Man H. Shiu

Myosarcomas of the stomach: Natural history, prognostic factors and management

A retrospective study was made of 41 patients treated for gastric myosarcoma to identify prognostic factors that influence results. The adjusted five‐ and ten‐year survival rates were 56% and 43% respectively, with no significant difference between leiomyosarcoma and malignant leiomyoblastoma. A histopathologic grade of malignancy could be assigned to each tumor according to the degree of hypercellularity, nuclear abnormality, mitotic rate and other characteristics. High histopathologic grade, large tumor size (<5 cm diameter) and invasion of adjacent organs adversely affected prognosis. Five‐year survival after curative treatment was: 100% (9/9) for small tumors, of which six were treated by wedge gastric resection; 67% (8/12) for large tumors, mostly after subtotal gastrectomy; and 0% for tumors that invaded adjacent organs, despite extended resections. It is concluded that the management of gastric myosarcomas can be planned according to these prognostic factors and that multimodal therapy of tumors with adverse factors warrants consideration.

Tendosynovial sarcoma. A clinicopathological study of 136 Cases

A series of 136 cases of tendosynovial sarcomas were studied from the histologic point of view. All of the primary, recurrent and metastatic tumors were reclassified according to histologic type, anatomic site and size; age and sex of the patients and modality of surgical treatment. The overall 5‐year survival rate was 40%. Among the factors which most favorably influenced the prognosis were: small size (74%, 5‐year survival), “exposed” primary site (53%, 5‐year survival), and histologic type (biphasic form: 55%, 5‐year survival and epithelioid sarcoma: 58%, 5‐year survival). Children and elderly patients had also better than the average prognosis. Sixty percent of the sarcomas recurred after wide local excision. Twelve percent of the tumors metastasized to regional lymph nodes and 10% to bones. Almost all of the 24 patients who were autopsied died because of cardio‐pulmonary insufficiency due to massive pleuropulmonary metastasis. It is hoped that better understanding of the natural history of these tumors will lead to optimal local and systemic therapy and better survival.

Trabecular (merkel cell) carcinoma of the skin. Treatment of primary, recurrent, and metastatic disease

Four new patients with trabecular (Merkel cell) carcinoma of the skin are described, and an additional 76 patients from the literature are reviewed. The mean age of the combined group of patients was 68; 84% were 60 years or older. Primary tumors appeared most frequently on the head and neck (44%), leg (28%), arm (16%), or buttock (9%). No primary tumor appeared on the trunk. The rate of local recurrence was 36%, regional metastatic disease, 53%; distant metastases, 28%; and death due to metastatic tumor (minimally), 25%. It appears that trabecular carcinoma of the skin is more aggressive and lethal than previously thought. The authors recommend that patients with this tumor undergo wide resection of the primary site and, in healthy patients, prophylactic regional node dissection. Both radiation therapy and chemotherapy are effective in palliating unresectable disease.

Adverse effect of pregnancy on melanoma. A reappraisal

The influence of pregnancy on the prognosis of cutaneous melanoma in women of childbearing age was examined in a retrospective review of 251 surgically treated cases. There was no statistical difference in survival at five years, free of disease, for Stage I melanoma between nulliparous, parous nonpregnant, and pregnant women. For Stage II melanoma, however, a significantly lower survival rate was observed for pregnant patients (29%) and parous women who had experienced activation of the lesion in a previous pregnancy (22%), as compared with that of nulliparous patients (55%) and other patients in the parous group (51%); p < 0.05. This discrepancy in survival, together with the observed higher frequencies of Stage II cases, melanomas occurring on the trunk, and symptoms such as bleeding, ulceration, irritation, and elevation of the lesion, strongly suggest an adverse influence of pregnancy on women with Stage II melanoma.

Surgical treatment of distant metastatic melanoma indications and results

A retrospective study was made of the surgical treatment of distant metastases from melanoma in 143 patients. The determinants of survival benefit were: (1) successful complete resection of all clinical disease; (2) single versus multiple metastatic site; and (3) anatomic location of disease. Complete resection was achieved with single‐ and multiple‐site lesions in 67% and 31% of the patients, respectively, yielding corresponding 5‐year survival rates of 33% and 9%, respectively. Incomplete resection yielded little survival benefit. Soft tissue and extraregional nodal lesions were completely resectable in 70%, whereas pulmonary, extrahepatic abdominal visceral, and osseous lesions were in 40% of the patients, resulting in similar 5‐year survival rates of 17% to 22%. The operative mortality rate was 1.4% (2/143). Unsuccessful resection frequently led to very long hospitalization periods for complications and disease, with some patients spending more than 50% of their remaining survival time in the hospital. These observations suggest that, with proper selection of patients, guided by these determinants, surgical resection can offer a reasonable expectation of prolonged survival.

Control of locally advanced extremity soft tissue sarcomas by function-saving resection and brachytherapy.

Amputation has often been advised for the treatment of deep‐seated or bulky soft tissue sarcomas of the limb because of proneness to local recurrence after conservative resection. The authors evaluated the efficacy of local control by means of function‐preserving resection and high‐dose brachytherapy of the tumor bed using Iridium‐192 implants in 33 patients with locally advanced sarcomas, 17 without prior therapy and 16 with locally recurrent tumors. Local control was achieved in 100% of the previously untreated group, and 62.5% of the previously treated, recurrent group after a median follow‐up time of 36 months (range, 19 months—7.5 years). Serious wound complications developed in nine patients, two of whom required amputation. Prehensile or walking function was preserved in 31 of the 33 treated limbs. These results indicate that conservative resection and brachytherapy can successfully control locally advanced limb sarcomas with good preservation of limb function. Cancer 53:1385‐1392, 1984.

Recent results of multimodal therapy of gastric lymphoma.

The efficacy of multimodality treatment of gastric lymphoma was examined in a retrospective study of 46 patients treated at the Memorial Sloan‐Kettering Cancer Center from 1971 to 1982. The principal treatment plan consisted of (1) surgical resection of the gastric lymphoma (n = 36) where feasible, followed by (2) radiation therapy of the whole abdomen (n = 23) with a boosting dose to the stomach‐bed to 3700 cGy, and/or (3) chemotherapy using mainly the CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) regimen as an adjuvant (n = 7), or CHOP plus other drugs for advanced disease. The median follow‐up time of patients was 61 months (range, 30 months to 14 years). There was no operative mortality. No patient developed known relapse in the abdomen after resection and total abdominal irradiation, and none suffered relapses after adjuvant chemotherapy, for Stages I‐E and II‐E. At 5 years, the estimated survival rate after treatment was 95%, 78%, and 25%, respectively for Stages I‐E (n = 20), II‐E (n = 9) and IV (n = 17). The results for Stage I‐E and II‐E resectable tumors were significantly improved (P < 0.05 and < 0.1 respectively) over those of similar tumors treated in 1949 to 1970.

Soft tissue sarcomas of the hand and foot.

A retrospective study was made of 82 soft tissue sarcomas of the hand and foot. Prognosis was related to histopathologic grade of malignancy and success or failure of local tumor control. After treatment with curative intent, low‐grade tumors gave a 5‐year survival rate of 90%, compared to 63% for high‐grade tumors. Simple excision or limited amputation of the digit, hand, or foot yielded a 5‐year survival rate of 68% (15/22) and a local recurrence rate of 32%. Amputation below the elbow or knee or higher resulted in a similar survival of 68% (19/28) but no local recurrences. All patients who developed local recurrences died, except for two with low‐grade tumors and one patient lost to follow‐up. These observations indicate the need for systemic chemotherapy to prevent death from metastasis, and for effective local tumor control. Conventional radiation therapy may be difficult to apply at these sites. Innovative local treatment approaches to preserve limb function without jeopardizing tumor control merit study.

Surgical treatment of tendosynovial sarcoma

Tendosynovial sarcoma is notorious for its high rates of local recurrence and metastases after surgical treatment. A retrospective study was made of 109 cases of monobloc wide soft part resection and amputation for primary tumors, and 29 patients who underwent resection of pulmonary metastases. Actuarial five‐year survival rates after soft part resection was 70% for untreated, and 61% for previously treated, locally recurrent neoplasms. Corresponding rates after amputation were 47% and 64%. Local tumor recurrence developed in 18% of the primary soft part resections and 4% of the amputations, usually when some basic surgical principle had been violated. 35% five‐year survival was achieved with judicious resection of solitary and multiple lung metastases in most cases without chemotherapy. Local control of a tendosynovial sarcoma can be achieved with properly executed surgical procedures which adhere to established tenets of cancer surgery. Resection of pulmonary metastases merits an important position in the management of these patients. Cancer 43:889–897, 1979.