bone and soft tissue tumors imad fadl-elmula al neelain university
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Bone and soft tissue Bone and soft tissue tumors tumors
Imad Fadl-ElmulaImad Fadl-ElmulaAl Neelain UniversityAl Neelain University
THE CLINICAL SCENARIOTHE CLINICAL SCENARIO
From Rydholm and PetterssonFrom Rydholm and Pettersson
May occur at all ages
Most common in the extremities
Benign>>malignant
Poor prognosis for malignant tumours (sarcomas)
Treatment choices:
Radical or conservative surgery?
Chemotherapy?
Radiotherapy?
Disease Mechanisms?
Environmental: 1. Radiation. 2. Viruses.
Inherited factors: Li-Fraumeni syndrome. Von Recklinghausen disease.
DN
A 3
D
stru
cture
Acquired genetic changes:
Bone and soft tissue lesions Bone and soft tissue lesions –– somatic mutations somatic mutations
Simple changes
Rings and markers
Complex changes
Benign
Borderline malignant
Malignant
Simple karyotype - benign
HMGA2
5’ 3’translocation
mRNA
Simple karyotype - benign
HMGA2 LipomaPleomorphic adenomaPulmonary hamartomaUterine leiomyoma
PLAG1 LipoblastomaPleomorphic adenoma
Rings and markers Rings and markers –– borderline borderline malignantmalignant
Dermatofibrosarcoma protuberans/ giant cell fibroblastoma
t(17;22)(q22;q13),+r(17;22)
COL1A1/PDGFB
Fibromatosis/desmoid del(5)(q),+8,+20 Loss of APC
Inflammatory myofibroblastic tumour
der(2)(p23) ALK/TPM3, ALK/TPM4
Lipomatous tumour, atypical
+r(12),+giant marker,tas Amplification of 12q sequences
Malignant fibrous histiocytoma, low-grade
+r(12),+giant marker,tas Amplification of 12q sequences
Osteosarcoma, parosteal
+r(12),+giant marker Amplification of chromosome 12 sequences
Rings and markers – borderline malignant
MDM2CDK4
Chromosome 9
Chromosome 12
MDM2
Chromosome 12
Chromosome 16
t(12;16)
Myxoid liposarcoma
Abnormal transcriptionfactor activity
“Molecular main switch”
Simple karyotype - Simple karyotype - malignantmalignant
FUS/CHOP
Ewing t(21;22)EWS/ERG
Rhabdomyosarcoma
Desmoplastic small round cell
Simple karyotype - malignant
translocations and fusionstranslocations and fusions
Alveolar soft part sarcoma
der(17)(q25)
Angiomatoid malignant fibrous histiocytoma
t(12;16)(q13;p11) FUS/ATF1
Chondrosarcoma, extraskeletal myxoid
t(9;22)(q22;q12), t(9;17)(q22;q11)
EWS/CHN, RBP56/CHN
Clear cell sarcoma t(12;22)(q13;q12),+8 EWS/ATF1
Desmoplastic small round cell tumour
t(11;22)(p13;q12) EWS/WT1
Fibrosarcoma, juvenile t(12;15)(p13;q25-26),+8,+11,+17,+20
ETV6/NTRK3
Liposarcoma, myxoid/round cell
t(12;16)(q13;p11), t(12;22)(q13;q12), i(7)(q10),+8
FUS/CHOP, EWS/CHOP
Peripheral primitive neuro-ectodermal/ Ewing family tumour
t(11;22)(q24;q12), t(7;22)(p22;q12),t(21;22)(q22;q12),+8,+12,+1q,-16q
EWS/FLI1, EWS/ETV1EWS/ERG
Rhabdomyosarcoma, alveolar
t(2;13)(q35;q14), t(1;13)(p36;q14),+2,+20
PAX3/FKHR, PAX7/FKHR
Synovial sarcoma t(X;18)(p11;q11),+7,+8,+12
SSX1/SYT or SSX2/SYT
Molecular pathogenesis poorly known
Osteosarcoma, 19 year old male
Complex Complex –– highly malignanthighly malignant
Complex – highly malignant
Unbalanced cell division Intratumour heterogeneity
Micro-evolution
Resistence to treatment
Leiomyosarcoma complex
Liposarcoma, pleomorphic
complex
Malignant fibrous histiocytoma, high grade
complex,der(1)(q11-12),der(19)(p13)
Osteosarcoma, classical complex,-3,-10,-13,der(17)(p)
Rhabdomyosarcoma, embryonal
+2,+8,+20
Chondrosarcoma, classical
der(12)(q13-15),+5,+7,-10,-13,+19,+20
Malignant peripheral nerve sheath tumour /neurofibrosarcoma
complex,der(7)(p22),der(17)(q11-21)
Loss of RB1, loss of TP53
Loss of NF1
Complex – highly malignant
Sarcoma groupMembers
cytopathologist
radiologistOrthopaedic surgeon
oncologist
cytogeneticist
Sarcoma group
Work-up
Clinical appearance
CT/MRI
FNAC or incisional biopsy
Cytogenetics
Molecular genetics
Hematox/Eo
ICH
DiagnosisRadiologyCT/MRI
Histopathology:Open or needle
biopsy
Clinical features
Cytogenetics
PrognosisAge Physical fitness
Treatment-radiotherapy-chemotherapy-SURGERY
OncologistBoneTumours
DiagnosisTreatment
Radiologist
Cytopathologist
Surgeon
HistopathologistMolecularPathologistGeneticist
psychiatrist
NursingAnd
Support staff
Audit
Gene changes Translocation Tumors
PAX3-FKHR t(2;13)(q35;q14) Alveolar rhabdomyosarcoma
PAX7-FKHR t(1;13)(p36;q14) ASPL-TFE3 t(X;17)(p11.2;q25) Alveolar soft-part sarcoma ATF1-EWS t(12;22)(q13;q12) Clear-cell sarcoma (malignant
melanoma of soft parts) ETV6-NTRK3 t(12;15)(p13;q25) Congenital fibrosarcoma and
mesoblastic nephroma COL1A1-PDGFB t(17;22)(q22;q13) Dermatofibrosarcoma protuberans
(giant-cell fibroblastoma) WT1-EWS t(11;22)(p13;q12) Desmoplastic round-cell tumor JAZF1-JJAZ1 t(7;17)(p15;q21) Endometrial stromal sarcoma EWS-FLI1 t(11;22)(q24;q12) Ewing sarcoma and peripheral
primitive neuroectodermal tumors
EWS-ERG t(21;22)(q22;q12) EWS-ETV1 t(7;22)(p22;q12) EWS-E1AF t(17;22)(q12;q12) FEV-EWS t(2;22)(q33;q12) ALK-TPM4 t(2;19)(p23;p13.1) Inflammatory myofibroblastic tumor TPM3-ALK t(1;2)(q22-23;p23) EWS-CHN(TEC) t(9;22)(q22;q12) Myxoid chondrosarcoma, extraskeletal RBP56-CHN(TEC) t(9;17)(q22;q11) TEC-TCF12 t(9;15)(q22;q21) TLS(FUS)-CHOP t(12;16)(q13;p11) Myxoid liposarcoma EWS-CHOP t(12;22)(q13;q12) SYT-SSX1 t(X;18)(p11;q11) Synovial sarcoma SYT-SSX2
Malignancy Chromosomal Translocations Gene Involved
Acute myelogenous leukemia t(8;21) (q22;q22) AML-1/ETO
inv (16) (p13;q22) CBFβ/MYH11t(15;17) (q22;q21) PML/RARαt(9;11) (p21-22;q23) MLL/AF9
Acute lymphoblastic leukemia t(12;21) (p12;q22) TEL/AML1
t(9;22) (q34;q11) BCR/ABLt(1;19) (q23;p13) E2A/PBX1t(4;11) (q21;q23) MLL/AF4
Chronic myelogenous leukemia t(9;22) (q34;q11) BCR/ABL
Follicular lymphoma t(14;18) (q32;q21) IGH/BCL2
Chondrosarcoma, myxoid t(9;22) (q22;q12) TEC/EWS
Clear cell sarcoma (MMSPa) t(12;22) (q13;q12) ATF1/EWS
Ewing's sarcoma/PNETb t(11;22) (q24;q12) FLI1/EWS
t(21;22) (q22;q12) ERG/EWSLiposarcoma, myxoid t(12;16) (q13;p11) CHOP/TLS
Rhabdomyosarcoma, alveolar t(2;13) (q35-37;q14) PAX3/FKHR
t(1;13) (p36;q14) PAX7/FKHRSynovial sarcoma t(X;18) (p11,q11) SSX1/SYT
SSX2/SYT