Lymphoma presenting as a soft tissue mass. A soft tissue sarcoma simulator

Lymphoma presenting as a soft tissue mass is rare and thus may be confused with the more common soft tissue sarcoma. No previous analysis of the clinical and radiologic features of lymphomas presenting as soft tissue masses is available because most of the cases reviewed are from the pathology literature. Four patients with diagnoses of extranodal lymphomas of the soft tissues were reviewed retrospectively with respect to their clinical features, primary tumor characteristics, stage, radiographic characteristics, treatment, and followup. Mean age was 72.5 years (range, 52-85 years). The soft tissue mass occurred in the thigh (three cases) and shoulder (one case). The median size of the soft tissue mass was 6.7 cm (range, 2-15 cm) in the largest dimension, as measured on magnetic resonance imaging. These patients each had evidence of lymphadenopathy at the time of diagnosis. Lactate dehydrogenase was increased significantly in two cases and increased slightly in two other cases. One case was Stage II(E) at presentation, one was Stage III(E), and two were Stage IV. All were B cell immunophenotype. All patients died between 2 and 24 months after diagnosis, despite the use of Cytoxan, vincristine, adriamycin, and prednisone chemotherapy in each case. Clinical and radiographic features that favor extranodal soft tissue lymphoma over sarcoma include pain and tenderness, lymphadenopathy (particularly when confluent radiologically), ipsilateral extremity swelling, and elevated lactate dehydrogenase.     

Dendritic cell and effector cell infiltration in soft tissue sarcomas with reactive lymphoid hyperplasia

The lymph node is the site of antigen presentation, and dendritic cells are sentinels for anti-tumor immunity. However, little is known about the histological features of lymph nodes and dendritic cells in soft tissue sarcomas. The reactive lymph node and infiltration of dendritic cells or effector cells were studied histologically in 10 soft tissue sarcomas with reactive lymphoid hyperplasia. The cases included four malignant fibrous histiocytomas, two malignant peripheral nerve sheath tumors, one synovial sarcoma, one epithelioid sarcoma, one malignant granular cell tumor, and one liposarcoma. The proportions of the T zone, lymphoid follicle, and lymphoid sinus (which was occupied by cells immunopositive for antibodies against CD3, CD20, or CD68) were 33.4% ± 11.0%, 6.1% ± 4.9%, and 13.5% ± 6.5%, respectively. T zone hyperplasia was observed in all cases, and sinus histiocytosis was found in four. The proportion of the T zone in regional lymph nodes of soft tissue sarcoma patients was significantly higher than that in adult autopsy cases without a cancer history. CD8-, TIA-1-, or granzyme B-positive effector cells were found in each sarcoma tissue. Whereas CD1a-positive dendritic cells were not detected, S-100 protein-positive or CD83-positive dendritic cells were observed in five sarcoma tissues. The coefficient correlation between the numbers of effector cells and dendritic cells positive for CD83 or S-100 protein were demonstrated. Although this is a preliminary report, the present study demonstrated that some soft tissue sarcoma patients showed reactive lymphoid hyperplasia. Furthermore, the association between the infiltration of dendritic cells and that of effector cells was observed in patients with soft tissue sarcomas.     

Parotid lymphomas--clinical and computed tomographic imaging features

OBJECTIVE: To review the clinical presentation and computed tomography (CT) imaging characteristics of all parotid lymphomas diagnosed at the study institution over a 7-year period. DESIGN: Retrospective chart review of parotid lymphomas diagnosed between 1997 and 2004. SUBJECTS: A total of 121 patients with parotid lesions were identified. After retrospective chart review, a total of 10 patients with histologically proven parotid lymphoma were included in the study, 8 of whom had CT scans available for assessment. RESULTS: Ten patients with histologically proven lymphoma of the parotid gland were identified from among 121 patients with parotid neoplasms, an incidence in this series of 8.3%. All lymphomas were of non-Hodgkin's type. All patients presented with a painless unilateral parotid swelling. Most patients had a short history of less than 4 months' duration, of whom 3 presented with a rapidly evolving swelling of less then 1 month's duration. No patient had a background of Sj?gren's disease or any other autoimmune disorders. The commonest finding noted on CT was of a unilateral, single mass of relative soft-tissue homogeneity with poorly defined, indistinct tumour margins. Associated loco-regional lymphadenopathy was identified in 2 cases, 1 clinically and another radiologically; multiple ipsilateral lesions were noted in 2 cases. No cases of contralateral disease were observed. CONCLUSION: Lymphoma has a clinical presentation similar to other neoplasms arising within the parotid gland. A unilateral, non-tender swelling was a universal finding. A history of less than 4 months may suggest the possibility of lymphoma. CT scanning is a useful adjunctive investigation to determine the site and extent of the disease, loco-regional nodal status and contralateral gland and neck status. Multifocality and associated adenopathy are associated with, but not exclusive to, parotid lymphoma. Although poor tumour boundary definition on CT imaging is a strong predictor of malignancy, no pathognomonic finding specific for lymphoma has been identified. The potential diagnosis of parotid lymphoma should be considered in all patients who present with a parotid mass.     

‘Telangiectatic’ Transformation in Soft Tissue Sarcomas. A Clinicopathology Analysis of an Aggressive Feature of High-grade Sarcomas

Background ‘Telangiectatic’ change, which contains a large fluid hemorrhagic component, occurs in a variety of high-grade soft tissue sarcomas. Methods In a retrospective database review, we identified 20 consecutive patients (3%) with ‘telangiectatic’ change in soft tissue sarcomas. Results Tumors were located in the thigh (55%), shoulder (15%), calf (15%), upper arm (10%), and buttock in one patient. All 20 tumors were high grade. Histological diagnoses were MFH (40%), leiomyosarcoma (15%), synovial sarcoma (10%), and one each of seven other sarcomas (35%). Tumor size was often large—more than 10 cm (35%), between 5 and 10 cm (60%), and less than 5 cm in one case. A history of contusion to the tumor site followed by swelling was recorded in 30% of patients and 80% presented with a painful mass. On MRI imaging, 60% of tumors appeared to contain more than 50% blood, 50% had a hemosiderin-laden rim, and 55% had well-defined tumor nodules within the wall of the hematoma. Limb-sparing surgery was carried out in 90% of patients, the other 10% underwent primary amputation. The 5-year, event-free survival rate was 30%. Of the patients, 15% presented initially with metastatic disease; in 53%, it developed within 2 years of diagnosis. The overall local recurrence rate was 30%. Conclusions Telangiectatic transformation in soft tissue sarcomas is a rare feature of aggressive high-grade soft tissue sarcomas and is unique in its clinical presentation, MRI characteristics, pathological pattern, and a tendency for a worse-off prognosis. This investigation was performed at the Department of Orthopedic Oncology, Washington Cancer Institute, Washington Hospital Center, Washington DC.     

Soft tissue sarcomas may present with deep vein thrombosis

PURPOSE: To bring attention to our observation that soft tissue sarcomas may present initially as deep venous thromboses (DVTs). METHOD: A query of our health system database (1996 to 2004) for patients diagnosed with soft tissue sarcomas and DVTs was undertaken. Patient medical records were reviewed to select those patients whose DVT occurred before the diagnosis of their tumor. Patient demographics, tumor classification, presentation, and outcome were noted. RESULTS: Six of 19 patients were identified (four men, two women; aged 41 to 85 years). All tumors occurred in the lower extremities. All DVTs occurred in the same extremity as the tumor. Pathology specimens indicated four different types of sarcomas. In five cases, sarcoma diagnosis was delayed as treatment of the DVT occurred. In one, a mass was seen on the initial venous duplex screen. Four are deceased, one remains in treatment, and one was lost to follow-up. The average length of follow-up was 10 months. CONCLUSION: Soft tissue sarcomas can initially present as, or even be misdiagnosed as, DVT. Given a delay in diagnosis adversely affects prognosis, it is important that physicians be vigilante for associated tumors when evaluating for suspected DVT.     

Surgical therapy of primary malignant bone tumours and soft tissue sarcomas of the chest wall: a two-institutional experience

Purpose

Primary malignant bone tumours and soft tissue sarcomas of the chest wall are exceedingly rare entities. The aim of this study was a retrospective two-institutional analysis of surgical therapy with respect to the kind and amount of the resection performed, the type of reconstruction and the oncological outcome.

Methods

Between September 1999 and August 2010 31 patients (seven women and 24 men) were treated due to a primary malignant bone tumour or soft tissue sarcoma of the chest wall in two centres. Eight low-grade sarcomas were noted as well as 23 highly malignant sarcomas. The tumours originated from the sternum in six cases, from the ribs in 12 cases, from the soft tissues of the thoracic wall in 11 cases and from a vertebral body and the clavicle in one case each.

Results

In 26 cases wide resection margins were achieved, while four were intralesional and one was marginal. In all 31 cases the defect of the chest wall was reconstructed using mesh grafts. At a mean follow-up of 51 months 20 patients were without evidence of disease, three were alive with disease, seven patients had died and one patient was lost to follow-up. One recurrence was detected after wide resection of a malignant triton tumour.

Conclusions

Primary malignant bone tumour or soft tissue sarcoma of the chest wall should be treated according to the same surgical oncological principles as established for the extremities. Reconstruction with mesh grafts and musculocutaneous flaps is associated with a low morbidity.     

A multidisciplinary approach to giant soft tissue sarcoma of the chest wall: A case report

IntroductionSoft tissue sarcomas of the chest wall are exceptionally rare entities that present as painless slow growing masses. Resection is often precarious due to involvement of vital structures, and patients are left with large chest wall defects postoperatively requiring extensive reconstruction.Presentation of caseWe present a case report of a 29 year-old man who presented with a giant soft tissue sarcoma of the chest that had been growing slowly for one year prior to presentation. The patient had a biopsy that was positive for sarcoma, and PET CT demonstrated a large lobulated mass in the left chest wall with an SUV of 6.7. He received 50 Gy of radiation therapy; however, the mass continued to grow in size. He subsequently underwent an en-bloc resection of the mass with latissimus and serratus muscle primary reconstruction. Final pathology showed a 27 cm high-grade fibrosarcoma with prominent myxoid component. To our knowledge, this is the largest soft tissue sarcoma of the chest wall reported in the literature. Postoperatively, the patient received 6 cycles of adjuvant chemotherapy.DiscussionSurgery is the mainstay of treatment, and chemotherapy and radiation are used in specific circumstances. Risk of recurrence is dependent on many factors, including histologic subtype, grade, and size of tumor. Long term surveillance with physical exam and imaging is recommended.ConclusionWe feel that the multidisciplinary approach is crucial for optimal management of large soft tissue sarcomas. We recommend this approach to all patients with chest wall sarcomas.     

Vascular homografts for vessel substitution in skeletal and soft tissue sarcomas of the limbs

Large vessel involvement by skeletal and soft tissue sarcomas of the extremities does not change the modern limb sparing surgery for those neoplasms. An arterial and, if the vein is open, a venous bypass should always be offered to any patient young or old, with high or low grade sarcoma, because preserving the limb permits quicker rehabilitation, which is particularly useful in the case of a short life expectancy. In 650 cases of skeletal sarcomas, 10 arterial (1.5%) and four venous bypasses were done, all with autologous veins but one in PTFE; we had no problems except a silent arterial occlusion. Of 1000 patients with soft tissue sarcomas, 32 (3%) had vessel involvement permitting limb sparing surgery. The arterial bypass, which is the limb-saving operation, was performed 16 times with a PTFE with one early occlusion and four cases of prosthesis infection, with two amputations despite redo operation with an autologous vein. The more recent 16 cases were, therefore, always done with biological vessel substitution--autologous vein or tissue bank vessel--with only one infection that healed without operation and one case of homograft rupture followed by amputation. Since 1999 in all 13 resected cases with an open vein, we did the arterial and the venous bypass (twice PTFE, six autologous vein, and five bank vessel) with the aim of avoiding postoperative venous hypertension, but only four of the venous bypasses remained open. Venous bypasses are a harmless, but still experimental, procedure.     

EBV-positive extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue in the posttransplant setting: a distinct type of posttransplant lymphoproliferative disorder?

The 2008 World Health Organization Classification of Tumours of Haematopoietic and Lymphoid Tissues defines monomorphic posttransplant lymphoproliferative disorders (M-PTLDs) as lymphoid or plasmacytic proliferations that fulfill the criteria for one of the B-cell or T/NK-cell neoplasms recognized in immunocompetent patients. However, indolent B-cell lymphomas, such as extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma), are specifically excluded from this category. In this study, we describe the clinicopathologic features of 4 posttransplant lymphoma-like proliferations that were Epstein-Barr virus (EBV) positive, but were otherwise completely typical for a MALT lymphoma. The 4 patients (age, 12 to 71 y) had received solid organ transplants (2 hearts, 1 kidney, 1 kidney/pancreas) at a median of 116 months before presentation, and had been maintained on varying immunosuppressive regimens that included cyclosporine, azathioprine, tacrolimus, and sirolimus. Three of the 4 patients presented with solitary subcutaneous masses, whereas the fourth patient presented with a solitary orbital soft tissue mass. All the 4 cases were morphologically typical for MALT lymphoma, demonstrated plasmacytic differentiation with IgA heavy chain restriction (3 cases κ positive, 1 case λ positive), and were diffusely EBV-encoded small RNA positive. Patients were followed for a median of 44.9 months, and all achieved a complete response following various regimens that included reduced immunosuppression with or without antiviral therapy, local surgical excision, rituximab, or local radiation therapy. The uniform EBV positivity and response to immune reconstitution in some cases suggest that EBV-positive MALT lymphomas arising in the posttransplant setting should be included among PTLDs. Whether their distinctive subcutaneous/soft tissue localization and IgA positivity are uniform features will require identification of additional cases.     

Extra nodal Rosai Dorfman disease masquerading as metastatic soft tissue sarcoma- A case report

Rosai Dorfman disease is rare benign disease of phagocytic histiocytosis usually present as painless massive lymphadenopathy. Extra nodal presentation of Rosai Dorfman disease is rare but also described. We hereby describe an unusual presentation of the extra nodal Rosai Dorfman disease with rapidly growing soft tissue lesion in the left thigh with associated osseous lesions in the right distal femur, left distal femur, left proximal tibia and presence of solitary pulmonary nodule. This case is unique as clinical presentation highly suspicious of soft tissue sarcoma but excision biopsy of thigh lesion showed Rosai Dorfman disease.Though RDD in extremities has been described in limited number of cases, to the best of our knowledge this is first case of lower extremity RDD associated with osseous lesions and pulmonary nodule but without lymphadenopathy.     

Distant Soft Tissue Metastases: A Series of 30 New Patients and 91 Cases From the Literature

Background: Thirty patients with soft-tissue metastases were reviewed retrospectively and compared with 91 cases previously reported. Soft tissue metastases were most commonly presented to the musculoskeletal oncologist as a painful mass in patients with no history of cancer. In this setting, lung carcinoma was the most frequent primary source. The purpose of this article is to report the largest single series of distant soft-tissue metastases and to compare the findings with those of the literature.Methods: Thirty consecutive patients were referred to musculoskeletal oncologists. Their cases were reviewed retrospectively for comparison with 91 cases from the clinical literature.Results: The most common clinical presentation of the soft-tissue mass was as the presenting symptom of previously undiagnosed cancer or concurrent with the primary source of cancer. A minority of cases were discovered in the setting of widespread metastases. Twenty-one new patients had carcinomas, 6 sarcomas, and 1 each multiple myeloma, lymphoma, and melanoma. Lung carcinoma was the most common primary source. The most common presenting symptom was that of a painful mass. Skeletal muscle of the thigh was the most common site. Radiological features were not specific. Soft tissue sarcoma was a common clinical misdiagnosis. Twenty-one new patients were dead of disease at a mean 5.4 months (range 1–19 months) after diagnosis of the metastasis: this percentage was similar to that reported in the literature.Conclusions: In this musculoskeletal oncology referral-based clinical series, soft tissue metastases most commonly occur in patients with a painful soft tissue mass and no history of cancer. Lung is the most frequent primary source. Treatment should be individualized according to the underlying disease and its prognosis.     

Myxofibrosarcoma involving the external saphenous nerve: a case report

Myxofibrosarcoma, also known as "myxoid malignant fibrous histiocytoma" is one of the most common soft tissue sarcomas in the extremities of adult patients. Most cases are characterized by a multinodular and/or infiltrative pattern with a tendency to infiltrate along fascial planes. We report a case of myxofibrosarcoma with an unusual presentation. Despite the clinical impression of a complete surgical resection, microscopic sarcomatous foci extended along the perineurium of the external saphenous nerve proximally up to 20 cm away from the main tumour. This unique case represents an extreme example of the locally agressive behaviour of soft tissue sarcomas and illustrates the microscopic tumour invasion along major nerves.     

Skeletal metastasis from sarcoma: a report of three cases

In the present report, we describe the very rare occurrence of soft tissue metastases from sarcoma at four sites in three patients, focusing on the clinical course and radiological features. All soft tissue masses occurred as a result of disseminated metastases from malignant sarcomas. The initial symptoms presented as painful masses. Magnetic resonance imaging demonstrated a non-specific appearance for the skeletal metastases derived from the sarcomas, corresponding to the signal of the primary lesion.     

TREATMENT OF ADVANCED AND INACCESSIBLE SARCOMAS WITH CONTINUOUS INTRA-ARTERIAL CHEMOTHERAPY PRIOR TO DEFINITIVE SURGERY OR RADIOTHERAPY—A POSSIBLE ALTERNATIVE TO AMPUTATION OR DISABLING RADICAL SURGERY

Four patients with advanced and inaccessible soft tissue sarcomas were treated with a regimen of intra-arterial chemotherapy followed by radiotherapy and/or surgical excision. Two of the patients had advanced sarcomas in the buttock and thigh regions which would otherwise have required hindquarter amputation in one case or disarticulation of the hip in the other case. These sarcomas responded significantly to intra-arterial chemotherapy to the extent that subsequent local surgery was effective in eradicating the residual tumours. No viable tumour cells were found in the resected specimens. In both patients amputation was avoided and local tumour eradication was achieved. In the other two patients, advanced and non-resectable sarcomas in the head were first treated with a similar regimen of intra-arterial chemotherapy. In both cases the tumours regressed in size prior to administration of local radiotherapy. After completion of chemotherapy and radiotherapy no viable tumour cells were detected in either lesion. In one case (originally a very extensive sarcoma of the jaw in a 5 year old child) a residual lump was resected but no viable tumour was detected in the resected specimen. These four patients represent our total experience with this plan of management. All responded well and there has been no evidence of local disease recurrence in any of the four patients. One patient (case 2) did develop pulmonary and bone metastases from which she died 2 years later but the other three patients remain well with no evidence of residual disease, 11 years, 4 years and 20 months after presentation.     

Myxofibrosarcoma Involving the External Saphenous Nerve: a Case Report

Myxofibrosarcoma, also known as “myxoid malignant fibrous histiocytoma” is one of the most common soft tissue sarcomas in the extremities of adult patients. Most cases are characterized by a multinodular and/or infiltrative pattern with a tendency to infiltrate along fascial planes. We report a case of myxofibrosarcoma with an unusual presentation. Despite the clinical impression of a complete surgical resection, microscopic sarcomatous foci extended along the perineurium of the external saphenous nerve proximally up to 20 cm away from the main tumour. This unique case represents an extreme example of the locally agressive behaviour of soft tissue sarcomas and illustrates the microscopic tumour invasion along major nerves.     

Lymphadenopathy as a primary presenting sign: a clinicopathological study of 228 cases

A total of 228 cases of lymphadenopathy as a primary presenting sign are reported. Tissue diagnoses were divided into: metastatic carcinoma (41 per cent), lymphoma (19 per cent), a specific non-neoplastic condition (10 per cent) and non-specific hyperplasia and inflammation (30 per cent); thus the overall yield of positive tissue diagnosis was 70 per cent. Just 5 primary sites: breast, lung, gastrointestinal and genito-urinary tracts and skin (mainly melanomas) accounted for all but one case. Hodgkin's and non-Hodgkin's lymphomas were evenly distributed. In those with generalized malignant lymphadenopathy a surprisingly even proportion of 1 to 1.5 was found between carcinoma and lymphoma. In those with localized malignant disease metastatic carcinoma predominated. The overall incidence of primary lymphadenopathy in increased with age, due to an increase in malignancy. Less than half of patients with carcinomatous lymphadenopathy had symptoms and these tended to be organ specific, whereas three-quarters of patients with lymphoma had symptoms which were usually non-specific. A haematological screen, liver function tests and chest X-ray were frequently abnormal but were not diagnostic.     

Treatment of advanced and inaccessible sarcomas with continuous intra-arterial chemotherapy prior to definitive surgery or radiotherapy--a possible alternative to amputation or disabling radical surgery

Four patients with advanced and inaccessible soft tissue sarcomas were treated with a regimen of intra-arterial chemotherapy followed by radiotherapy and/or surgical excision. Two of the patients had advanced sarcomas in the buttock and thigh regions which would otherwise have required hindquarter amputation in one case or disarticulation of the hip in the other case. These sarcomas responded significantly to intra-arterial chemotherapy to the extent that subsequent local surgery was effective in eradicating the residual tumours. No viable tumour cells were found in the resected specimens. In both patients amputation was avoided and local tumour eradication was achieved. In the other two patients, advanced and non-resectable sarcomas in the head were first treated with a similar regimen of intra-arterial chemotherapy. In both cases the tumours regressed in size prior to administration of local radiotherapy. After completion of chemotherapy and radiotherapy no viable tumour cells were detected in either lesion. In one case (originally a very extensive sarcoma of the jaw in a 5 year old child) a residual lump was resected but no viable tumour was detected in the resected specimen. These four patients represent our total experience with this plan of management. All responded well and there has been no evidence of local disease recurrence in any of the four patients. One patient (Case 2) did develop pulmonary and bone metastases from which she died 2 years later but the other three patients remain well with no evidence of residual disease, 11 years, 4 years and 20 months after presentation.     

Centralization of soft tissue sarcoma: Status in Sweden in 1982

We analyzed the management of all the patients with soft tissue sarcoma located in the trunk and extremities in Sweden in 1982. The total fraction of patients referred to musculoskeletal tumor centers for definitive treatment was 0.6. In more than four fifths of the patients operated on at the centers, surgery was performed with a wide or radical margin compared with one fifth of the patients treated at other hospitals.

In our center specifically, 10 patients with soft tissue lesions that turned out to be benign were referred per every unoperated on sarcoma patient. The treatment of soft tissue sarcomas outside tumor centers is less than optimal, and centralization is associated with substantially increased referral of patients with benign tumors to catch the majority of soft tissue sarcomas in the virgin state. Information to peripheral hospitals about indications for referral of patients with soft tissue lesions has been effective in our region.     

Neurological manifestations of the acquired immunodeficiency syndrome (AIDS): experience at UCSF and review of the literature

In this review of the acquired immunodeficiency syndrome (AIDS), the authors have evaluated a total of 352 homosexual patients with AIDS or generalized lymphadenopathy managed at the University of California, San Francisco (UCSF), between 1979 and 1984. Of an initial unselected group of 318 patients, 124 (39%) were neurologically symptomatic, and one-third already had their neurological complaints at the time of presentation. An additional 210 AIDS patients with neurological symptoms have been reported in the literature. Thus, a total of 366 neurologically symptomatic patients with AIDS or lymphadenopathy are reviewed. Central nervous system (CNS) complications, encountered in 315 patients, included the following viral syndromes: subacute encephalitis (54), atypical aseptic meningitis (21), herpes simplex encephalitis (nine), progressive multifocal leukoencephalopathy (six), viral myelitis (three), and varicella-zoster encephalitis (one). Non-viral infections were caused by Toxoplasma gondii (103), Cryptococcus neoformans (41), Candida albicans (six), Mycobacteria (six), Treponema pallidum (two), coccidioidomycosis (one), Mycobacterium tuberculosis (one), Aspergillus fumigatus (one), and Escherichia coli (one). Neoplasms included primary CNS lymphoma (15), systemic lymphoma with CNS involvement (12), and metastatic Kaposi's sarcoma (three). Cerebrovascular complications were seen in four patients with hemorrhage and five with infarction. Five patients in the UCSF series had multiple intracranial pathologies, including two cases of simultaneous Toxoplasma gondii infections and primary CNS lymphoma, two cases of coexistent Toxoplasma gondii and viral infections, and one case of combined Toxoplasma gondii and atypical mycobacterial infection. Cranial or peripheral nerve complications, seen in 51 patients, included cranial nerve syndromes secondary to chronic inflammatory polyneuropathy (five), lymphoma (five), and Bell's palsy (five). Peripheral nerve syndromes included chronic inflammatory polyneuropathy (12), distal symmetrical neuropathy (13), herpes zoster radiculitis (six), persistent myalgias (two), myopathy (two), and polymyositis (one). In light of the protean behavior of AIDS and the problems related to the clinical, radiological, and serological diagnosis of the unusual and varied associated nervous system diseases, patients with AIDS and neurological complaints require a rigorous and detailed evaluation. The authors' experience suggests that biopsy of all CNS space-occupying lesions should be performed for tissue diagnosis prior to the institution of other therapies.     

Clinico-pathological study of primary malignant chest wall tumors

Clinicopathological studies of primary malignant chest wall tumor on 16 cases operated between 1962 and 1988 were made. Of 9 osteogenic sarcomas, 8 cases were chondrosarcoma and 1 case was Ewing's sarcoma. Of 7 soft part sarcomas, 2 cases were fibrosarcoma, liposarcoma and neurogenic sarcoma respectively, and one case was hemangiosarcoma. Most of the cases had symptoms, such as chest mass and/or chest pain comprehend symptoms for more than one year. The intrathoracic growth of tumor is common, especially in osteogenic sarcoma. The maximum size of tumor was 8.2 cm in a mean diameter. Preoperative histological diagnosis is difficult to make even though various radiologic diagnosis or pathological technique as biopsy or cytology were assessed. And true rate of preoperative diagnosis is limited only 43.8%. Wide resection combined with the tissue distant more than 3 cm length from tumor is recommended and 6 cases underwent combined resection of diaphragm, pericardium or lung. 3 cases underwent chest wall reconstruction using the Marlex mesh and 10 cases were able to direct closure, in 13 cases with ribs resection. The 5 year survival rate of endurable cases was 62.2%, and that of soft tissue sarcoma (68.6%) is better than that of osteogenic sarcoma (41.7%). The recurrent or metastatic rate in high, 7 cases (43.8%), but reoperation was added for 5 cases of local recurrence or for a case of lung metastasis. 5 year survival rate of cases with recurrence or metastases is relatively good, 46.8%, especially excellent in 4 cases with recurred lesions after more than 2 years of tumor free interval.