Robert J. van Ginkel

Clinicopathologic prognostic factors in myxoid liposarcoma : A retrospective study of 49 patients with long-term follow-up

BackgroundThe main goal of this retrospective study was to investigate prognostic factors influencing the survival of myxoid liposarcoma (MLS) with emphasis on the role of transitional areas (TLS) and round cell morphology (RCLS).MethodsFrom 1977 to 2004, 49 patients—28 men (57%) and 21 women (43%) with a median age of 44 years (range, 7–83 years)—were diagnosed with an MLS. In 42 patients, the histology could be reviewed, and tumors were classified as MLS, TLS, or RCLS. Clinicopathologic factors were analyzed for influence on survival by univariate and multivariate methods.ResultsThe median follow-up of 49 patients was 101 months (range, 4–550 months). Of the 42 patients for whom histology was reviewed, 16 tumors were classified as MLS (38%), 19 as TLS (45%), and 7 as RCLS (17%). Sixteen patients (33%) developed a local recurrence after a median follow-up of 21 months (range, 2–108 months). Thirteen patients (27%) developed metastases. The median interval between diagnosis and metastasis was 41 months (range, 0–222 months). Median survival after metastasis was 18 months (range, 1–179 months). The 5- and 10-year disease-specific survival rates were 85% and 72%, whereas the 5- and 10-year overall survival rates were 83% and 68%, respectively. Age at presentation (P = .02), tumor grade (P = .01), and tumor size (P = .005) were significant prognostic factors associated with survival. Tumor grade was the only independent prognostic variable that remained significant with multivariate analysis. A TLS presentation had no negative influence on patient survival.ConclusionsAge at presentation, tumor grade, and tumor size had a negative influence on survival by univariate analysis, whereas tumor grade was the only independent prognostic factor by multivariate analysis. TLS was not associated with poor outcome.

Radiation-Induced Sarcoma: A Challenge for the Surgeon

BackgroundTreatment of radiation-induced sarcoma (RIS) remains an unsolved problem. To provide more insight into the disease process, its characteristics, outcome, and potential outcome determinants were defined.MethodsFrom 1978 to 2003, 27 patients—20 females (74%) and 7 males (26%) with a median age 44 years (range, 1–73 years) at the time of diagnosis of the primary tumor—developed an RIS after a median interval of 8 years (range, 3–41 years). The histology of the RIS was 10 (37%) undifferentiated high-grade pleomorphic sarcomas, 7 (26%) angiosarcomas, 6 (22%) fibrosarcomas, 2 (7%) osteosarcomas, 1 (4%) pleomorphic rhabdomyosarcoma, and 1 (4%) pleomorphic leiomyosarcoma. Surgical resection was performed in 21 patients: 13 (62%) R0 (microscopically radical), 4 (19%) R1 (microscopically irradical), 2 (9.5%) R2 (macroscopically irradical), and 2 (9.5%) RX (unknown radicality). Six (22%) patients underwent no resection.ResultsThe 5-year disease-free and overall survival rates were 27% and 30%, respectively. The local failure rate after R0 resection was 54%. The distant failure rate for the entire group was 41%. Patients with an R0 resection had a significantly better survival rate (P < .05) than patients with an R1, R2, or no resection.ConclusionsRISs are aggressive malignancies with a high tendency for local recurrence and distant metastases. Previously applied treatment often hampers adequate resection. Therefore, radical surgical resection is the only chance to improve disease-free and overall survival, but it may also have a palliative role. Still, the overall prognosis remains poor.

Isolated limb perfusion with tumor necrosis factor α and melphalan for locally advanced soft tissue sarcoma : The value of adjuvant radiotherapy

BackgroundThe aim was to investigate the value of adjuvant radiotherapy for locally advanced soft tissue sarcoma after hyperthermic isolated limb perfusion (ILP) with tumor necrosis factor α and melphalan followed by limb-saving surgery.MethodsFrom 1991 to 2003, 73 patients (median age, 54 years; range, 14–80 years) underwent 77 ILPs, followed by resection in 68 patients (93%). Radiotherapy was administered in case of marginally or microscopically positive resection margins. Local recurrences were scored and calculated according to the Kaplan-Meier method and log-rank test.ResultsAfter residual tumor mass resection, 58% received radiotherapy (external beam radiotherapy [EBRT]+ group), and 42% did not (EBRT− group). The median follow-up was 28 months (range, 2–159 months). A significantly better local control rate was observed in the EBRT+ compared with the EBRT− group (P < .0001). When only R0 resections in patients without metastasis were considered, the significance remained between groups (P = .0003). In the EBRT− group, an R1 or R2 resection resulted in earlier relapse of local disease compared with R0 resections (P = .0475).ConclusionsAdjuvant EBRT reduces the risk for local recurrence after delayed resection in soft tissue sarcoma patients treated with ILP and tumor necrosis factor and is indicated when resection margins are close or microscopically positive. It also seems beneficial after an R0 resection.

Quality of Life After Hyperthermic Isolated Limb Perfusion for Locally Advanced Extremity Soft Tissue Sarcoma

BackgroundQuality of life (QoL) and posttraumatic stress symptoms (PTSS) were studied in patients with soft tissue sarcoma (STS) of the extremities treated with isolated limb perfusion and delayed resection, with or without adjuvant irradiation.MethodsForty-one patients received a questionnaire that included the RAND-36 and Impact of Event Scale.ResultsThirty-nine STS survivors (16 [41%] male and 23 [59%] female; median age, 59 years; range, 15–78 years) participated in the questionnaire survey (response rate, 95%). The median age at perfusion was 49 years (range, 14–72 years). No significant differences were found in mean scores between STS survivors and the reference group with the exception of a worse physical functioning. Patients with amputations showed significantly worse physical and social functioning and more role limitations than patients whose limbs were saved. Eleven patients (28%) had a PTSS score of 0, and eight patients (20.5%) had a score ≥ 26, which suggested the need for psychological counseling. None of these eight patients had lost a limb. Patients who indicated that the choice of treatment was made by the surgeon rather than collaboratively showed significantly decreased social functioning, more role limitations, and intrusion. Greater treatment satisfaction was significantly related to better social functioning, more vitality, better general health perception, less intrusion, avoidance, and total Impact of Event Scale scores.ConclusionsEven though STS survivors’ QoL was different from that of a reference group only in physical functioning, one fifth of the patients had PTSS. An amputation, the physician’s decision rather than the patient’s decision for the perfusion treatment and a low satisfaction with the performed treatment negatively influenced QoL.

Approach and management of primary ectopic breast carcinoma in the axilla: Where are we? A comprehensive historical literature review

Primary ectopic breast carcinoma is a rare disease and, at present, no specific guidelines on its diagnosis and treatment are available. The purpose of this article is to review the world literature in English on primary ectopic breast carcinoma located in the armpit and to offer guidelines for diagnosis and treatment. Data for this review were identified by searches of MEDLINE, PubMed, The Cochrane Library, ACNP (Italian catalogue of journals) and references from relevant articles using relevant search terms and data published in the previous reviews. Primary ectopic breast carcinoma of the axilla mostly affects women of over 40 (range 28-90 yrs) years of age. The most frequent histological diagnosis is invasive ductal carcinoma not otherwise specified (NOS) (72%). Because of its rareness, in most cases, the diagnosis is delayed for on average 40.5 months. This disease is rare, but a high level of suspicion for carcinoma is mandatory when confronted with a tumour in this area. Once diagnosed, patients should undergo staging, and prognostic and adjuvant treatment procedures identical to orthotopic breast carcinoma guidelines. There are some limitations for the staging. Loco-regional treatment, on indication, combined with endocrine therapy and/or chemotherapy seems the treatment of choice.

Hyperthermic isolated limb perfusion with cisplatin in four patients with sarcomas of soft tissue and bone

The value of hyperthermic isolated limb perfusion (HILP) with cisplatin in the management of locally advanced soft tissue sarcomas or metastatic bone sarcoma was studied. Four patients were treated with HILP under mild hyperthermia (39-40 degrees C) with 20-30 mg cisplatin/l perfused limb volume. Toxicity in the perfused limbs was moderate, and the erythema and oedema that occurred resolved spontaneously within 7-14 days as did the slight motor and sensory neuropathy over a longer period of time. Clinically, a reduction of pain was observed in all patients. Two weeks after perfusion, tumour biopsies were taken to evaluate tumour response. Two patients showed a pathological complete response, one patient showed >90% necrosis and one patient showed no response. Currently patients are treated with tumour necrosis factor and melphalan as perfusion agents. The above-mentioned results make the combination of tumour necrosis factor with cisplatin in the isolated limb perfusion setting an interesting option.

TNF dose reduction and shortening of duration of isolated limb perfusion for locally advanced soft tissue sarcoma of the extremities is safe and effective in terms of long‐term patient outcome

Dose reduction and shortening of duration of perfusion in isolated limb perfusion with TNF‐α and Melphalan (TM‐ILP) are associated with less systemic toxicity and seem to be safe and effective on short‐term. However, data on long‐term patient outcome are scarce.

Molecular fluorescence-guided surgery of peritoneal carcinomatosis of colorectal origin: a single-centre feasibility study

BACKGROUND Optimum cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is essential for the curative treatment of peritoneal carcinomatosis of colorectal origin. At present, surgeons depend on visual inspection and palpation for tumour detection. Improved detection of tumour tissue using molecular fluorescence-guided surgery could not only help attain a complete cytoreduction of metastatic lesions, but might also prevent overtreatment by avoiding resection of benign lesions. METHODS For this non-randomised, single-centre feasibility study, we enrolled patients with colorectal peritoneal metastases scheduled for cytoreductive surgery and HIPEC. 2 days before surgery, 4·5 mg of the near-infrared fluorescent tracer bevacizumab-IRDye800CW was administered intravenously. The primary objectives were to determine the safety and feasibility of molecular fluorescence-guided surgery using bevacizumab-IRDye800CW. Molecular fluorescence-guided surgery was deemed safe if no allergic or anaphylactic reactions were recorded and no serious adverse events were attributed to bevacizumab-IRDye800CW. The technique was deemed feasible if bevacizumab-IRDye800CW enabled detection of fluorescence signals intraoperatively. Secondary objectives were correlation of fluorescence with histopathology by back-table imaging of the fresh surgical specimen and semi-quantitative ex-vivo analyses of formalin-fixed paraffin embedded (FFPE) tissue on all peritoneal lesions. Additionally, VEGF-α staining and fluorescence microscopy was done. This study is registered with the Netherlands Trial Registry, number NTR4632. FINDINGS Between July 3, 2014, and March 2, 2015, seven patients were enrolled in the study. One patient developed an abdominal sepsis 5 days postoperatively and another died from an asystole 4 days postoperatively, most probably due to a cardiovascular thromboembolic event. However, both serious adverse events were attributed to the surgical cytoreductive surgery and HIPEC procedure. No serious adverse events related to bevacizumab-IRDye800CW occurred in any of the patients. Intraoperatively, fluorescence was seen in all patients. In two patients, additional tumour tissue was detected by molecular fluorescence-guided surgery that was initially missed by the surgeons. During back-table imaging of fresh surgical specimens, a total of 80 areas were imaged, marked, and analysed. All of the 29 non-fluorescent areas were found to contain only benign tissue, whereas tumour tissue was detected in 27 of 51 fluorescent areas (53%). Ex-vivo semi-quantification of 79 FFPE peritoneal lesions showed a tumour-to-normal ratio of 6·92 (SD 2·47). INTERPRETATION Molecular fluorescence-guided surgery using the near-infrared fluorescent tracer bevacizumab-IRDye800CW is safe and feasible. This technique might be of added value for the treatment of patients with colorectal peritoneal metastases through improved patient selection and optimisation of cytoreductive surgery. A subsequent multicentre phase 2 trial is needed to make a definitive assessment of the diagnostic accuracy and the effect on clinical decision making of molecular fluorescence-guided surgery. FUNDING FP-7 Framework Programme BetaCure and SurgVision BV.

Galectin-9 activates and expands human T-helper 1 cells.

Galectin-9 (Gal-9) is known for induction of apoptosis in IFN-γ and IL-17 producing T-cells and amelioration of autoimmunity in murine models. On the other hand, Gal-9 induced IFN-γ positive T-cells in a sarcoma mouse model and in food allergy, suggesting that Gal-9 can have diametric effects on T-cell immunity. Here, we aimed to delineate the immunomodulatory effect of Gal-9 on human resting and ex vivo activated peripheral blood lymphocytes. Treatment of resting lymphocytes with low concentrations of Gal-9 (5–30 nM) induced apoptosis in ∼60% of T-cells after 1 day, but activated the surviving T-cells. These viable T-cells started to expand after 4 days with up to 6 cell divisions by day 7 and an associated shift from naïve towards central memory and IFN-γ producing phenotype. In the presence of T-cell activation signals (anti-CD3/IL-2) Gal-9 did not induce T-cell expansion, but shifted the CD4/CD8 balance towards a CD4-dominated T-cell response. Thus, Gal-9 activates resting T-cells in the absence of typical T-cell activating signals and promotes their transition to a TH1/C1 phenotype. In the presence of T-cell activating signals T-cell immunity is directed towards a CD4-driven response by Gal-9. Thus, Gal-9 may specifically enhance reactive immunological memory.

The Glycan-Binding Protein Galectin-9 Has Direct Apoptotic Activity toward Melanoma Cells

TO THE EDITOR In recent years, a regulatory role has emerged for the glycan-binding protein galectin-9 (Gal-9) in normal physiology and pathology (reviewed by Wiersma et al. (2011). In melanoma and other malignancies, the available data suggest that Gal-9 has a tumor-suppressor function, with loss of Gal-9 being closely associated with metastatic progression (Kageshita et al., 2002; Irie et al., 2005; Yamauchi et al., 2006; Liang et al., 2008). In particular, melanocytic nevi and primary melanoma lesions highly express Gal-9, whereas metastatic melanoma lesions have no or minimal expression of Gal-9 (Kageshita et al., 2002). Furthermore, ectopic expression of Gal-9 abrogates the formation of metastases by Gal-9-deficient B16F10 murine melanoma cells (Nobumoto et al., 2008). Similarly, treatment of Gal-9-deficient B16F10 cells with a recombinant form of Gal-9, designated Gal-9(0), strongly reduced metastasis formation (Nobumoto et al., 2008). This anti-metastatic activity of Gal-9(0) on B16F10 has been attributed mainly to inhibition of melanoma cell adhesion to endothelial cells and/or extracellular matrix components, such as collagen type I (collagen-I; Nobumoto et al., 2008). The data presented in the current letter suggest that within the 1-h time frame of adhesion-type assays, treatment with Gal-9(0) triggers early apoptotic cellular changes. In line with earlier findings, Gal-9(0) inhibits the adhesion of B16F10 and 7 human melanoma cell lines to collagen-I (Figure 1a). However, the morphology of Gal-9(0)-treated cells that had adhered to collagen-I-coated wells resembled that of dying cells (Figure 1b; illustrated for B16F10). Subsequent analysis of this melanoma cell line panel, as well as primary patient–derived malignant melanoma cells for the early apoptotic marker phosphatidyl serine (PS), revealed that treatment with Gal-9(0) induced ∼90% cell death within the time frame used in the adhesion assay (Figure 1c). Early apoptotic PS exposure was followed by apoptotic cell death within 24 h of treatment, as evidenced by loss of viability (Supplementary Figure S1a online), the presence of late apoptotic Annexin-V/PI double-positive cells (Supplementary Figure S1b and c online), and an increase in DNA fragmentation (Supplementary Figure S1d online). In primary human melanocytes, Gal-9(0) also triggered PS exposure, albeit to a lesser extent (Figure 1c; ∼55%). More importantly, the viability of these normal cells was not negatively affected after 24 h (Supplementary Figure S1a online). Thus, Gal-9(0) induces rapid apoptotic cell death in melanoma cells, but not in normal human melanocytes. PS exposure induced by Gal-9(0) was fully dependent on the glycan-binding specificity of Gal-9(0), as it was selectively blocked by the competitive Gal-9 inhibitor alpha-lactose but not by the irrelevant carbohydrate sucrose (Figure 1d). Sensitivity to Gal-9(0) did not or only weakly correlated with expression of endogenous Gal-9 (Supplementary Figure S2 online; r2=0.250). Time-course analysis in five of the human melanoma cell lines demonstrated that treatment with Gal-9(0) induced PS exposure in >60% of melanoma cells within 5 minutes of treatment (Figure 1e). Furthermore, the extent of PS exposure closely correlated with the inhibitory effect of Gal-9(0) on collagen I binding (Figure 1f, MM-RU; r2=0.693). Together, these data suggest that the biological effect of Gal-9(0) in adhesion assays is mediated, at least partly, through the induction of cell death. It is noteworthy that pan-caspase inhibition failed to block the anti-adhesive and apoptotic activity of Gal-9(0; Supplementary Figure S1e and f online). Thus, Gal-9(0)-mediated melanoma apoptosis does not require caspase activation, which is in line with e.g. reports on gal-1-mediated cell death of T cells (Hahn et al., 2004). Figure 1 Galectin-9 (Gal-9(0)) rapidly induces apoptosis in serum-free conditions. (a). Adhesion of B16F10 and a panel of human melanoma cell lines to collagen-I-coated wells is inhibited by recombinant Gal-9. In brief, 3 × 104 melanoma cells were added ... Adhesion assays are typically performed in serum-free conditions, whereas in normal physiological situations the presence of serum and/or plasma components may affect the biological activity of Gal-9. Indeed, it is well established that Gal-9 can interact with serum components (Cederfur et al., 2008). Therefore, the biological activity of Gal-9(0) was next evaluated in the presence of 10% fetal calf serum (FCS), the standard serum additive in cell death assays. The inclusion of 10% FCS in these apoptosis experiments completely abrogated the morphological changes in melanoma cells, with induction of PS exposure by Gal-9(0) being abrogated in six of the seven cell lines tested (Figure 2a). Similarly, PS exposure by Gal-9(0) was also strongly inhibited in the primary melanoma cells (Figure 2a). Indeed, FCS dose dependently inhibited PS exposure induced by Gal-9(0) (illustrated for cell line A2058 in Figure 2b) and blocked the binding of Gal-9(0) to A2058 cells (Figure 2c). When using dialysed FCS or heat-inactivated FCS, the activity of Gal-9(0) was still inhibited (Figure 2d). Thus, the inhibitory component present in FCS is not heat labile (i.e., complement factors) and is >10 kDa in size. Notably, FCS did not inhibit Gal-9(0) activity toward SK-MEL-28 cells (Figure 2a), which suggests that the inhibitory effect of FCS is not merely due to binding of a serum component to Gal-9(0). Possibly, a serum component may shield the receptor(s) of Gal-9 on most melanoma cells. On Sk-MEL-28 cells, Gal-9(0) may interact with an alternative receptor not subject to binding/inhibition by FCS. Figure 2 Cell death induction by galectin-9 (Gal-9(0)) is blocked by fetal calf serum (FCS) but not by human pooled plasma. (a) A panel of melanoma cells and primary patient–derived melanoma cells (n=1) were treated for 1 h with Gal-9(0) in standard ... Although FCS is the standard additive in in vitro cell death assays, a better approximation of physiological settings is the addition of human plasma. Importantly, 10% human pooled plasma did not abrogate Gal-9(0)-induced PS exposure in A2058 cells, with only a slight reduction in PS exposure compared with serum-free conditions (Figure 2d). Similar results were obtained in six melanoma cell lines and in primary patient–derived melanoma cells (Figure 2e). These experiments suggest that an important biological effect of Gal-9(0) on human melanoma cells is the induction of apoptosis. This biological effect of Gal-9(0) is masked by as yet unidentified components present in FCS, but is unmasked in serum-free conditions or when human plasma is used. Indeed, in standard FCS-containing culture conditions, apoptotic cell death of the melanoma cell line MM-RU was only detected after 72 h of treatment with Gal-9 (Kageshita et al., 2002). The use of FCS may similarly mask the biological activity of other gal family members. In this respect, gal-2, -3, -4, and -8 interact with various serum components (Cederfur et al., 2008). Notably, plasma levels of several of the gal family members are increased in malignancy (Barrow et al., 2011). The use of human pooled serum/plasma instead of FCS for in vitro biological assays with members of the Gal family therefore appears prudent. In conclusion, recombinant Gal-9 has a hitherto unrecognized cytotoxic effect toward human melanoma cells, which further highlights its potential therapeutic applicability for the treatment of human metastatic melanoma.