Embryonal and Alveolar Rhabdomyosarcoma in Adults: Real-Life Data From a Tertiary Sarcoma Centre.

AIMS: Embryonal and alveolar rhabdomyosarcoma (ERMS, ARMS) are subtypes of RMS that mainly occur in children, with relatively good outcomes. The incidence in adults is extremely low and survival is significantly worse compared with children. Data are scarce and literature generally combines all RMS subtypes, including pleomorphic RMS, which primarily occurs in adults and behaves more like undifferentiated pleomorphic sarcoma. The aim of this study was to evaluate patient and tumour characteristics, outcome and prognostic factors in adult patients with ERMS and ARMS. MATERIALS AND METHODS: All adult (18 years or older) ERMS and ARMS patients (presenting 1990-2016) were identified from a prospectively maintained database and were included in this analysis. RESULTS: Overall, 66 patients were included (42 men, 24 women). The median age at presentation was 28 years (range 18-71). The median overall survival for all ARMS (n = 42) and ERMS (n = 24) patients was 18 months, with a 5-year overall survival rate of 27%. Patients presenting with localised disease (n = 38, 58%) and metastatic disease (n = 25, 42%), had a 5-year overall survival rate of 36% and 11%, respectively. In univariate analysis we found alveolar subtype, fusion gene positivity, infiltrative tumour and metastatic presentation to be negative prognostic factors. CONCLUSION: Survival in adult ERMS and ARMS patients is poor and the current data may be useful in the design of trials with novel agents. Ideally, paediatric and adult oncologists should set up trials together to get a better understanding of biological, genetic and clinically relevant factors in this disease.

Fusion status in patients with lymph node-positive (N1) alveolar rhabdomyosarcoma is a powerful predictor of prognosis: Experience of the European Paediatric Soft Tissue Sarcoma Study Group (EpSSG).

BACKGROUND: Alveolar rhabdomyosarcoma (aRMS) with lymph node involvement (N1 classification) accounts for up to 10% of all cases of RMS. The prognosis is poor, and is comparable to that of distant metastatic disease. In the European Paediatric Soft Tissue Sarcoma Study Group (EpSSG) RMS2005 protocol, patients with a histologic diagnosis of aRMS/N1 received intensified chemotherapy with systematic locoregional treatment. METHODS: Patients with aRMS/N1 were enrolled prospectively after primary surgery/biopsy and fusion status was assessed in tumor samples. All patients received 9 cycles of induction chemotherapy and 6 months of maintenance therapy. Local treatment included radiotherapy to the primary site and lymph nodes with or without secondary surgical resection. RESULTS: A total of 103 patients were enrolled. The clinical characteristics of the patients were predominantly unfavorable: 90% had macroscopic residual disease after initial surgery/biopsy, 63% had locally invasive tumors, 77% had a tumor measuring >5 cm, and 81% had disease at unfavorable sites. Fusion genes involving forkhead box protein O1 (FOXO1) were detected in 56 of 84 patients. Events occurred in 52 patients: 43 developed disease recurrence, 7 had disease that was refractory to treatment, and 2 patients developed second neoplasms. On univariate analysis, unfavorable disease site, tumor invasiveness, Intergroup Rhabdomyosarcoma Study group III, and fusion-positive status correlated with worse prognosis. The 5-year event-free survival rate of patients with fusion-positive tumors was 43% compared with 74% in patients with fusion-negative tumors (P = .01). On multivariate analysis, fusion positivity and tumor invasiveness proved to be unfavorable prognostic markers. CONCLUSIONS: Fusion status and tumor invasiveness appear to have a strong impact on prognosis in patients with aRMS/N1. Fusion status will be used to stratify these patients in the next EpSSG RMS study, and treatment will be intensified in patients with fusion-positive tumors. Cancer 2018. © 2018 American Cancer Society.

Childhood rhabdomyosarcoma in Kano, Nigeria: a retrospective analysis of 52 cases.

BACKGROUND: Rhabdomyosarcoma is the most common soft tissue sarcoma in children ≤ 15 years of age. There is, however, a paucity of reports on the pattern of its occurrence in Nigeria and other parts of Africa. OBJECTIVE: The aim of this review is to highlight the age and sex distribution, anatomical location and morphological characteristics of rhabdomyosarcoma among children in Kano, northwestern Nigeria. PATIENTS AND METHOD: This is a 14 year retrospective study of all cases of rhabdomyosarcomas occurring in children diagnosed at the Pathology Department of Aminu Kano Teaching Hospital, Kano, Nigeria. Clinical data obtained included sex, age, tumour site and histologic subtype. RESULTS: Fifty two children were seen with a male to female ratio of 1 : 1.3. The ages of these Patients ranged from 4 months to 15 years with a mean (SD) age of 6.99 (4.1) years and peak age frequency in the 0 to 5 years age group. The embryonal variant was the most common histological subtype (69%). The others were alveolar (27%) and pleomorphic (4%) variants. The head and neck was the most affected region (44%) and the most common primary site was the orbit (19.2%). CONCLUSION: Rhabdomyosarcoma is the most common childhood soft tissue sarcoma in Kano. It occurs in females more frequently than males and the most common histologic subtype is embryonal rhabdomyosarcoma affecting predominantly the orbit.

High incidence of regional and in-transit lymph node metastasis in patients with alveolar rhabdomyosarcoma.

BACKGROUND: Rhabdomyosarcoma has different extension patterns, including a higher propensity for lymph nodes metastasis, compared with other types of soft tissue sarcoma. The aims of this study were to investigate the patterns of regional and distant metastasis in patients with rhabdomyosarcomas, particularly lymphatic route metastasis, and clarify the clinical factors that affect the pattern of metastasis. METHODS: Forty-four patients with rhabdomyosarcomas were enrolled in this study. The mean age of the patients was 26 (range 1-69) years, and 18 were males. The histological subtypes included alveolar (17 patients), embryonal (10 patients), pleomorphic (7 patients), and unknown (10 patients). Based on location, the sarcomas were divided into three groups: extremity (17 cases), favorable prognosis (10 cases), and unfavorable prognosis (15 cases). There were three cases (7 %) of local relapse, ten cases of regional lymph node relapse, and three cases of in-transit metastasis (total 30 %). Twenty-one patients (48 %) developed distant metastases. Initial sites of metastases were bone (9 patients, 20 %), lung (5 patients), and bone marrow dissemination (5 patients). Clinico-pathological variables affecting relapse patterns were analyzed. RESULTS: Of the three cases of local relapse, two were alveolar type and one was unknown. The three cases of in-transit metastasis were all alveolar type. Patients with alveolar type had a significantly high propensity for lymph node metastasis (P = 0.027). Excluding the pleomorphic type, alveolar type was still a significant factor for lymph node metastasis (P = 0.017). CONCLUSION: Physicians should be aware of in-transit spread, particularly in patients with alveolar-type rhabdomyosarcoma. Novel treatment modalities are required to detect and treat in-transit metastasis.

Adult rhabdomyosarcoma survival improved with treatment on multimodality protocols.

PURPOSE: Rhabdomyosarcoma (RMS) is a pediatric sarcoma rarely occurring in adults. For unknown reasons, adults with RMS have worse outcomes than do children. METHODS AND MATERIALS: We analyzed data from all patients who presented to Memorial Sloan-Kettering Cancer Center between 1990 and 2011 with RMS diagnosed at age 16 or older. One hundred forty-eight patients met the study criteria. Ten were excluded for lack of adequate data. RESULTS: The median age was 28 years. The histologic diagnoses were as follows: embryonal 54%, alveolar 33%, pleomorphic 12%, and not otherwise specified 2%. The tumor site was unfavorable in 67% of patients. Thirty-three patients (24%) were at low risk, 61 (44%) at intermediate risk, and 44 (32%) at high risk. Forty-six percent were treated on or according to a prospective RMS protocol. The 5-year rate of overall survival (OS) was 45% for patients with nonmetastatic disease. The failure rates at 5 years for patients with nonmetastatic disease were 34% for local failure and 42% for distant failure. Among patients with nonmetastatic disease (n=94), significant factors associated with OS were histologic diagnosis, site, risk group, age, and protocol treatment. On multivariate analysis, risk group and protocol treatment were significant after adjustment for age. The 5-year OS was 54% for protocol patients versus 36% for nonprotocol patients. CONCLUSIONS: Survival in adult patients with nonmetastatic disease was significantly improved for those treated on RMS protocols, most of which are now open to adults.

Head and neck rhabdomyosarcoma: a critical analysis of population-based incidence and survival data.

OBJECTIVE: To evaluate trends in incidence, survival, and treatment of rhabdomyosarcoma (RMS) of the head and neck. STUDY DESIGN: Retrospective review of a national database. SETTING: Tertiary medical center. SUBJECT AND METHODS: Incidence and survival trends were examined for head and neck RMS diagnosed between 1973 and 2007 using the Surveillance, Epidemiology, and End Results Program. Frequencies, incidence rates, and relative survival curves were calculated for various RMS subtypes and primary sites. RESULTS: Between 1973 and 2007, the incidence of RMS of the head and neck increased significantly, with an annual percentage change of 1.16%. Relative 5-year survival was statistically unchanged during the study period at 62.8% ± 2.3%. When analyzed by univariate analysis, overall survival was found to be dependent on sex, age, primary site, extent of disease, and histology. When evaluated by stage, most orbital tumors (60.6%) presented with localized disease, while most parameningeal tumors presented with either regional (53.2%) or distant (28.1%) spread. Multivariate analysis found that age less than 10 years at diagnosis and tumors with localized or regional spread were associated with improved overall survival. Relative survival was found to be largely dependent on extent of disease rather than primary site. CONCLUSIONS: Despite reported advances in overall and disease-free survival for patients with RMS, population-based analysis shows no substantial improvement during the past 30+ years. The prognosis of these patients is largely dependent on extent of disease at diagnosis.

Birth characteristics and the risk of childhood rhabdomyosarcoma based on histological subtype.

BACKGROUND: Little is known about risk factors for childhood rhabdomyosarcoma (RMS) and the histology-specific details are rare. METHODS: Case-control studies formed by linking cancer and birth registries of California, Minnesota, New York, Texas and Washington, which included 583 RMS cases (363 embryonal and 85 alveolar RMS) and 57 966 randomly selected control subjects, were analysed using logistic regression. The associations of RMS (overall, and based on embryonal or alveolar histology) with birth weight across five 500 g categories (from 2000 to 4500 g) were examined using normal birth weight (2500-3999 g) as a reference. Large (>90th percentile) and small (<10th percentile) size for gestational age were calculated based on birth weight distributions in controls and were similarly examined. RESULTS: High birth weight increased the risk of embryonal RMS and RMS overall. Each 500 g increase in birth weight increased the risk of embryonal RMS (odds ratio (OR)=1.27, 95% confidence interval (CI)=1.14-1.42) and RMS overall (OR=1.18, 95% CI=1.09-1.29). Large size for gestational age also significantly increased the risk of embryonal RMS (OR=1.42, 95% CI=1.03-1.96). CONCLUSIONS: These data suggest a positive association between accelerated in utero growth and embryonal RMS, but not alveolar RMS. These results warrant cautious interpretation owing to the small number of alveolar RMS cases.

Trends in childhood rhabdomyosarcoma incidence and survival in the United States, 1975-2005.

BACKGROUND: Rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma in children and adolescents aged<20 years; its etiology remains largely unknown. It is believed that embryonal (ERMS) and alveolar rhabdomyosarcoma (ARMS), the most common subtypes, arise through distinct biologic mechanisms. The authors of this report evaluated incidence and survival trends by RMS demographic subgroups to inform future etiologic hypotheses. METHODS: Incidence and survival trends in RMS among children and adolescents aged<20 years were analyzed using data from the Surveillance, Epidemiology, and End Results Program. Frequencies, age-adjusted incidence and survival rates, and joinpoint regression results, including annual percentage change (APC) and 95% confidence interval (CI), were calculated. RESULTS: Between 1975 and 2005, the incidence of ERMS was stable, whereas a significant increase in the incidence of ARMS was observed (APC, 4.20%; 95% CI, 2.60%-5.82%). This trend may have been attributable in part to shifts in diagnosis, because a significant negative trend in RMS, not otherwise specified was observed concurrently. A bimodal age peak for ERMS was observed, with the second, smaller peak in adolescence noted for males only; ARMS incidence did not vary by age or sex. Five-year survival rates for RMS and ERMS increased during the period from 1976 to 1980 (52.7% and 60.9%, respectively) to the period from 1996 to 2000 (61.8% and 73.4%, respectively), whereas there was little improvement for ARMS (40.1% and 47.8%, respectively). CONCLUSIONS: Observed differences in incidence and survival for 2 major RMS subtypes across sex and age subgroups further supported the hypothesis that there are unique underlying etiologies for these tumors. Exploration of these differences presents an opportunity to increase current knowledge of RMS.

Childhood rhabdomyosarcoma in Ibadan, Nigeria: 1984-2003.

BACKGROUND: Rhabdomyosarcoma is the most common soft tissue sarcoma in children under 15 years of age. There is, however, a paucity of reports on the pattern of its occurrence in Nigeria and other parts of Africa. AIM: To describe the pattern of childhood rhabdomyosarcoma in Ibadan with respect to demography, morphology and tumour site. METHODS: This retrospective study was based on data obtained from the Ibadan cancer registry, College of Medicine, University of Ibadan. All histologically confirmed cases of rhabdomyosarcoma in children under 15 years of age seen at the University College Hospital Ibadan between 1984 and 2003 were included. Information obtained includes age, gender, morphology and sites of the tumours. RESULTS: Ninety-one children were seen with a male:female ratio of 1.5:1. Ages ranged from <1 to 14 years with a mean (SD) of 6.2 (4.1) years. The embryonal variant was the most common histological subtype (61.5%). Other subtypes were alveolar (13.2%), pleomorphic (4.4%) and rhabdomyosarcoma 'not otherwise specified' (20.9%). The majority (50.6%) of tumours were in the head and neck region and the common primary sites were soft tissue of the head, face (24.2%) and orbit (14.3%). Other sites included soft tissue of the pelvis (11.0%), genito-urinary tract (9.9%) and abdomen (9.9%). CONCLUSION: The pattern of rhabdomyosarcoma in Nigeria is similar to that in the United States and Europe, except for the rarity of parameningeal sites and extremities. There is a need for larger descriptive studies on childhood rhabdomyosarcoma in Africa.

Juvenile rhabdomyosarcomas in Port Harcourt, Nigeria: A twelve year review.

BACKGROUND: Juvenile rhabdomyosarcoma (JRMS) though rare, is the most common soft tissue malignancy of childhood that exhibits bimodal age distribution pattern. OBJECTIVE: Review the pattern of JRMS in Port Harcourt based on sex, age, tumor sites and histologic types. DESIGN: A retrospective descriptive study. SETTING: The study was conducted in the University of Port Harcourt Teaching Hospital (UPTH), Port Harcourt, Nigeria over 12 years. METHODOLOGY: We studied 21 juvenile rhabdomyosarcomas during the period under review. The hematoxylin and eosin stained histological slides were retrieved and reviewed to confirm previous diagnosis and histologically typed for the study. The sex, age and tumor sites were retrieved from the histology consultation forms, RESULT: These tumors were diagnosed from patients aged 0 - 20 years with the highest frequencies (38.1% each) occurring at 0 - 5 and 16 - 20 years age group. Males are more affected with a ratio 3.2:1. The trunk is the most common site of occurrence (47.7%) of which the genitourinary system is the most affected (23.8%) in this study. The most common histologic type is the embryonal rhabdomyosarcoma (71.5%). Alveolar rhabdomyosarcoma accounted for (19%) and the sarcoma botryoides (9.5%). CONCLUSION: The age of presentation and anatomic sites of the tumor are important in the diagnosis of these tumors. If a tumor histologically shows as small round blue cells, rhabdomyosarcoma should be considered as a differential diagnosis.

[Soft tissue malignancies in childhood and adolescence. Pathology and clinical relevance based on data from the kiel pediatric tumor registry]. / Weichteilmalignome bei Kindern und Jugendlichen -- Pathologische Anatomie und ihre klinische Relevanz. Mit Daten aus dem Kieler Kindertumorregister.

Soft tissue malignancies in childhood and adolescence encompass a wide variety of histologically and genetically different tumor entities. In the files of the Kiel Pediatric Tumor Registry, 4,272 soft tissue malignancies were collected since 1977. Rhabdomyosarcomas are by far the most frequent sarcomas (44.6 % of the cases), followed in decreasing order of frequency by the family of Ewing tumors (peripheral primitive neuroectodermal tumors and extraosseous Ewing's sarcomas; altogether 22.3 %), malignant peripheral nerve sheath tumors (8.1 %), synovial sarcomas (5.0 %), leiomyosarcomas (3.2 %), fibrosarcomas (2.4 %), extrarenal malignant rhabdoid tumors (2.0 %), and alveolar soft tissue sarcomas (1.1 %). A further group (11.3 %) includes rare tumors, intermediate fibrohistiocytic tumors, and unclassified sarcomas. Embryonal rhabdomyosarcomas are 2.5 times more frequent than the alveolar rhabdomyosarcomas, which are prognostically unfavorable and located predominantly in the extremities and the trunk. With regard to clinical findings, histology, molecular biology and prognosis, embryonal and alveolar rhabdomyosarcomas have to be considered as two different tumor types. The family of Ewing tumors includes extraosseous Ewing's sarcoma and peripheral primitive neuroectodermal tumors (synonym: malignant peripheral neuroectodermal tumors), the former tumors without and the latter with neural differentiation. Many cases of infantile malignant peripheral nerve sheath tumors and infantile fibrosarcomas are low-grade malignancies and prognostically more favorable than their "adult" counterparts.

Treatment strategies for perianal rhabdomyosarcoma: report of two cases.

Intensive chemotherapy and high-dose radiation with complete excision of the tumor are the treatment of choice for rhabdomyosarcoma (RMS). However, because there are so few reports of perianal RMS, a mainstream treatment has not been established. We report two cases of perianal RMS and review 13 cases documented in Japan since 1990. Case 1 was a 7-year-old boy first treated by tumor excision followed by chemotherapy and external irradiation. He has since been tumor-free but suffered severe perianal erosion and ulceration. Case 2 was a 17-year-old girl first treated by preoperative chemotherapy to reduce the tumor size, after which the tumor was completely excised with anatomical guidance using three-dimensional computed tomography via the posterior sagittal approach, followed by open intraoperative irradiation. She has since been tumor-free with preserved anal function. These case reports show the importance of cogitated treatments for preservation of anal function and optimal therapeutic outcome in patients with perianal RMS.

Rhabdomyosarcoma of the oral and maxillofacial region in Jordanians: a retrospective analysis.

OBJECTIVE: The objective was to study the clinicopathologic features of rhabdomyosarcoma (RMS) of the oral and maxillofacial region in Jordanians. STUDY DESIGN: Data were collected from records of patients treated between 1989 and 2000 at the Maxillofacial Unit of Jordan University of Science and Technology. The main outcome measures were age, gender, location, stage of disease, histopathologic type, treatment received, follow-up period, and eventual outcome. RESULTS: Nine patients with RMS aged 4 to 17 years were found, with a male to female ratio of 2:1. Six (67%) bony sites and 7 (78%) soft tissue sites were involved. The extent of disease was locoregional in 8 (89%) cases, nodal in 3 (33%) cases, and distant metastatic in 2 (22%) cases. The Intergroup Rhabdomyosarcoma Study classification of clinical groups was as follows: 2 (22%) cases in stage II, 5 (56%) cases in stage III, and 2 (22%) cases in stage IV. The histopathologic types found were 6 (67%) embryonal, 2 (22%) alveolar, and 1 (11%) undifferentiated. Triple agent chemotherapy was used in the treatment of 8 cases, singly or in combination with surgery or radiotherapy. Two patients are still alive, and 5 patients have died of disease. CONCLUSIONS: The clinicopathologic features of maxillofacial RMS in this group of Jordanians are different from those of people from other countries. Further studies are needed to have a better understanding of the behavior of RMS in the oral and maxillofacial area.

Orbital rhabdomyosarcoma: a twenty-year survey in Turkey.

Orbital rhabdomyosarcoma is the most frequently encountered primary malignant orbital tumor in children. Between 1970 and 1991, 68 primary orbital rhabdomyosarcoma cases were diagnosed and treated in our clinic. Mean age at the time of diagnosis was 8.8 years. Seventy-two percent of the cases were of the embryonal type while 14% had alveolar and 14% had botryoid tumors. Following tissue diagnosis by anterior orbitotomy, radiotherapy and multimodal chemotherapy were instituted promptly. Subtotal exenteration was used in massive orbital involvement and total exenteration in recurrences. Using the Kaplan-Meier method of analysis, the survival rate was 84% at three years and 80% at five years. While morbidity due to the disease itself and treatment complications may still be a problem, the survival rates achieved in the long term are promising.