1. Musculoskeletal Oncology Service, National Cancer Center Hospital Musculoskeletal Oncology Service, Keio University Hospital An Analysis of Clinicopathological Factors Related to the Tail-like Pattern of Myxofibrosarcoma on MRI Kazutaka Kikuta 1, 2, 3, Daisuke Kubota 1, Akihiko Yoshida 3, Hideo Morioka 2, Yoshiaki Toyama 2, Hirokazu Chuman 1, Akira Kawai 1 1, Divison of Orthopedic Surgery, National Cancer Center Hospital 2, Department of Orthopedic Surgery, Keio University School of Medicine 3, Division of Diagnostic Pathology, National Cancer Center Hospital Tail-like pattern of myxofibrosarcoma October, 15-18 th, 2014 InterContinental Berlin Hotel Berlin, Germany

2. Superficial location is significantly correlated to the tail-like pattern on MRI Tail-like pattern of myxofibrosarcoma October, 15-18 th, 2014 InterContinental Berlin Hotel Berlin, Germany Tail–like pattern Gd MRI Superficial layer Musculoskeletal Oncology Service, National Cancer Center Hospital Musculoskeletal Oncology Service, Keio University Hospital

3. Tail-like pattern of myxofibrosarcoma October, 15-18 th, 2014 InterContinental Berlin Hotel Berlin, Germany The 2014 CTOS Annual Meeting Conflict of Interest (COI) Presentator: Kazutaka Kikuta The authors have no conflict of interest to disclose with respect to this presentation Musculoskeletal Oncology Service, National Cancer Center Hospital Musculoskeletal Oncology Service, Keio University Hospital

4. Backgrounds Tail-like pattern of myxofibrosarcoma October, 15-18 th, 2014 InterContinental Berlin Hotel Berlin, Germany Musculoskeletal Oncology Service, National Cancer Center Hospital Musculoskeletal Oncology Service, Keio University Hospital

5. Myxofibrosarcoma (MFS) ► Most often affects the extremities of the elderly ► The number of patients will increase due to the aging society ► High recurrence rate even after wide resection: 50-60 % Tail-like pattern of myxofibrosarcoma October, 15-18 th, 2014 InterContinental Berlin Hotel Berlin, Germany Musculoskeletal Oncology Service, National Cancer Center Hospital Musculoskeletal Oncology Service, Keio University Hospital

6. If It Recurs… Amputation or death due to metastasis Tail-like pattern of myxofibrosarcoma October, 15-18 th, 2014 InterContinental Berlin Hotel Berlin, Germany Musculoskeletal Oncology Service, National Cancer Center Hospital Musculoskeletal Oncology Service, Keio University Hospital

7. Tail-like Pattern Tail (+) Tail-like pattern of myxofibrosarcoma October, 15-18 th, 2014 InterContinental Berlin Hotel Berlin, Germany What is the relationship between the tail-like pattern and clinical factors? Gd MRI Musculoskeletal Oncology Service, National Cancer Center Hospital Musculoskeletal Oncology Service, Keio University Hospital

8. Purpose of This Study To identify clinical factors related to the tail-like pattern on MRI Tail-like pattern of myxofibrosarcoma October, 15-18 th, 2014 InterContinental Berlin Hotel Berlin, Germany Musculoskeletal Oncology Service, National Cancer Center Hospital Musculoskeletal Oncology Service, Keio University Hospital

9. Materials and Methods Tail-like pattern of myxofibrosarcoma October, 15-18 th, 2014 InterContinental Berlin Hotel Berlin, Germany Musculoskeletal Oncology Service, National Cancer Center Hospital Musculoskeletal Oncology Service, Keio University Hospital

10. Materials 50 patients (1999-2008, National Cancer Center) ►Confirmed as MFS by a certified pathologist ►MRI reviewed by a certified radiologist Tail-like pattern of myxofibrosarcoma October, 15-18 th, 2014 InterContinental Berlin Hotel Berlin, Germany Musculoskeletal Oncology Service, National Cancer Center Hospital Musculoskeletal Oncology Service, Keio University Hospital

11. Clinical Variables ►Tail-like pattern (+) or (-) ►Age at surgery (60 ≦ or 60>) ►Gender ►Size (5cm ≦ or 5cm>) ►Site (Extremity or Trunk) ►Location (Subcutaneous or deep) ► Histological grade (G1 or G2+G3) ► 5-year recurrence free survival (5-year RFS) ► 5-year disease free survival (5-year DFS) Tail-like pattern of myxofibrosarcoma October, 15-18 th, 2014 InterContinental Berlin Hotel Berlin, Germany Chi-square test P<0.01 Log-rank test P<0.01 Musculoskeletal Oncology Service, National Cancer Center Hospital Musculoskeletal Oncology Service, Keio University Hospital

12. Different Patterns on Gd MRI Tail-like pattern Solid pattern Tail (-) Tail (+) Tail-like pattern of myxofibrosarcoma October, 15-18 th, 2014 InterContinental Berlin Hotel Berlin, Germany Musculoskeletal Oncology Service, National Cancer Center Hospital Musculoskeletal Oncology Service, Keio University Hospital (Kikuta K, et al. 2014)

13. Results Tail-like pattern of myxofibrosarcoma October, 15-18 th, 2014 InterContinental Berlin Hotel Berlin, Germany Musculoskeletal Oncology Service, National Cancer Center Hospital Musculoskeletal Oncology Service, Keio University Hospital

14. Analysis of Clinical Data Tail-like pattern of myxofibrosarcoma October, 15-18 th, 2014 InterContinental Berlin Hotel Berlin, Germany Average age: 64.1y (23 – 97y) Follow-up period: 1-154 months (Median: 62 m, Mean: 56.4 m) Recurrence: 9/ 50 patients Oncological outcome CDF:31 patients NED:11 patients AWD: 4 patients DOD: 4 patients Metastasis: 6 patients Musculoskeletal Oncology Service, National Cancer Center Hospital Musculoskeletal Oncology Service, Keio University Hospital

15. The 5-Year RFS and DFS of All 50 Patients Tail-like pattern of myxofibrosarcoma October, 15-18 th, 2014 InterContinental Berlin Hotel Berlin, Germany 5-year RFS5-year DFS 80 % 68.9 % Musculoskeletal Oncology Service, National Cancer Center Hospital Musculoskeletal Oncology Service, Keio University Hospital (Kikuta K, et al. 2014)

16. IIHC Protein X 200x Tail-like pattern of myxofibrosarcoma October, 15-18 th, 2014 InterContinental Berlin Hotel Berlin, Germany Superficial location was significantly correlated to the tail-like pattern Musculoskeletal Oncology Service, National Cancer Center Hospital Musculoskeletal Oncology Service, Keio University Hospital

17. Tail-like pattern of myxofibrosarcoma October, 15-18 th, 2014 InterContinental Berlin Hotel Berlin, Germany 5-year RFS5-year DFS MFS with the tail-like pattern Poorer prognosis Musculoskeletal Oncology Service, National Cancer Center Hospital Musculoskeletal Oncology Service, Keio University Hospital (Kikuta K, et al. 2014)

18. Discussion Tail-like pattern of myxofibrosarcoma October, 15-18 th, 2014 InterContinental Berlin Hotel Berlin, Germany Musculoskeletal Oncology Service, National Cancer Center Hospital Musculoskeletal Oncology Service, Keio University Hospital

19. Tail (+) Tail-like pattern of myxofibrosarcoma October, 15-18 th, 2014 InterContinental Berlin Hotel Berlin, Germany Tail-like pattern is most obvious on Gd MRI No research regarding the relationship between the tail-like pattern and clinical factors Gd MRI Musculoskeletal Oncology Service, National Cancer Center Hospital Musculoskeletal Oncology Service, Keio University Hospital (Kaya M, et al. 2008)

20. Tail-like Pattern poor prognosis? Tail-like pattern of myxofibrosarcoma October, 15-18 th, 2014 InterContinental Berlin Hotel Berlin, Germany (Manoso MW, et al. 2006) Tail-like pattern High local recurrence rate High invasive activity Musculoskeletal Oncology Service, National Cancer Center Hospital Musculoskeletal Oncology Service, Keio University Hospital

21. Tail-like pattern is more prevalent in the superficial layer Tail-like pattern Tail-like pattern of myxofibrosarcoma October, 15-18 th, 2014 InterContinental Berlin Hotel Berlin, Germany (Mentzel T, et al. 1996) Superficial Deep Solid pattern Musculoskeletal Oncology Service, National Cancer Center Hospital Musculoskeletal Oncology Service, Keio University Hospital

22. The tumor with a Tail-like Pattern lead to Poorer Prognosis Tail-like pattern of myxofibrosarcoma October, 15-18 th, 2014 InterContinental Berlin Hotel Berlin, Germany 5-year RFS5-year DFS Musculoskeletal Oncology Service, National Cancer Center Hospital Musculoskeletal Oncology Service, Keio University Hospital (Kikuta K, et al. 2014)

23. Conclusions Tail-like pattern of myxofibrosarcoma October, 15-18 th, 2014 InterContinental Berlin Hotel Berlin, Germany Musculoskeletal Oncology Service, National Cancer Center Hospital Musculoskeletal Oncology Service, Keio University Hospital

24. Conclusions ► This study identified the significant relationship between the tail-like pattern and superficial location. ► MFS with the tail-like pattern had worse prognosis. ► Further studies are warranted to elucidate the biological nature of the tail-like pattern of MFS. Tail-like pattern of myxofibrosarcoma October, 15-18 th, 2014 InterContinental Berlin Hotel Berlin, Germany Musculoskeletal Oncology Service, National Cancer Center Hospital Musculoskeletal Oncology Service, Keio University Hospital

25. Danke für deine Aufmerksamkeit!! Tail-like pattern of myxofibrosarcoma October, 15-18 th, 2014 InterContinental Berlin Hotel Berlin, Germany Musculoskeletal Oncology Service, National Cancer Center Hospital Musculoskeletal Oncology Service, Keio University Hospital