Vanished MDM2 amplification in multiple recurrences of an irradiated poorly differentiated sarcoma with amplified TRIO::TERT fusion gene

Among sarcomas, MDM2 amplification is usually a molecular hallmark of well-differentiated liposarcoma and dedifferentiated liposarcoma (DDLPS) and occasionally a secondary genetic anomaly in other sarcomas. Histological evaluation and FISH analysis showing MDM2 amplification led to the diagnosis of DDLPS for a tumor located on the left arm of a 71-year-old patient. The patient was treated by adjuvant radiotherapy (RT) but the tumor recurred soon after. Array-comparative genomic hybridization and targeted RNA/DNA sequencing of the primary tumor and of four recurrences were done. Strikingly, the MDM2 amplification observed in the primary tumor had vanished in the recurrences. In contrast, other rearrangements, such as amplification of the genes TRIO and TERT as well as TRIO::TERT fusion were detected retrospectively in the primary tumor and in all the recurrences. The transitory nature of the MDM2 amplification raised the hypothesis that RT was active on cells that contained MDM2 amplification but not on other tumor cells with only the TERT and TRIO alterations. In contrast to MDM2 amplification, the TRIO::TERT amplified fusion was stable over time. The detection of this fusion was crucial in the analysis of the diagnostically challenging last tumor; it allowed to determine that it was a fourth recurrence, instead of a new independent tumor. It also suggested the diagnosis undifferentiated pleomorphic sarcoma rather than DDLPS. The TRIO::TERT fusion is not well explored. The current study shows that its role in sarcomas, with or without MDM2 amplification, should be more extensively researched.