Prognostic factors associated with uterine sarcomas: the experience of a single institution.

Uterine sarcomas are infrequent and heterogeneous mesenchymal tumours, associated with aggressive characteristics and a poor clinical outcome. The aim of the study is to describe the prognostic factors associated with uterine sarcomas. The clinical records between 2000 and 2014 of women diagnosed with uterine sarcomas and initially treated surgically were reviewed. A histological comparison was performed. The overall survival (OS) and disease-free survival (DFS) were calculated and compared. Seventy-three women had surgery (12.3% had endometrial stromal sarcomas, 24.7% undifferentiated endometrial sarcomas, 49.3% leiomyosarcomas and 13.7% other subtypes). Complete cytoreduction had a mean DFS of 25.1 months, while the incomplete cytoreduction averaged in a DFS of 4.33 months (p = .04). The median five-year OS with a complete cytoreduction was not reached; the incomplete cytoreduction OS was 10.1 months (p = .002). Our data suggests that undifferentiated endometrial sarcomas have the lowest DFS (p = .004); while OS was negatively influence by stage IV (p < .001). Impact statement What is already known about this subject? Uterine sarcomas compared with the more common endometrial carcinomas (epithelial neoplasms), behave aggressively and are associated with a poorer prognosis. The rarity of uterine sarcoma has made it difficult to perform large studies to identify risk factors. What do the results of this study add? Complete cytoreduction improves the DFS and OS and may be a valuable prognostic factor. Poorer DFS and OS prognosis was observed in undifferentiated endometrial sarcomas. What are the implications of these findings for clinical practice and/or further research? Our results demonstrate the importance of an early diagnosis, and thus an early identification of disease that benefits from complete cytoreduction regardless of histology. For the advanced clinical stage of uterine sarcomas further research is necessary and participation in clinical trials should be encouraged.

[Laparoscopic anterior pelvic exenteration in a patient with locally advanced melanoma]. / Exenteración pélvica anterior laparoscópica en un paciente con melanoma localmente avanzado.

BACKGROUND: Pelvic exenteration is one of the most mutilating surgical procedures with high post-operative morbidity. The laparoscopic technique aims to reduce perioperative complications and reduce post-surgical recovery. OBJECTIVE: We present the first case of laparoscopic anterior exenteration for locally advanced melanoma, held at the National Cancer Institute and published in Mexico. CASE REPORT: Patient 60 years of age diagnosed with invasive vulvar melanoma with bladder extension upon whom laparoscopic anterior pelvic exenteration with external urinary reconstruction was performed. Time in surgery was 505minutes and estimated blood loss was 400ml. No complications occurred during or immediately after surgery. The final histopathological study reported: nodular lesion that completely replaces the clitoris and spreads to the left labia majora, measures 3×2.5×2cm and is located relative to the free margins with perineural invasion intraepithelial spread in space and urethra and bladder trigone. CONCLUSIONS: The laparoscopic anterior pelvic exenteration is a safe alternative in well-selected patients, with acceptable time in surgery, surgical complications and recovery time.

Colonic cribriform carcinoma, a morphologic pattern associated with low survival.

Colorectal carcinoma is one of the most common cancers in the human body. Colorectal carcinoma is a heterogeneous disease with variegated morphological patterns; some have shown themselves to have prognostic value. The World Health Organization classification recognizes many histological variants associated with adverse prognostic factors, one is the cribriform colonic carcinoma (CCC). In this work, we analyzed 18 cases of CCC compared with 228 conventional adenocarcinomas of colon, with the hypotheses that CCC compared with non-CCC have worse prognosis and decreased overall survival. CCC represent 7.3% of all colonic adenocarcinomas in this series, it presents in a median age of 56.3 years, all cases are in clinical stage III and IV, all invade subserosal adipose tissues or serosa, 90% have >5 positive lymph nodes and 89% have lymphovascular invasion. These known adverse prognostic factors reflect a lower 5-year survival, stage by stage, than conventional intestinal-type adenocarcinoma (56.8% vs 83.3%, P = .035). Cribriform carcinoma is a morphologic pattern that is underrecognized; in this work, we demonstrate its association with low survival, extensive lymphovascular invasion, and extensive lymph node metastasis, strong indicators of aggressive disease. Their proper recognition is mandatory to increase the number of cases and series to support our findings and include it in the current classifications.

Conjunctival melanoma: survival analysis in twenty-two Mexican patients.

PURPOSE: To describe the cases of conjunctival melanoma (CM) and report the disease-free interval (DFI) and overall survival (OS). METHODS: The charts of 22 patients who were admitted to two hospitals between 1985 and 2006 were reviewed for pertinent data, including demographics, site of involvement in the conjunctiva and sub-sites, surgical treatment, and adjuvant treatment. RESULTS: There were 10 (45.45%) males and 12 (54.55%) females. Mean age was 52.3 years. In this group, 15 patients (68.1%) involved the bulbar conjunctiva, and 7 (31.9%) involved the palpebral conjunctiva. Of the 22 patients, 72.72% had a history of conjunctival melanosis. The average tumor size was 20.4 mm. Eight (36.36%) patients underwent orbital exenteration, 2 (9.06%) had enucleation, 5 (22.72%) had wide excision of the lesion followed by radiotherapy, 2 (9.06%) had orbital exenteration with neck dissection, and the remaining 5 patients (22.72%) were considered adequately treated only with wide excision. Eight (36.36%) patients received adjuvant treatment. Disease-free survival at 5 years was 51% and the overall survival at 5 and 10 years was 50% and 37%, respectively. CONCLUSION: Conjunctival melanoma is a rare entity. Tumor behavior is aggressive, and the optimal treatment is surgery with adjuvant therapy.

Conjunctival melanoma: survival analysis in twenty-two Mexican patients / Melanoma conjuntival: análise de sobrevivência em vinte e dois pacientes mexicanos

Purpose: To describe the cases of conjunctival melanoma (CM) and report the disease-free interval (DFI) and overall survival (OS). Methods: The charts of 22 patients who were admitted to two hospitals between 1985 and 2006 were reviewed for pertinent data, including demographics, site of involvement in the conjunctiva and sub-sites, surgical treatment, and adjuvant treatment. Results: There were 10 (45.45%) males and 12 (54.55%) females. Mean age was 52.3 years. In this group, 15 patients (68.1%) involved the bulbar conjunctiva, and 7 (31.9%) involved the palpebral conjunctiva. Of the 22 patients, 72.72% had a history of conjunctival melanosis. The average tumor size was 20.4 mm. Eight (36.36%) patients underwent orbital exenteration, 2 (9.06%) had enucleation, 5 (22.72%) had wide excision of the lesion followed by radiotherapy, 2 (9.06%) had orbital exenteration with neck dissection, and the remaining 5 patients (22.72%) were considered adequately treated only with wide excision. Eight (36.36%) patients received adjuvant treatment. Disease-free survival at 5 years was 51% and the overall survival at 5 and 10 years was 50% and 37%, respectively. Conclusion: Conjunctival melanoma is a rare entity. Tumor behavior is aggressive, and the optimal treatment is surgery with adjuvant therapy. .

Objetivo: Descrever o intervalo livre de doença (DFI) e sobrevida global (OS) de pacientes com melanoma conjuntival (CM). Método: Prontuários de 22 pacientes que foram internados em dois hospitais entre 1985 e 2006 foram revisados para dados pertinentes, incluindo dados demográficos, local de envolvimento na conjuntiva e outros locais de acometimento, tratamento cirúrgico e tratamento adjuvante. Resultados: Dez (45,45%) homens e 12 (54,55%) mulheres foram selecionados. A média de idade foi de 52,3 anos. Em 15 pacientes (68,1%) CM envolveu a conjuntiva bulbar, e em 7 (31,9%) envolveu a conjuntiva palpebral. Dos 22 pacientes, 72,72% tinham história de melanose conjuntival. O tamanho médio do tumor foi de 20,4 mm. Oito (36,36%) pacientes foram submetidos à exenteração orbital, 2 (9,06% ) à enucleação, 5 (22,72%) à ampla excisão da lesão seguida de radioterapia, 2 (9,06%) à exenteração orbital com esvaziamento cervical e os restantes 5 pacientes (22,72%) foram considerados adequadamente tratados apenas com excisão ampla. Oito (36,36%) pacientes receberam tratamento adjuvante. Sobrevida livre de doença em 5 anos foi de 51% e sobrevida global em 5 e 10 anos foi de 50% e 37%, respectivamente. Conclusão: Melanoma conjuntival é uma entidade rara. Comportamento do tumor é agressivo, e o melhor tratamento é a cirurgia com terapia adjuvante. .

Soft tissue sarcomas of the head and neck. Clinical and pathological evaluation of 108 cases in Mexico.

BACKGROUND: Sarcomas constitute 1% of all malignancies, but 10% occur in the head and neck (HN), and they are poorly understood. We present a large series of Soft Tissue HN sarcomas in Mexican patients with survival analysis. STUDY DESIGN: This is a retrospective study of cases in a cancer hospital. METHODS: Review of files and pathology material. Literature review. RESULTS: We analysed 108 patients (55 men / 53 women). The age at presentation was 37 years. The original diagnosis changed in nine cases (8.3%). The most common subtype was rhabdomyosarcoma. Ninety percent of tumours were deep, 91% were high grade, 44% had metastasis, 63% measured >5 cm, overall 5-year survival (5 y-OS) was 48%, and histological high grade was associated with poor survival (p = 0.026). CONCLUSION: Sarcomas of the HN are rare. The most affected sites were paranasal sinuses. The majority of tumours were deep, > 5 cm and high grade, 50% had metastasis, the 5 y-OS was 48% and the only independent factor associated with 5 y-OS was histologic grade.

Importance of tumor size in soft tissue sarcomas: a proposal for a nomogram based on a score system to staging soft tissue sarcomas in the postoperative setting.

In order to adequately stage patients with extremity soft tissue sarcomas (ESTS), it is mandatory to include all adverse prognostic factors and create an integral staging system. We were able to evaluate a nomogram based on a score (STSSS), to improve ESTS staging. We retrospectively evaluated 596 patients with ESTS in stages I-III, of the American Joint Committee on Cancer (AJCC), who had a complete resection. We analyzed the influence of clinicopathological factors on metastasis, recurrence, and disease-specific survival. The STSSS was based on histologic grade (HG), profundity, tumor size (TS), and surgical margins; we also compared STSSS versus AJCC systems in their ability to stage ESTS. The mean TS was 11.8 cm, with 50%>10 cm. Large TS and high HG were independent but adverse prognostic factors for metastasis. In addition, large TS, high grade, and R1 resection were independent adverse prognostic factors for decreased survival. There was a progressive decline in survival as TS increased, although AJCC staging did not correlate well between stages (IA vs. IB p=0.233, IA vs. IIA p=0.123, IA vs. IIB p=0.075, IB vs. IIA p=0.472, IB vs. IIB p=0.211). STSSS showed differences between these categories for 5-year survival (I vs. II p=0.003, II vs. III p=0.002, III vs. IV p<0.001). Surgical margins, HG, and TS are important determinants for metastases and survival. We also found a strong correlation between survival and prognosis with the use of STSSS in the immediate postoperative setting.

[Relevance of an adequate pathologic evaluation of radical rectal resection specimens]. / Relevancia de una evaluación patológica adecuada de la resección radical de recto.

BACKGROUND: The most important prognostic factors influencing survival of patients with rectal carcinoma (RC) are lymph node metastases and mesorectal excision (ME). The adequate pathologic examination (APE) of rectal specimens is a standardized pathologic work-up that differs of the conventional colonic/intestinal pathologic work-up. The aim of this study was to determine the impact of APE on staging, lymph node retrieval and survival, with the hypotheses that APE allows high lymph node retrieval and better survival. METHODS: We retrospectively analyzed patient with surgery for RC from 2004 to 2011. We described the APE of radical rectal resection and we compared the clinical and pathological characteristics and the oncologic results, including survival after and before APE. RESULTS: A total of 185 patients were evaluated, 114 constituted the pre-APE group and 71 the APE group. The mean lymph node retrieval was 13.7 in the pre-APE group and 19.6 in the APE group (P = 0.007). In the APE group we found less local recurrence (20% vs 34%, P = 0.024), more lymph-vascular invasion (20% vs 5%, P = 0.003), higher prevalence of high grade tumors (20% vs 4%, P = 0.001), more alive patients free of disease (75% vs 49%, P = 0.001), more frequent use of neoadjuvant therapy (58% vs 31%, P = 0.001), and and better 4-year survival (78% vs 53%, P = 0.044). CONCLU- SION: The APE is crucial in patients with RC for staging and planning further treatment. An APE added to neoadjuvant or adjuvant therapy was associated with better survival.

Two cases of sternectomy for bone metastasis due to aggressive variants of thyroid papillary carcinoma.

INTRODUCTION: There are only few cases reported about the role of surgery in the presence of single or multiple bulky bone metastases. The literature about treatment for bulky sternal metastases is scarce. PRESENTATION OF CASE: We present two patients treated surgically for metastatic thyroid lesions. Case 1 is a female with tumor of the thyroid right lobe, mediastinal extension and multiple pulmonary metastases. Bony infiltration was observed in the sternum and ribs. Case 2 is a female with a lesion in the cervical region of the thyroid left lobe and increase in volume on the upper sternal manubrium. DISCUSSION: Patients with well-differentiated thyroid cancer may present with extracervical metastasis in 5-10% of cases at diagnosis. Bone metastases occur in 0.4% of cases of papillary carcinoma. Management remains controversial. There are only isolated cases reported in the literature of the role surgery plays in the presence of single or multiple bulky bone metastases. The basis for initial surgical approach is keeping in mind that the surgical procedure is palliative in order to achieve optimal hypothetical ablation as a result of reduced tumor volume. CONCLUSION: Surgery is the elective treatment and can be performed safely and with adequate results, allowing proper optimization of the dose of (131)I for ablative therapy.

A high body mass index is not a worse prognostic factor for endometrial carcinoma in a predominantly obese population.

AIM: We investigate if body mass index (BMI, kg × m(2)) is related to clinical-pathological characteristics in primary tumor and disease outcome in endometrial cancer. BACKGROUND: Endometrial cancer incidence is increasing in industrialized countries. High BMI is associated with worse prognosis for many diseases. INTRODUCTION: Endometrial carcinoma is the most common gynecological malignancy in industrialized countries and the incidence has been increasing over the last few decades associated with obesity, however, it is not clear if a high BMI is associated with poor prognosis. PATIENTS AND METHODS: In total, 147 women primarily treated for endometrial carcinoma at the Instituto Nacional de Cancerología during 2000-2005 were studied. Body mass index was available for all patients and related to comprehensive clinical and histopathological data. RESULTS: High BMI was related to endometrioid histology and low/intermediate grade, and overweight/obese women had the same survival as the normal/underweight women. In survival analysis adjusting for age, histological subtype and grade, BMI showed no independent prognostic impact. CONCLUSION: High BMI was significantly associated with markers of non-aggressive disease and women with high BMI had the same survival time in univariate analysis.

Mixed gastric carcinoma with intestinal and cribriform patterns: a distinctive pathologic appearance associated with poor prognosis in advanced stages and a potential mimicker of metastatic breast carcinoma.

Gastric adenocarcinoma is characterized by marked heterogeneity at cytological and architectural level and frequently shows overlap between microscopic patterns. This article describes a peculiar pattern of gastric adenocarcinoma, previously unreported, that combines intestinal type adenocarcinoma with areas of cribriform pattern that resembles both architectural and cytological in situ ductal carcinoma of the breast and to the best of the authors' knowledge, there are no earlier reports of this pattern in the stomach, which has been named "gastric carcinoma with cribriform component (CGA). The authors analyzed 12 cases of intestinal type adenocarcinoma with areas at least 20% of cribriform pattern (range from 20% to 90%) that was present in 9% of intestinal type gastric adenocarcinomas in their institution. There is slight predilection for male sex, and the median age of presentation is 55.8 years. The phenotype by immunohistochemistry is the same as with conventional (non-CGA) carcinomas. CGA shows more frequent lymphovascular invasion (P = .039), perineural invasion (P = .027) and resembles both in situ and invasive cribriform carcinoma of the breast. In clinical stage III the overall 3-year survival of CGA was worse than those with non-CGA component (38.6% vs 25%; 3-year survival, P = .010) and proves to be an independent adverse factor for overall survival in a multivariate analysis. Compared with conventional gastric carcinomas, CGA is deep infiltrating, has more nodal metastases, more lymphovascular and perineural invasion, and has decreased overall survival. Thus, proper recognition and report is important, even in small biopsies or small foci.

Synovial sarcomas of the head and neck: comparative analysis with synovial sarcoma of the extremities.

OBJECTIVE: This study analyzed synovial sarcoma (SS) of the head and neck in order to identify features associated with survival improvement and compared them with the survival of SS of limbs. METHODS: Clinical charts and histopathologic material with analysis for SYT/SSX gene rearrangement of 16 patients were reviewed. The clinicopathologic features and their association with survival were analyzed and compared with 174 SS of limbs. RESULTS: The average age was 24.2 years (range 21-86). Eight cases occurred in each sex. The most frequent site was the parapharyngeal space (PPS). The mean tumor size was 5.38cm. Sixty-nine percent occurred in Stages II-III and 9% in Stage IV. Fifteen cases were excised: R0 resection in seven (46.7%) cases and R1 resection in eight (53.3%) cases. No patient with R0 resection has recurred, and three patients (37.5%) with R1 resection have recurred (p=0.035). Patients with R0 surgery had better survival rates compared to those who received other treatments (p=0.045). SS of head and neck showed a 5-year survival rate of 58% compared to 44.6% of the limbs (p=0.450). CONCLUSION: The most prevalent location was the PPS. Surgical resection with clear margins correlated with low recurrence. Head and neck sarcomas had similar survival rates compared to sarcomas of limbs.

Relevancia de una evaluación patológica adecuada de la resección radical de recto. / [Relevance of an adequate pathologic evaluation of radical rectal resection specimens].

BACKGROUND: The most important prognostic factors influencing survival of patients with rectal carcinoma (RC) are lymph node metastases and mesorectal excision (ME). The adequate pathologic examination (APE) of rectal specimens is a standardized pathologic work-up that differs of the conventional colonic/intestinal pathologic work-up. The aim of this study was to determine the impact of APE on staging, lymph node retrieval and survival, with the hypotheses that APE allows high lymph node retrieval and better survival. METHODS: We retrospectively analyzed patient with surgery for RC from 2004 to 2011. We described the APE of radical rectal resection and we compared the clinical and pathological characteristics and the oncologic results, including survival after and before APE. RESULTS: A total of 185 patients were evaluated, 114 constituted the pre-APE group and 71 the APE group. The mean lymph node retrieval was 13.7 in the pre-APE group and 19.6 in the APE group (P = 0.007). In the APE group we found less local recurrence (20

vs 34

, P = 0.024), more lymph-vascular invasion (20

vs 5

, P = 0.003), higher prevalence of high grade tumors (20

vs 4

, P = 0.001), more alive patients free of disease (75

vs 49

, P = 0.001), more frequent use of neoadjuvant therapy (58

vs 31

, P = 0.001), and and better 4-year survival (78

vs 53

, P = 0.044). CONCLU- SION: The APE is crucial in patients with RC for staging and planning further treatment. An APE added to neoadjuvant or adjuvant therapy was associated with better survival.

Relevancia de una evaluación patológica adecuada de la resección radical de recto / [Relevance of an adequate pathologic evaluation of radical rectal resection specimens].

BACKGROUND: The most important prognostic factors influencing survival of patients with rectal carcinoma (RC) are lymph node metastases and mesorectal excision (ME). The adequate pathologic examination (APE) of rectal specimens is a standardized pathologic work-up that differs of the conventional colonic/intestinal pathologic work-up. The aim of this study was to determine the impact of APE on staging, lymph node retrieval and survival, with the hypotheses that APE allows high lymph node retrieval and better survival. METHODS: We retrospectively analyzed patient with surgery for RC from 2004 to 2011. We described the APE of radical rectal resection and we compared the clinical and pathological characteristics and the oncologic results, including survival after and before APE. RESULTS: A total of 185 patients were evaluated, 114 constituted the pre-APE group and 71 the APE group. The mean lymph node retrieval was 13.7 in the pre-APE group and 19.6 in the APE group (P = 0.007). In the APE group we found less local recurrence (20

, P = 0.003), higher prevalence of high grade tumors (20

, P = 0.001), more alive patients free of disease (75

, P = 0.001), more frequent use of neoadjuvant therapy (58

, P = 0.001), and and better 4-year survival (78

, P = 0.044). CONCLU- SION: The APE is crucial in patients with RC for staging and planning further treatment. An APE added to neoadjuvant or adjuvant therapy was associated with better survival.

Ovarian undifferentiated carcinoma with voluminous mesenteric presentation.

INTRODUCTION: About 5% of ovarian cancers are so poorly differentiated and difficult to classify that they are called undifferentiated carcinomas and usually have disseminated disease at presentation. Extra pelvic debulking it is difficult to complete. PRESENTATION OF CASE: We report a case of a rare ovarian tumor presented as a large mesenteric tumor of 14cm diameter in a 73 years old woman. DISCUSSION: Undifferentiated carcinomas are usually large, solid with hemorrhage and necrosis, bilateral and most are difficult to classify histologically. Rarely are pure, generally identified through the extensive sampling of lesions, some other components of surface epithelial carcinoma and usually the predominant element is the latter. Cases with predominantly undifferentiated component are rare. CONCLUSION: The treatment and diagnostic approach is the same as for other high-grade epithelial tumors of the ovary, but in this particular case the differential diagnosis and diagnostic approach is that of a mesenteric tumor.

[A rare case of colorectal micropapillary carcinoma]. / Carcinoma rectal micropapilar. Un caso inusual.

Micropapillary carcinoma is regarded as an aggressive variant of adenocarcinoma in any location. It is histologically characterized by papillary cell clusters surrounded by clear spaces. The reported proportion of micropapillary carcinoma component in the entire tumor ranges from 5-80% and no pure cases have been reported. To date, there are approximately 130 cases reported in the colorectum. We recently examined a patient with a pure micropapillary carcinoma showing co-expression of CK7, CK20, and absence of CDX2, which had an aggressive tumor with extensive perineural, vascular, and lymphatic invasion as well as extensive nodal metastasis. The presence of a micropapillary carcinoma in the colorectum seemed to be closely related with nodal metastasis, as observed in micropapillary carcinomas from other organs. Thus, if a micropapillary component is identified in a tumor, particularly in a biopsy specimen, extensive surgical resection should be considered due to the high potential for nodal metastasis, even if the preoperative diagnosis is a pedunculated early colorectal cancer.