling, findings usually held as contributory signs of malignancy in the diagnosis of soft tissue tumors. Microangiographic studies of these hibernomas, earlier reported, also demonstrated their high vascularity. A followup study has shown the benign course of intermuscular and intramuscular lipoma and hibernoma.

Neoadjuvant, adjuvant and palliative treatment of gastrointestinal stromal tumours (GIST) with imatinib : a centre-based study of 17 patients

Malignant gastrointestinal stromal tumours (GIST) have a poor prognosis. Since these tumours are resistant to conventional radiation and chemotherapy, surgery has been the mainstay of treatment. However, surgery is usually inadequate for the treatment of malignant GIST. Imatinib, a KIT tyrosine kinase inhibitor, has recently been found to have a dramatic antitumour effect on GIST. In this centre-based study of 17 consecutive patients with high-risk or overtly malignant GIST, imatinib was used in three different settings – palliatively, adjuvantly, and neoadjuvantly. The treatment was found to be safe and particularly effective in tumours with activating mutations of exon 11 of the KIT gene. Clinical response to imatinib treatment correlated morphologically to tumour necrosis, hyalinisation, and reduced proliferative activity. The value of neoadjuvant imatinib treatment was illustrated in one case.

Adjuvant imatinib treatment improves recurrence-free survival in patients with high-risk gastrointestinal stromal tumours (GIST)

Palliative imatinib treatment has dramatically improved survival in patients with malignant gastrointestinal stromal tumours, particularly in patients with tumours harbouring activating KIT mutations. To evaluate the effectiveness of adjuvant imatinib after radical surgery, a consecutive series of patients with high-risk tumours (n=23) was compared with historic controls (n=48) who were treated with surgery alone. The mean follow-up period was over 3 years in both groups. Only 1 out of 23 patients (4%) in the adjuvant treatment group developed recurrent disease compared to 32 out of 48 patients (67%) in the control group. This preliminary study indicates that 1 year of adjuvant treatment with imatinib dramatically improves recurrence-free survival. Confirmation of these findings awaits the results of ongoing randomised studies.