201
|
Fernebro J, Wiklund M, Jonsson K, Bendahl PO, Rydholm A, Nilbert M, Engellau J. Focus on the tumour periphery in MRI evaluation of soft tissue sarcoma: infiltrative growth signifies poor prognosis. Sarcoma 2006; 2006:21251. [PMID: 17496992 PMCID: PMC1779504 DOI: 10.1155/srcm/2006/21251] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2006] [Revised: 09/18/2006] [Accepted: 10/01/2006] [Indexed: 12/05/2022] Open
Abstract
Purpose. Infiltrative microscopical peripheral growth of soft tissue sarcomas (STS) has been shown to be of prognostic importance and preoperative risk stratification could individualize neoadjuvant treatment.
Patients and methods. We assessed peripheral tumour growth pattern on preoperative MRI from 78 STS. The findings were correlated to histopathology and to outcome.
Results. The MRI-based peripheral tumour growth pattern was classified as pushing in 34 tumours, focally infiltrative in 25, and diffusely infiltrative in 19. All tumours with diffuse infiltration on MRI also showed microscopical infiltration, whereas MRI failed to identify infiltration in two-thirds of the microscopically infiltrative tumours. Diffusely infiltrative growth on MRI gave a 2.5 times increased risk of metastases (P = .01) and a 3.7 times higher risk of local recurrence (P = .02).
Discussion. Based on this observation we suggest that MRI evaluation of STS should focus on the peripheral tumour growth pattern since it adds prognostic information of value for decisions on neoadjuvant therapies.
Collapse
Affiliation(s)
- Josefin Fernebro
- Department of Oncology, Institute of Clinical Sciences, Lund University Hospital, 221 85 Lund, Sweden
- *Josefin Fernebro:
| | - Marie Wiklund
- Department of Diagnostic Radiology, Institute of Clinical Sciences, Lund University Hospital, 221 85 Lund, Sweden
| | - Kjell Jonsson
- Department of Diagnostic Radiology, Institute of Clinical Sciences, Lund University Hospital, 221 85 Lund, Sweden
| | - Pär-Ola Bendahl
- Department of Oncology, Institute of Clinical Sciences, Lund University Hospital, 221 85 Lund, Sweden
| | - Anders Rydholm
- Department of Orthopedics, Institute of Clinical Sciences, Lund University Hospital, 221 85 Lund, Sweden
| | - Mef Nilbert
- Department of Oncology, Institute of Clinical Sciences, Lund University Hospital, 221 85 Lund, Sweden
| | - Jacob Engellau
- Department of Oncology, Institute of Clinical Sciences, Lund University Hospital, 221 85 Lund, Sweden
| |
Collapse
|
202
|
Stoeckle E, Gardet H, Coindre JM, Kantor G, Bonichon F, Milbéo Y, Thomas L, Avril A, Bui BN. Prospective evaluation of quality of surgery in soft tissue sarcoma. Eur J Surg Oncol 2006; 32:1242-8. [PMID: 16793237 DOI: 10.1016/j.ejso.2006.05.005] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2005] [Accepted: 05/03/2006] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Prospective application of the French Sarcoma Group (FSG) method of surgery reporting in soft tissue sarcoma (STS) in a single centre. METHODS Patients with primary STS of the extremities or trunk wall consecutively operated at the same institution from January 1996 to December 2002 were evaluated for local recurrence (LR). There were 205 patients, with AJCC/UICC stages III and IV in 51% of cases. Resection types according to FSG were R0 in 147, R1 in 53 and R2 in five cases. Radiotherapy was delivered in 163 patients and chemotherapy in 103. Multivariate analysis was performed. Overall five-year survival was 75%. Median follow-up for surviving patients was 53 months. RESULTS Actuarial five-year LR incidence was 13% in 200 patients with gross resection (R0+R1), it was 7% in R0 and 30% in R1 patients (p<0.0001). At univariate analysis, significant prognosticators for LR were age, histotype, tumour invasion, grade and resection type R. At multivariate analysis, resection R1 (relative risk (RR) 4.3, p=0.001) and grade 3 (RR 3.9, p=0.013) independently predicted LR. Combining these two variables produced three prognostic groups for LR: group 0 (no factor, n=70), group 1 (one factor, n=94) and group 2 (two factors, n=36) with five-year LR of 4%, 12% and 39%, respectively (p=6.4x10(-7)). CONCLUSION This first prospective evaluation of surgery reporting in STS evidences a fourfold, highly discriminating difference in LR between resections R0 and R1.
Collapse
Affiliation(s)
- E Stoeckle
- Department of Surgery, Institut Bergonié, Regional Cancer Centre, 229 Cours de l'Argonne, 33076 Bordeaux Cedex, Bordeaux, France.
| | | | | | | | | | | | | | | | | |
Collapse
|
203
|
Milbéo Y, Kantor G, Lagarde P, Stoeckle E, Duparc A, Thomas L, Bui BN. Approche conservatrice et fonctionnelle dans les sarcomes des tissus mous des membres : place de la radiothérapie. Cancer Radiother 2006; 10:410-5. [PMID: 16987679 DOI: 10.1016/j.canrad.2006.07.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Recent publications have permitted to quantify the benefit of radiotherapy in the conservative treatment of soft tissue sarcoma of the limbs. The aim of this review is to focus on aspects of radiotherapy witch influence local control and functional outcome for early and late normal tissue damage. The evaluation of late effects is performed according to Soma-Lent (Subjective-Objective-Management-Analytic-Late Effects of Normal Tissues) classification. About complications, neurological complications are probably under estimated and are related to total dose of radiation therapy.
Collapse
Affiliation(s)
- Y Milbéo
- Département de Radiothérapie, Institut Bergonié, Centre Régional de Lutte Contre le Cancer, 229, Cours de l'Argonne, 33076 Bordeaux Cedex, France
| | | | | | | | | | | | | |
Collapse
|
204
|
Manoso MW, Pratt J, Healey JH, Boland PJ, Athanasian EA. Infiltrative MRI pattern and incomplete initial surgery compromise local control of myxofibrosarcoma. Clin Orthop Relat Res 2006; 450:89-94. [PMID: 16801862 DOI: 10.1097/01.blo.0000229292.98850.14] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
UNLABELLED Myxofibrosarcoma (MFS) has a high local failure rate of up to 79%. We conducted a retrospective analysis on all patients with the diagnosis of myxofibrosarcoma seen between 1990 and 2004 to assess whether improved imaging with MRI reduced local recurrence, increased survival, and whether radiotherapy following resection influenced outcome. Twenty-one patients were treated for MFS with a median followup of 52 months (range, 18-122). All patients were surgically treated, with 19 receiving limb-sparing surgery. All patients with high grade disease, positive margins, or a pre-referral procedure received radiation therapy. The local recurrence rate was 57% for patients with a prior outside procedure (8 of 14), while patients with no prior surgery had a rate of 14% (1 of 7). Prior marginal excision and diffuse fascial spread on MRI predicted an increased local recurrence rate. The disease-free survival at 5 years was 43% (SE, 22%) for low-grade disease and 39% (SE, 18%) for high- grade disease. Magnetic resonance imaging observations suggest a unique pattern of diffuse spread along fascial planes that could be responsible for the high local recurrence. Radiation did not compensate for positive margins, nor did it reduce recurrence after negative margins. LEVEL OF EVIDENCE Therapeutic study, level IV (case series).
Collapse
Affiliation(s)
- Mark W Manoso
- Orthopedic Surgery Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center/Weill College of Medicine, Cornell University, New York, NY 10021, USA
| | | | | | | | | |
Collapse
|
205
|
Tomita Y, Morooka T, Hoshida Y, Zhang B, Qiu Y, Nakamichi I, Hamada KI, Ueda T, Naka N, Kudawara I, Aozasa K. Prognostic significance of activated AKT expression in soft-tissue sarcoma. Clin Cancer Res 2006; 12:3070-7. [PMID: 16707604 DOI: 10.1158/1078-0432.ccr-05-1732] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE AKT is a serine/threonine kinase which is important in tumorigenesis. Several molecules involved in AKT pathway are dysregulated in various kinds of human cancers. PATIENTS AND METHODS Ninety-three patients (53 males and 40 females), ages ranging from 19 to 77 years (median, 57 years), with localized soft-tissue sarcomas arising in the trunk and extremities, were analyzed. Immunoperoxidase procedure (avidin-biotin complex method) was done on paraffin-embedded sections with anti-phosphorylated AKT (Thr308), anti-phosphorylated p44/42 extracellular signal-regulated kinase 1 and 2 (ERK1/2) (Thr202/Tyr204), anti-phosphorylated forkhead in rhabdomyosarcoma (FKHR) (Ser256), and anti-Ki 67 antibodies. Expression levels of phosphorylated AKT (p-AKT), phosphorylated ERK1/2 (p-ERK1/2), and phosphorylated FKHR (p-FKHR) were categorized as either weaker (level 1) or equal to or stronger (level 2) compared with those in the endothelial cells of the same specimens. Percentage of cells showing intranuclear staining with Ki-67 was shown as the Ki-67 labeling index (LI). Cases were divided into two groups: level 1, Ki-67 LI < 20%; level 2, Ki-67 LI > or = 20%. RESULTS Twenty-six (28.0%), 6 (6.5%), and 46 (44.1%) of the tumors showed level 2 expression for p-AKT, p-ERK1/2, and Ki-67 LI, respectively. Tumors with level 2 p-AKT expression showed a higher ratio of level 2 p-FKHR expression (P < 0.01). Multivariate analysis revealed p-AKT expression and Ki-67 LI to be independent prognosticators for overall survival, and p-AKT expression for disease-free survival. CONCLUSION p-AKT expression level is a significant prognosticator in soft-tissue sarcoma.
Collapse
Affiliation(s)
- Yasuhiko Tomita
- Department of Pathology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
206
|
Abstract
The goal of this review was to provide an overview of the use of radiotherapy in the management of sarcomas and skin cancer. Radiotherapy can be an important component of treatment in these patients. It can help optimize local control of the tumor and often allows preservation of organ function with excellent cosmesis.
Collapse
Affiliation(s)
- Elena Antoaneta Nedea
- Northeast Proton Therapy Center, Massachusetts General Hospital, 30 Fruit Street, Boston, MA 02114, USA
| | | |
Collapse
|
207
|
Lin CN, Chou SC, Li CF, Tsai KB, Chen WC, Hsiung CY, Yen CF, Huang HY. Prognostic factors of myxofibrosarcomas: implications of margin status, tumor necrosis, and mitotic rate on survival. J Surg Oncol 2006; 93:294-303. [PMID: 16496357 DOI: 10.1002/jso.20425] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Myxofibrosarcomas (MFS) are characterized by tumor progression with increased metastases after local recurrences (LR). Few series had appropriately addressed what parameters independently affect prognosis. METHODS Seventy primary localized MFS were analyzed for local recurrence-free survival (LRFS), metastasis-free survival (MeFS), and disease-specific survival (DSS). Follow-up was obtained in 61 cases. RESULTS Thirty-eight males and 32 females had primary tumors ranging from 1.5 to 24 cm. Thirty and 40 tumors were superficial and deep, respectively, with 26 cases (38%) having positive margins. The 5-year LRFS-, MeFS-, and DSS-rates were 30%, 60%, and 73%. Positive margins (P = 0.0003) were the only inferior LRFS predictor. High grade (FNCLCC 2 and 3) was a negative factor of both MeFS (P = 0.0078) and DSS (P = 0.0174), and high stage (AJCC stage 3) was predictive of MeFS (P = 0.0470). However, both grading and staging were not prognostically independent. In multivariate analyses, mitoses >or=20/10 HPF (P = 0.0009, RR = 9.71) and positive margins (P = 0.0203, RR = 4.27) were independent adverse DSS predictor. However, tumor necrosis >or=10% (P = 0.0092, RR = 3.91) independently correlated with worse MeFS, together with mitoses >or=20/10 HPF (P = 0.0176, RR = 3.80) and positive margins (P = 0.0121, RR = 3.41). CONCLUSIONS Margin status and histologic property both affect the prognosis of MFS. The former correlates with improved LRFS and translates into final survival benefits.
Collapse
Affiliation(s)
- Ching-Nan Lin
- Department of Pathology, Chi-Mei Foundation Medical Center, Tainan, Taiwan
| | | | | | | | | | | | | | | |
Collapse
|
208
|
Dickinson IC, Whitwell DJ, Battistuta D, Thompson B, Strobel N, Duggal A, Steadman P. SURGICAL MARGIN AND ITS INFLUENCE ON SURVIVAL IN SOFT TISSUE SARCOMA. ANZ J Surg 2006; 76:104-9. [PMID: 16626341 DOI: 10.1111/j.1445-2197.2006.03615.x] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The goal of surgeons treating soft tissue sarcoma is to gain local control, to avoid risk of local recurrence and to avoid compromise of the patient's potential survival. The aim of the investigation was to assess the significance of the extent of surgical margin on the chance of death, metastasis and local recurrence. METHODS Two hundred and seventy-nine patients who presented with soft tissue sarcoma without metastatic disease were analysed. RESULTS The extent of the surgical margin was not clinically or statistically significant in the development of metastatic disease. The presence of a contaminated surgical margin led to a significantly higher rate of local recurrence (as did a narrow surgical margin less than 1 mm). A margin greater than 1 mm allowed a satisfactory outcome in terms of low local recurrence rates. In terms of overall survival, the failure to achieve a wide surgical margin (wide contaminated margin) led to an increased relative death rate. However, when the margin was not contaminated (even if the margin was very close, less than 1 mm), the overall survival rate was similar across all groups. Patients who had radical resections did poorly; they generally belonged to a group in which palliative surgery was carried out, and they showed very high relative metastasis and death rates. CONCLUSION The present study provides statistically significant evidence that increasing the width of resection improves local control and overall survival.
Collapse
Affiliation(s)
- Ian C Dickinson
- Department of Orthopaedics, The Wesley Medical Centre, Brisbane, Queensland, Australia.
| | | | | | | | | | | | | |
Collapse
|
209
|
Stoeckle E. Chirurgie des sarcomes des tissus mous des membres et de la paroi du tronc. Cancer Radiother 2006; 10:34-40. [PMID: 16309941 DOI: 10.1016/j.canrad.2005.10.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2005] [Indexed: 11/26/2022]
Abstract
UNLABELLED For this review of surgery in soft tissue sarcoma, we reviewed literature and added our personal experience. In front of a soft tissue tumour, the major objective is to think it could be a sarcoma. Diagnosis actually is made by core needle biopsies, but sometimes a surgical biopsy is needed. Surgical resection is better defined since ten years and distinguishes resection R0 (in sano), R1 (microscopic residual disease) and R2 (macroscopic residual disease). Quality of resection is determined collegially by confrontation of surgical and pathological reports according recommendations of the French Sarcoma Group (FSG). The risk of local recurrence depends on resection-type and tumour grade. With the help of the surgical classification from FSG, local prognosis is better understood and treatment can be adapted to individual tumours. In experienced hands, local recurrence can be pushed down to near 10 against 20% formerly. Severe complications after sarcoma surgery occur in 14% of cases. Functional outcome studies have benefited from new scoring systems, which complete each other. Isolated limb perfusion is a method that could save limbs in some desperate situations. CONCLUSION Due to rarity and treatment specifications, soft tissue sarcoma should be treated in specialised centres.
Collapse
Affiliation(s)
- E Stoeckle
- Service de chirurgie, Institut Bergonié, CRLCC Bordeaux, 229, cours de l'Argonne, 33076 Bordeaux cedex, France.
| |
Collapse
|
210
|
Huang HY, Kang HY, Li CF, Eng HL, Chou SC, Lin CN, Hsiung CY. Skp2 Overexpression Is Highly Representative of Intrinsic Biological Aggressiveness and Independently Associated with Poor Prognosis in Primary Localized Myxofibrosarcomas. Clin Cancer Res 2006; 12:487-98. [PMID: 16428491 DOI: 10.1158/1078-0432.ccr-05-1497] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Two SCF(Skp2) ubiquitin ligase-related proteins, Skp2 and cyclin-dependent kinase subunit 1 (Cks1), are involved in posttranscriptional degradation of p27(Kip1) tumor suppressor. We analyzed the prognostic utility of p27(Kip1) and its interacting cell cycle regulators in myxofibrosarcomas. EXPERIMENTAL DESIGN Clinicopathologic features and tissue microarray-based immunohistochemical expression of p27(Kip1), Skp2, Cks1, cyclin E, cyclin A, Ki-67, and minichromosome maintenance protein 2 (Mcm2) were assessed in 70 primary myxofibrosarcomas and correlated with clinical outcomes. Skp2 mRNA expression and the relationship between Skp2 and p27(Kip1) proteins were examined in six cases by semiquantitative reverse transcription-PCR and Western blotting, respectively. RESULTS High indices of Skp2 (> or =10%), cyclin A (> or =10%), and Mcm2 (> or =50%) were adverse prognosticators at the univariate level. Furthermore, co-overexpression of Skp2 and cyclin A identified highly lethal cases in the entire cohort [P < 0.0001 for disease-specific survival (DSS), P = 0.0004 for overall survival (OS)] and the lower-grade subset (Fédération Nationale des Centres de Lutte Contre le Cancer grade 1 and 2; P = 0.0006 for DSS, P = 0.0093 for OS). In multivariate analyses, Skp2 overexpression overshadowed most intrinsic clinicopathologic factors and independently correlated with worse metastasis-free survival (P = 0.0012), DSS (P = 0.0234), and OS (P = 0.0056). Notably, positive margins independently predicted inferior local recurrence-free survival (P = 0.0012) and also negatively affected metastasis-free survival (P = 0.0471), DSS (P = 0.0152), and OS (P = 0.0173). Reverse transcription-PCR showed up-regulation of Skp2 mRNA in four cases and Western blotting displayed a matched expression pattern of Skp2. CONCLUSIONS Margin status and intrinsic property of myxofibrosarcomas both affect patient survival. Skp2 overexpression is highly representative of the biological aggressiveness of myxofibrosarcomas and plays an important prognostic role.
Collapse
Affiliation(s)
- Hsuan-Ying Huang
- Departments of Pathology and Radiation Oncology and Graduate institute of Clinical Medical Science, Chang Gung Memorial Hospital, Kaohsiung Medical Center, Chang Gung University, 123 Ta-Pei Road, Niao-Sung, Kaohsiung County, Taiwan
| | | | | | | | | | | | | |
Collapse
|
211
|
Fiore M, Casali PG, Miceli R, Mariani L, Bertulli R, Lozza L, Collini P, Olmi P, Mussi C, Gronchi A. Prognostic effect of re-excision in adult soft tissue sarcoma of the extremity. Ann Surg Oncol 2006; 13:110-7. [PMID: 16372156 DOI: 10.1245/aso.2006.03.030] [Citation(s) in RCA: 120] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2005] [Accepted: 08/04/2005] [Indexed: 11/18/2022]
Abstract
BACKGROUND We explored the outcome of patients with primary adult soft tissue sarcoma (STS) of the extremities undergoing re-excision after previous unplanned surgery. METHODS A total of 597 consecutive adult patients with primary extremity STS were treated with conservative surgery at our institution over a 20-year time span. A total of 318 patients were referred after unplanned excisions, and the remaining 279 underwent primary resection at our center. The two groups significantly differed in tumor size and depth. The assessed end points were sarcoma-specific mortality, local recurrence, and distant metastasis. Univariable and multivariable analyses, adjusted for other prognostic factors, were performed in the competing risks framework. RESULTS The adjusted 10-year cumulative incidences in re-excised and primarily operated patients were, respectively, 18.7% and 16.4% (P = .535) for local relapse, 17.6% and 20.2% (P = .541) for metastasis, and 20.4% and 22.4% (P = .645) for mortality. Among patients who underwent re-excision, evidence of microscopic residual disease on pathologic examination had a significant prognostic effect on multivariable analysis for distant metastases (P = .002). A trend for survival was detected as well. CONCLUSIONS At a referral center with a liberal policy of re-excisions in adult primary STS of the extremities, the outcome of patients who underwent re-excision was similar to that of patients who had primary resections. Evidence of microscopic residual disease at re-excision was a marker of clinical aggressiveness.
Collapse
Affiliation(s)
- Marco Fiore
- Department of Surgery, Istituto Nazionale per lo Studio e la Cura dei Tumori, Via Venezian, 1, Milan, 20133, Italy
| | | | | | | | | | | | | | | | | | | |
Collapse
|
212
|
Anghileri M, Miceli R, Fiore M, Mariani L, Ferrari A, Mussi C, Lozza L, Collini P, Olmi P, Casali PG, Pilotti S, Gronchi A. Malignant peripheral nerve sheath tumors. Cancer 2006; 107:1065-74. [PMID: 16881077 DOI: 10.1002/cncr.22098] [Citation(s) in RCA: 278] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The authors explored the prognostic factors and clinical outcomes of patients who had malignant peripheral nerve sheath tumors (MPNST) with and without neurofibromatosis type 1 (NF-1). METHODS Two hundred five patients with localized MPNST who underwent surgery at the Istituto Nazionale per lo Studio e la Cura dei Tumori (Milan, Italy) over 25 years were reviewed. Forty-six patients had concomitant NF-1 syndrome, and 159 patients did not. Local recurrence, distant metastases, and survival rates were studied. RESULTS One hundred thirty patients presented with primary disease, and 75 patients had locally recurrent tumors. The disease-specific mortality rate was 43% at 10 years, with a continuously disease-free survival rate of no greater than 40%. Presentation with either primary or recurrent disease, tumor size, and tumor site (trunk vs. extremity) were the strongest independent predictors of survival. Margin status and radiation therapy also played a role, mostly related to their effect on local outcome. Pathologic grade influenced distant metastases, but only a trend for survival could be observed. No significant independent differences between patients with and without NF-1 were observed. CONCLUSIONS To the authors' knowledge, this was among the largest single-institution series to date. The results confirmed that patients with MPNST share similar prognostic factors with patients who have other soft tissue sarcomas and have some of the worst clinical outcomes. The presence of NF-1 syndrome per se did not affect survival, but patients with NF-1 were more likely to have larger tumors. Therefore, such patients should be followed carefully to detect disease as early as possible.
Collapse
Affiliation(s)
- Matteo Anghileri
- Department of Surgery, Istituto Nazionale per lo Studio e la Cura dei Tumori, Milan, Italy
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
213
|
Taieb S, Ceugnart L, Gauthier H, Penel N, Vanseymortier L. [Soft sarcoma tissue of extremities: medical imagery in post-therapeutic follow-up]. Cancer Radiother 2005; 10:78-82. [PMID: 16300981 DOI: 10.1016/j.canrad.2005.09.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2005] [Indexed: 10/25/2022]
Abstract
After treatment of primary soft tissue sarcoma, a third of patients will develop local or distant (lung in 90% of cases) recurrence. For an individual patient, the issue of cancer recurrence is a binary event. However, when developing surveillance strategies for large groups of patients, knowledge of the risks (tumor biology, natural history of the disease), the benefits (potential efficacy of salvage therapy) and diagnosis test performances is necessary to formulate a rationale and resource effective follow-up algorithm.
Collapse
Affiliation(s)
- S Taieb
- Département d'Imagerie, Centre Régional de Lutte contre le Cancer Oscar-Lambret, 3, rue Frédéric-Combemale, BP 309, 59020 Lille cedex, France.
| | | | | | | | | |
Collapse
|
214
|
Abstract
Unlike common malignancies, such as breast and colorectal carcinoma, where treatment modalities can be investigated with large prospective randomized trials, such an endeavor has been hampered with soft tissue sarcomas (STS) due to its rarity. In absence of such randomized clinical trials, controversy exists with regards to numerous clinically relevant questions and clinicians are left with single institutional experiences gathered either in a retrospective or prospective fashion. Some of these frequently encountered issues in the management of STS include (1) whether poorly executed biopsies affect outcome? (2) Do all unplanned excisions require re-excisions? (3) Is MRI a superior imaging modality? (4) Whether radiation should be provided pre- or post-operatively? (5) Does extent of surgical margin influence local control? (6) Is adjuvant radiation therapy necessary for stage IIB STS? (7) Does adjuvant chemotherapy influence local control? (8) Does local recurrence influence survival? We will address these topics in this review.
Collapse
Affiliation(s)
- Vijay P Khatri
- Division of Surgical Oncology, University of California, Davis, 4501 X Street, Suite 3010, Sacramento, CA 95817, USA
| | | |
Collapse
|
215
|
Milbéo Y, Kantor G, Laharie H, Lagarde P, Stoeckle E, Bonichon F, Thomas L, Brouste V, Bui BN. [Adjuvant radiation therapy for soft tissue sarcoma of the extremities: analysis of local control according to volume and dose]. Cancer Radiother 2005; 9:293-303. [PMID: 16005654 DOI: 10.1016/j.canrad.2005.06.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2004] [Revised: 05/30/2005] [Accepted: 06/07/2005] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate retrospectively the anatomical definition of target volumes in the treatment of soft tissue sarcomas of the limbs and to study the radiation dose in the local control and toxicity. METHODS AND PATIENTS Seventy-seven patients were consecutively treated for primary soft tissue sarcoma of the extremity with limb sparing surgery and external beam radiotherapy (EBRT) in the same institution. The median follow up was 56 months (17-89 months). RESULTS Fifty-two patients (67%) had clear microscopic surgical margin (R0 resection), 23 (30%) had histologically positive microscopic margin (R1 resection), 2 had a macroscopic residual disease (R2 resection). An anatomical definition of target volumes has been realised. The mean dose was 50 Gy in 25 or 28 fractions; 23 patients received a boost restricted to the tumor bed: 13 with EBRT, 10 with brachytherapy (BRT). Thirty-four patients had an adjuvant chemotherapy. The overall 5 year local relapse rate was 10%. Seven local relapses were described, five of the high-grade tumours, and five in patients with positive margin. In univariate analysis, quality of surgery shows a significant effect for local control. By using LENT-SOMA scale for late toxicity, a significant difference was found for neurological complications for patients receiving a boost. CONCLUSIONS The results of the series validate the concept of anatomical definition of the initial target volume. A boost should be realised for positive margin tumors and may be for high-grade tumors. Neurological toxicity must be considered for the evaluation of the prescribed dose.
Collapse
Affiliation(s)
- Y Milbéo
- Service de radiothérapie, institut Bergonié, centre régional de lutte contre le cancer, 229, cours de l'Argonne, 33076 Bordeaux cedex, France
| | | | | | | | | | | | | | | | | |
Collapse
|
216
|
Currier MA, Adams LC, Mahller YY, Cripe TP. Widespread intratumoral virus distribution with fractionated injection enables local control of large human rhabdomyosarcoma xenografts by oncolytic herpes simplex viruses. Cancer Gene Ther 2005; 12:407-16. [PMID: 15665822 DOI: 10.1038/sj.cgt.7700799] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Novel methods of local control for sarcomas are needed. We investigated the antitumor effect of two related herpes simplex virus (HSV) mutants, NV1020 and NV1066, on human rhabdomyosracoma cells and xenografts. Cell death correlated with virus replication and apoptosis in cultured cells and tumors. Complete regression was seen in all tumors <250 mm(3) following a single injection, yet only half of tumors >250 mm(3) showed a complete response. Fractionation of the virus dose into five injection sites did not increase transduction efficiency, transgene expression, or virus production, but did yield more widespread intratumoral distribution. Despite the same total dose of virus, improved control of large tumors was seen using fractionated injections as all large tumors (500-700 mm(3)) had durable, complete regression. Our data suggest that oncolytic HSVs may be useful for local control of bulky rhabdomyosarcoma tumors and that fractionated virus administration results in a more widespread virus infection and better tumor control. Therefore, strategies to maximize intratumoral virus distribution at initial delivery should be sought.
Collapse
Affiliation(s)
- Mark A Currier
- Division of Hematology/Oncology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio 45229, USA
| | | | | | | |
Collapse
|
217
|
Scurr M, Judson I. Neoadjuvant and Adjuvant Therapy for Extremity Soft Tissue Sarcomas. Hematol Oncol Clin North Am 2005; 19:489-500, vi. [PMID: 15939193 DOI: 10.1016/j.hoc.2005.03.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Despite the overall good prognosis in patients who have localized soft tissue sarcoma (STS) of the extremities, approximately half of those who have high-risk features ultimately will die from metastatic disease that was present as microscopic foci at the time of diagnosis. The principal role of adjuvant and neoadjuvant chemotherapy is to improve the "cure" rate through eradication of these microscopic foci. Over the last 30 years there have been numerous studies attempting to determine whether adjuvant or neoadjuvant systemic chemotherapy does lead to an improvement in disease-specific survival in patients who have localized STS. It is still unclear whether there may be a role for systemic chemotherapy in patients who have high-risk localized STS of the extremities. This article discusses some of the issues surrounding this most controversial area in the management of STS.
Collapse
Affiliation(s)
- Michelle Scurr
- Cancer Research-UK Centre for Cancer Therapeutics, Institute of Cancer Research, Sycamore House, Downs Road, Sutton, Surrey SM2 5PT, UK.
| | | |
Collapse
|
218
|
DeLaney TF. Optimizing radiation therapy and post-treatment function in the management of extremity soft tissue sarcoma. Curr Treat Options Oncol 2005; 5:463-76. [PMID: 15509480 DOI: 10.1007/s11864-004-0035-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
When treating soft tissue sarcomas (STS) of the extremities, the major therapeutic goals are survival, local tumor control, optimal function, and minimal morbidity. Surgical resection of the primary tumor is the essential component of treatment for virtually all patients. However, local control by surgery alone is poor for the majority of patients with extremity lesions unless the procedure removes large volumes of grossly normal tissue (ie, widely negative margins are attained, because sarcomas tend to infiltrate normal tissue adjacent to the evident lesion). Thus, removal of the gross lesion by a simple excision alone is followed by local recurrence in 60% to 90% of patients. Radical resections reduce the local recurrence rate to 10% to 30%, but may compromise limb function. The combination of function-sparing surgery and radiation achieves better outcomes than either treatment alone for nearly all patients with STS. Because both surgical and radiation technique are critically important for optimizing local control of tumor and functional outcome, it is important to manage these patients in dedicated multispecialty clinics comprised of physicians with expertise in sarcomas, including orthopedic and general oncologic surgeons, radiation oncologists, medical oncologists, sarcoma pathologists, and bone and soft tissue diagnostic radiologists. Radiation therapy can be given by external beam radiation therapy (EBRT) or brachytherapy (BRT) or combination thereof. External beam radiation can be given either preoperatively or postoperatively. The clinical considerations and the outcome data that must be considered in choosing the most appropriate treatment technique for the individual patient are discussed.
Collapse
Affiliation(s)
- Thomas F DeLaney
- Northeast Proton Therapy Center, Massachusetts General Hospital, 30 Fruit Street, Boston, MA 02114, USA.
| |
Collapse
|
219
|
Zhang P, Brooks JSJ. Modern pathological evaluation of soft tissue sarcoma specimens and its potential role in soft tissue sarcoma research. Curr Treat Options Oncol 2005; 5:441-50. [PMID: 15509478 DOI: 10.1007/s11864-004-0033-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The vast majority of soft tissue tumors (STT), especially sarcomas, should be examined according to a national standard for pathologic evaluation, including a national consensus on a grading system and elements of a synoptic pathology report. The margins should be separated into fascial margins and other surgically cut margins. If questions about the diagnosis arise, a second opinion should be sought from an expert in sarcoma pathology. Whenever possible, tissue should be frozen for potential molecular diagnosis and additional tissue banked for research. Finally, there is a need for a national registry for rare sarcoma types.
Collapse
Affiliation(s)
- Paul Zhang
- Pennsylvania Hopsital, Philadelphia 19107, USA
| | | |
Collapse
|
220
|
Gronchi A, Casali PG, Mariani L, Miceli R, Fiore M, Lo Vullo S, Bertulli R, Collini P, Lozza L, Olmi P, Rosai J. Status of Surgical Margins and Prognosis in Adult Soft Tissue Sarcomas of the Extremities: A Series of Patients Treated at a Single Institution. J Clin Oncol 2005; 23:96-104. [PMID: 15625364 DOI: 10.1200/jco.2005.04.160] [Citation(s) in RCA: 205] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Purpose To explore the prognostic effect of microscopic marginal status after surgery for extremity soft tissue sarcomas. Patients and Methods We analyzed 911 consecutive patients surgically treated throughout a 20-year span at a single referral center. Six hundred forty-two were first seen with a primary tumor, and 269, with a locally recurrent tumor. All patients underwent macroscopically complete resection. Microscopic marginal status was negative (tumor size > 1 mm) in 748 patients and positive (≤ 1 mm) in 163 patients. Median follow-up was 107 months. Results Patients with primary disease had a lower disease-specific mortality in comparison to those first examined for recurrence (25% v 37%, respectively, at 10 years). Size, malignancy grade, depth, histotype, and local recurrence had a statistically significant prognostic effect at multivariable analysis, while microscopically positive surgical margins had not, though a trend in favor of negative margins was observed. However, an extra risk was observed for patients with positive margins after 3 to 5 years (hazard ratio, 1.8 after 5 years v 0.8 before 5 years). In patients treated for a local recurrence, the prognostic impact of positive margins was higher (hazard ratio, 1.6). Conclusion Positive surgical margins had a weak adverse prognostic effect, which was more pronounced for those patients escaping an early relapse. This would seem to justify a policy of surgical adequacy in adult soft tissue sarcomas, though clinical decision making in borderline presentations for conservative surgery might be reasonably flexible and shared with the patient. Once a local relapse has occurred, the impact of local treatments seems more critical.
Collapse
Affiliation(s)
- A Gronchi
- Department of Surgery, Istituto Nazionale per lo Studio e la Cura dei Tumori, via Venezian,1 - 20133 Milano, Italy.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
221
|
Ghert MA, Abudu A, Driver N, Davis AM, Griffin AM, Pearce D, White L, O'Sullivan B, Catton CN, Bell RS, Wunder JS. The Indications for and the Prognostic Significance of Amputation as the Primary Surgical Procedure for Localized Soft Tissue Sarcoma of the Extremity. Ann Surg Oncol 2004; 12:10-7. [PMID: 15827772 DOI: 10.1007/s10434-004-1171-3] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2004] [Accepted: 08/19/2004] [Indexed: 11/28/2022]
Abstract
BACKGROUND The indications for primary amputation of a localized soft tissue sarcoma (STS) of the extremity are not well defined in the literature. However, it has been suggested that patients who require an amputation to treat an STS are at increased risk for developing metastases. We categorized the main indications for primary amputation in our patient population and compared their oncological outcome with the outcome of patients who underwent limb-sparing surgery. METHODS 413 consecutive patients treated surgically at a single center for primary, nonmetastatic, deep, intermediate-, or high-grade STS of the extremity were reviewed. Indications for primary amputation were identified. Demographics and outcomes were compared between the amputation and limb-salvage groups. Multivariate Cox model analysis was used to identify independent risk factors for systemic relapse. RESULTS Twenty-five (6%) of 413 patients with STS underwent primary amputation: they were older (P = .05), had larger tumors (P = .001), and had a significantly greater risk of developing metastatic disease than patients who underwent limb-sparing procedures (P = .008). However, multivariate analysis demonstrated that the only independent predictors of systemic relapse were tumor size (P = .0001) and tumor grade (P = .0001). Primary amputation was not an independent risk factor for metastatic disease. CONCLUSIONS The decision to perform a primary amputation for an STS of the extremity is based on the location and local extent of the tumor, and the expected function of the extremity after tumor resection. The higher risk of metastases for patients who require primary amputation is accounted for by independent risk factors associated with their tumors--predominantly large tumor size.
Collapse
Affiliation(s)
- Michelle A Ghert
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, 600 University Avenue, Suite 476E, Toronto, Ontario, M5G 1X5, Canada
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
222
|
Abstract
PURPOSE OF REVIEW To examine the factors predictive of recurrence for soft tissue sarcomas, the role of salvage therapy, and the data in support of current surveillance strategies. RECENT FINDINGS There are multiple primary tumor characteristics and other factors that can stratify patients into low- or high-risk groups for developing recurrent disease. The available data also support a limited role for salvage therapy in the setting of isolated local recurrence or distant metastases. The use of routine chest computed tomography as opposed to conventional chest x-ray for pulmonary surveillance is costly and provides little additional benefit if the risk for lung metastases is low. When examined scientifically, standard laboratory studies and surveillance imaging of the primary tumor site for extremity soft tissue sarcomas add little to the detection of recurrent disease. In addition to predictive variables, physician experience and opinion influence surveillance strategies. SUMMARY For soft tissue sarcomas, patient education and office visits with thorough history and physical examination will detect the vast majority of recurrent disease. Routine surveillance imaging is only of significant benefit if the risk for asymptomatic recurrence is high or if other factors make clinical assessment difficult. There is no benefit to basic laboratory studies in standard follow-up regimens.
Collapse
Affiliation(s)
- John M Kane
- Division of Surgical Oncology-Melanoma/Sarcoma, Roswell Park Cancer Institute, Buffalo, New York 14263, USA.
| |
Collapse
|
223
|
|
224
|
Ferguson PC, Deshmukh N, Abudu A, Carter SR, Tillman RM, Grimer RJ. Change in histological grade in locally recurrent soft tissue sarcomas. Eur J Cancer 2004; 40:2237-42. [PMID: 15454248 DOI: 10.1016/j.ejca.2004.04.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2004] [Revised: 04/21/2004] [Accepted: 04/22/2004] [Indexed: 11/28/2022]
Abstract
Histological examination of locally recurrent soft tissue sarcomas usually reveals an appearance similar to that of the original tumour. Occasionally, however, recurrent sarcomas appear more or less malignant histologically than the initial lesion. The goals of this paper were to identify the frequency with which this phenomenon occurs, factors that predict for a change in grade and to determine if this change is associated with a different prognosis from other patients with local recurrence. From a large sarcoma database, 124 patients with local recurrence were identified. These patients were distributed into groups who had no change in histological grade, increased histological grade or decreased histological grade on local recurrence. Increased grade occurred approximately 20% of the time, whereas decreased grade occurred in 7% of cases. A histological diagnosis of myxofibrosarcoma was predictive of an increase in histological grade on local recurrence. An increase in histological grade with local recurrence was not associated with a poorer survival.
Collapse
Affiliation(s)
- Peter C Ferguson
- University of Toronto and Mount Sinai Hospital, 600 University Ave., Suite 476G, Toronto, Ont., Canada.
| | | | | | | | | | | |
Collapse
|
225
|
Riad S, Griffin AM, Liberman B, Blackstein ME, Catton CN, Kandel RA, O'Sullivan B, White LM, Bell RS, Ferguson PC, Wunder JS. Lymph node metastasis in soft tissue sarcoma in an extremity. Clin Orthop Relat Res 2004:129-34. [PMID: 15346063 DOI: 10.1097/01.blo.0000141660.05125.46] [Citation(s) in RCA: 109] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
For patients with soft tissue sarcoma in an extremity, the outcome is thought to be poor if lymph node metastasis develops. The purpose of this study was to examine the impact of lymphatic involvement from soft tissue sarcoma on patient survival. Thirty-nine (3.7%) of 1066 patients who had surgery for soft tissue sarcoma in an extremity had lymph node metastases develop. Three (20%) of 15 patients with epithelioid sarcoma, four (19%) of 21 patients with rhabdomyosarcoma, two (11.1%) of 18 patients with clear cell sarcoma, and two (11.1%) of 18 patients with angiosarcoma had lymphatic involvement. Thirty patients who had resection of involved lymph nodes had an estimated 5-year survival of 57%, whereas nine patients treated without surgery all died within 30 months. An estimated 4-year survival of 71% for patients with isolated lymph node metastases was significantly better than 21% for patients with synchronous systemic and lymph node involvement. There was no difference in outcome for patients with isolated lymphatic involvement compared with patients with American Joint Committee on Cancer Stage III extremity sarcomas. These results suggest that long-term survival is possible after surgical resection of lymphatic metastases from soft tissue sarcoma. The American Joint Committee on Cancer should consider separating isolated nodal metastases from systemic involvement in patients with Stage IV sarcoma.
Collapse
Affiliation(s)
- Soha Riad
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
226
|
Engellau J, Anderson H, Rydholm A, Bauer HCF, Hall KS, Gustafson P, Akerman M, Meis-Kindblom J, Alvegård TA, Nilbert M. Time dependence of prognostic factors for patients with soft tissue sarcoma: a Scandinavian Sarcoma Group Study of 338 malignant fibrous histiocytomas. Cancer 2004; 100:2233-9. [PMID: 15139069 DOI: 10.1002/cncr.20254] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Prognostic factors for metastasis in soft tissue sarcoma govern decisions regarding adjuvant treatment. However, the significance of initial tumor-related prognostic factors over time is largely unknown. METHODS The current study included 338 patients with malignant fibrous histiocytoma (MFH) of the extremities or the trunk wall whose tumors were reviewed by the Scandinavian Sarcoma Pathology Review Group. Of these 338 patients, 329 (97%) had high-grade tumors. The median follow-up period was 7 years. Metastases occurred in 110 of 338 of patients after a median follow-up period of 14 months, with roughly one-third (32 of 110) occurring after 2 years. The authors investigated the prognostic significance of tumor size, tumor depth, histologic grade, microscopic tumor necrosis, vascular invasion, mitotic rate, and local tumor recurrence at various time intervals using metastases as an endpoint. RESULTS On univariate analysis, all investigated factors were found to be correlated with metastases for the entire follow-up period and also for the first 2 years of follow-up; beyond this time point, only size, tumor depth, and local recurrence were significant. On multivariate analysis, necrosis and local tumor recurrence were significant for the entire follow-up duration and also for the first 2 years of follow-up, whereas only tumor depth and local recurrence were significant beyond 2 years of follow-up. For all initial factors, the annual metastasis risks in the high-risk and low-risk groups converged to < 0.1 after 2 years and to near 0 after 5 years. CONCLUSIONS Prognostic factors for metastasis in MFH were time dependent. The predictive value of the initial prognostic factors was limited to the first 2 years of follow-up. The lack of observed prognostic value beyond 2 years of follow-up probably was attributable to heterogeneity within risk categories as a result of measurement errors and unknown biologic variations.
Collapse
Affiliation(s)
- Jacob Engellau
- Department of Oncology, The Jubileum Institute, Lund University, Lund, Sweden.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
227
|
McKee MD, Liu DF, Brooks JJ, Gibbs JF, Driscoll DL, Kraybill WG. The prognostic significance of margin width for extremity and trunk sarcoma. J Surg Oncol 2004; 85:68-76. [PMID: 14755506 DOI: 10.1002/jso.20009] [Citation(s) in RCA: 127] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND OBJECTIVES To evaluate the significance of resection margin for soft tissue sarcoma (STS), we determined local recurrence-free interval (LRFI), distant metastases-free interval (DMFI), and overall survival (OS) for primary extremity and truncal STS with clear margins (> or =10 mm), close margins (1-9 mm), and positive margins (0 mm). METHODS Patients were evaluated via review of charts and tumor specimens. RESULTS Among 111 patients, tumors were predominantly high grade (86%), > or =5 cm (76%), and deep (81%). A minority of patients received adjuvant radiation (38%) and/or adjuvant chemotherapy (34%). Margin width was > or =10 mm (48%), 1-9 mm (40%), or 0 mm (12%). Margins > or =10 mm were less common for large (P = 0.009) or deep (P = 0.02) tumors. By multivariate analysis, independent factors for LRFI were tumor size (P = 0.04) and margin width (P = 0.03). Independent factors related to DMFI were tumor grade (P = 0.002), size (P = 0.007), and patient age (P = 0.02). Independent factors relating to OS were tumor grade (P = 0.001), size (P = 0.004), and depth (P = 0.03). CONCLUSIONS Margins > or =10 mm independently predicted longer LRFI and are optimal for extremity STS resection. Adjuvant radiotherapy should be considered for all STS resected with margins <10 mm, and margin width should be considered when reporting and interpreting LR outcomes for these patients.
Collapse
Affiliation(s)
- Mark D McKee
- Division of Surgical Oncology, Roswell Park Cancer Institute and State University of New York, Elm & Carlton Streets, Buffalo, NY 14263, USA
| | | | | | | | | | | |
Collapse
|
228
|
Zagars GK, Ballo MT, Pisters PWT, Pollock RE, Patel SR, Benjamin RS. Prognostic factors for disease-specific survival after first relapse of soft-tissue sarcoma: Analysis of 402 patients with disease relapse after initial conservative surgery and radiotherapy. Int J Radiat Oncol Biol Phys 2003; 57:739-47. [PMID: 14529779 DOI: 10.1016/s0360-3016(03)00714-4] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE To document the prognostic factors for survival of patients with soft-tissue sarcoma sustaining a first relapse after definitive treatment. METHODS AND MATERIALS The clinicopathologic features, relapse patterns, and disease-specific survival rates for 402 consecutive patients sustaining a first relapse of sarcoma after combined surgery and radiotherapy were retrospectively reviewed. Factors affecting disease-specific survival after relapse were evaluated with univariate and multivariate techniques. RESULTS The median follow-up after relapse was 6.8 years. The overall disease-specific survival rate was 25%, 19%, and 16% at 5, 10, and 15 years, respectively, after the first relapse. The median survival duration was 21 months. Patients with an isolated local recurrence had a 5- and 10-year disease-specific survival rate of 48% and 46%, respectively, and those with an initial metastatic relapse had a disease-specific survival rate of 16% and 10%, respectively (p < 0.001). For isolated local recurrences, the independent determinants of survival were (favorable feature first) the primary tumor site (extremity and superficial trunk vs. head and neck and deep trunk); tumor grade (low and intermediate vs. high); time to recurrence (>12 vs. <or =12 months); and initial tumor size (<or =5 vs. >5 cm). Although the development of subsequent metastasis was the major cause of death, a significant fraction of patients died of uncontrolled primary tumor. For patients presenting with metastasis as the first relapse, the time to metastasis was the major determinant of survival (>12 vs. < or =12 months). Long-term salvage was largely confined to patients who could and did undergo resection of relapsed disease, either local or metastatic. CONCLUSION On the whole, patients whose sarcoma relapses fare poorly. However, select subgroups are potentially salvageable. Patients with an isolated local recurrence at sites other than the head and neck and deep trunk have a reasonable prospect for satisfactory outcome. Surgical resection of recurrences and metastases appears to play a major role in potential salvage.
Collapse
Affiliation(s)
- Gunar K Zagars
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA.
| | | | | | | | | | | |
Collapse
|
229
|
Zagars GK, Ballo MT. Significance of dose in postoperative radiotherapy for soft tissue sarcoma. Int J Radiat Oncol Biol Phys 2003; 56:473-81. [PMID: 12738323 DOI: 10.1016/s0360-3016(02)04573-x] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE For soft tissue sarcoma, adjuvant postoperative radiotherapy improves the local control rate over surgery alone. However, the issue of a dose-control relationship is controversial and was addressed in this study. METHODS AND MATERIALS We retrospectively reviewed the records of 775 consecutive patients who received postoperative external beam radiotherapy and used univariate and multivariate analysis to determine whether a dose-control relationship exists for the whole group and for specific high-risk subgroups. RESULTS With a median follow-up of 12.3 years, overall local control rates were 82%, 80%, and 79% at 5, 10, and 15 years. Factors adverse for local control were positive resection margins; tumor location in the head and neck and deep trunk; presentation with locally recurrent disease; patient age >64 years; histopathologic subtype of malignant fibrous histiocytoma, neurogenic sarcoma or epithelioid sarcoma; and tumor size >10 cm. In multivariate analysis, radiation dose > or = 64 Gy vs. <64 Gy independently correlated with improved local control. Significant interactions were noted between increased effectiveness of a higher dose and presentation with locally recurrent disease, with head and neck and deep trunk tumor sites, and with positive or uncertain resection margins such that local control was specifically improved under these circumstances with doses on the order of 64-68 Gy compared with doses on the order of 60 Gy. Higher dose, however, did not completely abrogate the adverse effect of positive margins. CONCLUSION After gross total resection, soft tissue sarcoma with features predictive of a higher than average local recurrence rate benefited from doses of 64-68 Gy compared with 60 Gy.
Collapse
Affiliation(s)
- Gunar K Zagars
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA
| | | |
Collapse
|
230
|
Zagars GK, Ballo MT, Pisters PWT, Pollock RE, Patel SR, Benjamin RS. Surgical margins and reresection in the management of patients with soft tissue sarcoma using conservative surgery and radiation therapy. Cancer 2003; 97:2544-53. [PMID: 12733154 DOI: 10.1002/cncr.11367] [Citation(s) in RCA: 134] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Patients with localized soft tissue sarcoma (STS) who present to specialist centers after undergoing apparent macroscopic total resection often have a significant incidence of residual tumor and may benefit from reresection of the tumor bed. The potential benefits of such reresection have not been documented adequately. METHODS The clinicopathologic features and disease outcome for 666 consecutive patients with localized STS who presented after undergoing apparent macroscopic total tumor resection were analyzed to elucidate the relative merits of reresection. Actuarial univariate and multivariate methods were used to compare disease outcome of patients who presented with positive or uncertain microscopic resection margins according to whether they underwent reresection. All patients received adjuvant radiation therapy. RESULTS Two hundred and ninety-five patients underwent reresection of their tumor bed, and residual tumor was found in 136 patients (46%), including macroscopic tumor in 73 patients (28%). Final resection margins among patients who underwent reresection were negative in 257 patients (87%), positive in 35 patients (12%), and uncertain in 3 patients (1%). Patients who did not undergo reresection had final margins that were negative in 117 patients (32%), positive in 47 patients (13%), and uncertain in 207 patients (56%). Local control rates at 5 years, 10 years, and 15 years for patients who underwent reresection were 85%, 85%, and 82%, respectively; for patients who did not undergo reresection, the respective local control rates were 78%, 73%, and 73% (P = 0.03). Reresection remained a significant determinant of local control when other prognostic factors were incorporated into a multivariate proportional hazards regression analysis. A similar beneficial effect of reresection was found for metastasis free survival and disease specific survival. CONCLUSIONS Patients with localized STS who were referred to a specialist center after undergoing apparent macroscopic total resection of their tumor had a high incidence of residual tumor in their tumor bed and benefited from undergoing reresection, even if radiation was administered routinely.
Collapse
Affiliation(s)
- Gunar K Zagars
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA.
| | | | | | | | | | | |
Collapse
|
231
|
Zagars GK, Ballo MT, Pisters PWT, Pollock RE, Patel SR, Benjamin RS, Evans HL. Prognostic factors for patients with localized soft-tissue sarcoma treated with conservation surgery and radiation therapy: an analysis of 1225 patients. Cancer 2003; 97:2530-43. [PMID: 12733153 DOI: 10.1002/cncr.11365] [Citation(s) in RCA: 496] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Prognostic factors for patients with soft-tissue sarcoma who are treated with conservative surgery and radiation are documented poorly. METHODS The clinicopathologic features and disease outcome for 1225 patients with localized sarcoma who were treated with conservative surgery and radiation were reviewed retrospectively. Actuarial univariate and multivariate statistical methods were used to determine significant prognostic factors for local control, metastatic recurrence, and disease specific survival. RESULTS The median follow-up of surviving patients was 9.5 years. The respective local control rates at 5 years, 10 years, and 15 years were 83%, 80%, and 79%. Factors predictive of local recurrence were positive or uncertain resection margins; tumors located in the head and neck and the deep trunk; presentation with local recurrence; patient age > 64 years; malignant fibrous histiocytoma, neurogenic sarcoma. or epithelioid sarcoma histopathology; tumor measuring > 10 cm in greatest dimension; and high pathologic grade. Freedom from metastasis at 5 years, 10 years, and 15 years was 71%, 68%, and 66%, respectively. Factors that were predictive of metastatic recurrence were high tumor grade; large tumor size (> 5 cm); and leiomyosarcoma, rhabdomyosarcoma, synovial sarcoma, or epithelioid sarcoma. The respective disease specific survival rates at 5 years, 10 years, and 15 years were 73%, 68%, and 65%. Adverse factors for disease specific survival were high tumor grade; large tumor size (> 5 cm); tumors located in the head and neck and deep trunk; rhabdomyosarcoma, epithelioid sarcoma, or clear cell sarcoma; patient age > 64 years; and positive or uncertain resection margins. CONCLUSIONS Soft-tissue sarcoma comprises a heterogeneous group of diseases. Prognostic factors for local recurrence, metastatic recurrence, lymph node recurrence, disease free survival, and disease specific survival are different, and optimal treatment strategies need to take this complexity into account.
Collapse
Affiliation(s)
- Gunar K Zagars
- Department of Radiation Oncology, University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA
| | | | | | | | | | | | | |
Collapse
|
232
|
Zagars GK, Ballo MT. Sequencing radiotherapy for soft tissue sarcoma when re-resection is planned. Int J Radiat Oncol Biol Phys 2003; 56:21-7. [PMID: 12694820 DOI: 10.1016/s0360-3016(02)04413-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE To evaluate whether disease outcome for localized soft-tissue sarcoma (STS) excised before referral to a specialist center and there re-resected was influenced by the timing of radiation therapy (XRT)-before or after re-resection. MATERIALS AND METHODS Two hundred ninety-five consecutive patients with localized grossly excised STS were retrospectively evaluated for local control, freedom from metastasis, disease-free survival, and disease-specific survival, according to whether they had XRT before (121) or after (174) re-resection of their tumor bed. Univariate and multivariate statistical techniques were employed. RESULTS At re-resection, residual STS was found in 159 patients (54%), including gross tumor in 73 (25%). The incidence of residual disease was lower in those receiving preoperative XRT (median dose 50 Gy) (36%) than in those having postoperative RT (median dose 60 Gy) (54%) (p = 0.024). With a median follow-up of 9.1 years, the local control rates for all patients at 5, 10, and 15 years were 86%, 84%, and 81%, respectively, and there were no differences between the two XRT sequences. In multivariate regression, there was no evidence that XRT sequence influenced local control, metastatic control, disease-free survival, or disease-specific survival. There was a trend toward fewer XRT-related late complications with preoperative XRT, but this was not significant, and the incidence of complications was low (5% at 15 years). CONCLUSIONS Patients who present after total but oncologically inadequate excision of STS can receive approximately 50 Gy before re-resection or approximately 60 Gy after re-resection, with approximately equivalent, satisfactory local control and overall disease outcome. Decisions as to the most appropriate treatment sequence for any individual patient can be made regardless of considerations as to the effectiveness of one sequence compared with the other.
Collapse
Affiliation(s)
- Gunar K Zagars
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA
| | | |
Collapse
|
233
|
Abstract
Many of the soft tissue sarcomas that occur in children are of the same histology as those in adults; however, the relative prevalence of these sarcomas is different between children and adults. In some cases, the biologic behavior of pediatric sarcomas is more benign than that in adults. Treatment for sarcomas in children is also different. Pediatric sarcomas are more commonly responsive to chemotherapy. Furthermore, in children who are still growing, surgery and radiation are associated with higher morbidity than in adults. This article discusses the diagnosis and treatment of rhabdomyosarcoma and undifferentiated sarcomas, with an emphasis on surgical considerations, and the diagnosis and treatment of nonrhabdomyosarcomatous soft tissue sarcomas in children.
Collapse
Affiliation(s)
- Cynthia E Herzog
- Division of Pediatrics, University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Boulevard, Box 87, Houston, TX 77030, USA.
| | | | | |
Collapse
|
234
|
Gerrand CH, Bell RS, Wunder JS, Kandel RA, O'Sullivan B, Catton CN, Griffin AM, Davis AM. The influence of anatomic location on outcome in patients with soft tissue sarcoma of the extremity. Cancer 2003; 97:485-92. [PMID: 12518373 DOI: 10.1002/cncr.11076] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The anatomic location of an extremity soft tissue sarcoma may influence the patient's presentation, management, and local and systemic recurrence rates. The objective of this study was to compare the presentation, management, and outcome of patients with soft tissue sarcomas of the upper extremity and the lower extremity. METHODS Prospectively collected data from patients who underwent limb-sparing surgery for extremity soft tissue sarcoma between January, 1986 and April, 1997 were analyzed. Local recurrence free rates and metastasis free rates were calculated using the method of Kaplan and Meier. Univariate and multivariate analyses of potential predictive factors were evaluated with the log-rank test and the Cox proportional hazards model. RESULTS Of 480 eligible patients, 48 patients (10.0%) had a local recurrence, and 131 patients (27.3%) developed distant metastasis. The median follow-up of survivors was 4.8 years (range, 0.1-12.9 years). Patients with upper extremity tumors had smaller lesions (6.0 cm vs. 9.3 cm; P < 0.001), more often underwent unplanned excision before referral (89 patients [64.0%] vs. 160 patients [46.9%]; P < 0.001), and less often received radiotherapy (98 patients [70.5%] vs. 289 patients [84.8%]; P < 0.001). The 5-year local recurrence free rate was 82% for patients with sarcomas of the upper extremity and 93% for patients with sarcomas of the lower extremity (P = 0.002). The 5-year metastasis free rate was 82% for patients with sarcomas of the upper extremity and 69% for patients with sarcomas of the lower extremity (P = 0.013). CONCLUSIONS Local recurrence was more frequent in patients who had sarcomas of the upper extremity compared with patients who had sarcomas of the lower extremity. Factors that contributed to this difference included histologic type, the use of radiotherapy, and local anatomy. Metastasis was more frequent among patients with sarcomas of the lower extremity, because those tumors tended to be large and deeper compared with upper extremity tumors.
Collapse
Affiliation(s)
- Craig H Gerrand
- University Musculoskeletal Oncology Unit, Department of Surgery, Mount Sinai Hospital, the University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | | | | | | |
Collapse
|
235
|
Youssef E, Fontanesi J, Mott M, Kraut M, Lucas D, Mekhael H, Ben-Josef E. Long-term outcome of combined modality therapy in retroperitoneal and deep-trunk soft-tissue sarcoma: analysis of prognostic factors. Int J Radiat Oncol Biol Phys 2002; 54:514-9. [PMID: 12243830 DOI: 10.1016/s0360-3016(02)02942-5] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the long-term outcome of surgery and postoperative radiotherapy (RT) in retroperitoneal and deep-trunk soft-tissue sarcoma, and to identify the prognostic factors for local control, disease-free survival, and overall survival. METHODS AND MATERIALS Between January 1980 and December 1998, 60 patients with nonmetastatic retroperitoneal and deep-trunk soft-tissue sarcoma were treated at Wayne State University using combined surgery and RT. The location was retroperitoneal in 38 patients (63%) and deep trunk in 22 (27%). Forty-six patients (76%) were treated for primary disease and 14 (24%) for recurrent disease. The resection margins were negative in 24 patients (40%), close in 3 (5%), and positive in 33 (55%; 18 microscopic and 15 macroscopic). The median tumor size was 8.6 cm (range 2-55). External beam RT (EBRT; median dose 5220 cGy) was given to 44 patients (73%) and combined EBRT (median dose 4200 cGy) and brachytherapy (median dose 1600 cGy) to 16 patients (27%). Univariate and multivariate Cox regression analyses were conducted to identify the possible associations between patient age, race, gender, tumor site, histologic features, grade, size, stage, surgical margin, RT dose, modality (EBRT vs. EBRT plus brachytherapy), and presentation (primary vs. recurrent) and disease control. RESULTS The actuarial 5- and 10-year disease-free survival rate was 53% and 44%, respectively. Disease-free survival was significantly associated with female gender on univariate analysis (67% for female patients and 37% for male patients at 5 years, p = 0.05). On multivariate analysis, both gender and surgical margin had borderline significance (p = 0.06). The actuarial local control rate was 71% and 54% at 5 and 10 years, respectively. The median time to local relapse was 10.2 months, with 75% of all failures occurring within 29 months. The surgical margin status was significantly associated with local control (78% for patients with negative or close margins vs. 52% for patients with positive margins at 5 years, p = 0.04). Gender was borderline significant (85% for female patients vs. 54% for male patients at 5 years, p = 0.06). On multivariate analysis, only surgical margin status remained significant (p = 0.032). The distant metastasis-free survival rate at 5 and 10 years was 58% and 54%, respectively. The median time to distant metastases was 15.6 months. The lungs were the most common site of metastases. The only significant factor associated with distant metastasis-free survival was local control (73% for patients with locally controlled tumors vs. 19% for patients with local recurrence at 5 years, p = 0.0013). The actuarial 5- and 10-year overall survival rate was 56% and 47%, respectively. Gender (74% for female patients vs. 37% for male patients at 5 years), surgical margin status (66% for patients with negative or close margins vs. 48% for patients with positive margins at 5 years), and local control (64% for patients with locally controlled tumors vs. 21% for patients with uncontrolled primary tumors at 5 years) were significant predictors on both univariate and multivariate analyses (p <0.05). CONCLUSION The results of this study demonstrate the paramount importance of local control and complete surgical resection in the management of soft-tissue sarcoma of the retroperitoneum and deep trunk.
Collapse
Affiliation(s)
- Emad Youssef
- Department of Radiation Oncology, Barbara Ann Karmanos Cancer Institute, Wayne State University, Detroit, MI, USA
| | | | | | | | | | | | | |
Collapse
|
236
|
Landheer MLEA, Therasse P, van de Velde CJH. The importance of quality assurance in surgical oncology. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2002; 28:571-602. [PMID: 12359194 DOI: 10.1053/ejso.2002.1255] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
AIMS The aims were to review the existing methods of quality assurance in surgical oncology and to determine a relationship between surgery-related factors and the variety in outcomes in the treatment of solid cancers. METHODS The literature was reviewed by searching Medline and Cancerlit databases. RESULTS Wide variations were found in virtually all tumour types. Clear evidence was found that an improvement in the quality of the surgical procedure could have major implications for the prognosis and quality of life of cancer patients. CONCLUSIONS These findings emphasize the need for strict quality control procedures in surgical oncology and might imply a considerable change in cancer treatment strategies, because the routine use of adjuvant therapies could be questioned.
Collapse
|
237
|
Lohman RF, Nabawi AS, Reece GP, Pollock RE, Evans GRD. Soft tissue sarcoma of the upper extremity: a 5-year experience at two institutions emphasizing the role of soft tissue flap reconstruction. Cancer 2002; 94:2256-64. [PMID: 12001125 DOI: 10.1002/cncr.10419] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The objective of this study was to define the impact of soft tissue flap reconstruction on multimodality therapy for patients with soft tissue sarcomas of the upper extremity. Treatment standards continue to evolve for these patients, and, with multimodality therapy, most of them are candidates for limb-preserving surgery. Consequently, the role of soft tissue flap reconstruction is expanding. METHODS A review was conducted of 100 consecutive patients with soft tissue sarcomas of the upper extremity who underwent surgery at several institutions between 1992 and 1997. RESULTS Seventy-one patients underwent direct closure of defects after tumor resection, and 29 patients required soft tissue reconstruction with flaps. These groups were similar in most respects, except that 52% of the patients who required soft tissue reconstruction presented with recurrent disease (P = 0.0004), and 79% of them had tumors measuring > 5 cm in greatest dimension (P = 0.0003). The patients who required flap reconstruction had larger skin deficits after undergoing tumor resection (140 cm2) compared with the patients who had wounds that were managed by direct closure (40 cm2; P < 0.00001). Margins around the resected tumors were larger (1.62 cm) when flaps were employed compared with margins when defects were closed directly (0.87 cm; P = 0.0005). However, the number of patients with intralesional, marginal, wide, and radical resections was the same regardless of wound management. Major complications occurred in 14% of patients, but none led to death or amputation. The median follow-up was 31 months, and 66% of patients had no evidence of disease at that time. Rates of local recurrence and survival were similar for patients who underwent flap reconstruction compared with patients who underwent direct closure. CONCLUSIONS Soft tissue flap reconstruction facilitates therapy for patients with soft tissue sarcomas of the upper extremity, so that patients with larger tumors can undergo resection, limiting complications and limb sacrifice.
Collapse
Affiliation(s)
- Robert F Lohman
- Section of Plastic Surgery, The University of Chicago, Chicago Illinois, USA
| | | | | | | | | |
Collapse
|
238
|
Weiss SW. 44th Maude Abbott Lecture. Soft tissue sarcomas: lessons from the past, challenges for the future. Mod Pathol 2002; 15:77-86. [PMID: 11796845 DOI: 10.1038/modpathol.3880494] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Sharon W Weiss
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, 1364 Clifton Road, Atlanta, GA 30322, USA.
| |
Collapse
|
239
|
Wendtner C, Abdel-Rahman S, Baumert J, Falk MH, Krych M, Santl M, Hiddemann W, Issels RD. Treatment of primary, recurrent or inadequately resected high-risk soft-tissue sarcomas (STS) of adults: results of a phase II pilot study (RHT-95) of neoadjuvant chemotherapy combined with regional hyperthermia. Eur J Cancer 2001; 37:1609-16. [PMID: 11527685 DOI: 10.1016/s0959-8049(01)00191-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The efficacy of thermochemotherapy in adult patients with primary, recurrent or inadequately resected non-metastatic high-risk soft-tissue sarcomas (STS) was assessed. 54 patients were prospectively treated with four cycles of etoposide, ifosfamide and doxorubicin (EIA) combined with regional hyperthermia (RHT) followed by surgery, another four cycles of EIA without RHT and external beam radiation. The objective response rate was 16% and at a median follow-up time of 57 months, the 4-year estimated rates of local failure-free survival (LFFS), distant metastasis-free survival (DMFS), event-free survival (EFS) and overall survival (OS) were 59% (95% confidence interval (CI) 45-73%), 59% (95% CI 44-73%), 26% (95% CI 14-38%) and 40% (95% CI 27-53%), respectively. OS was in favour of patients responding to neoadjuvant treatment (P=0.073). In comparison to a preceding phase II study including pre- and postsurgical thermochemotherapy (RHT-91), at a 4-year follow-up the RHT-95 study cohort showed an inferior LFFS rate (P=0.027), but this did not affect DMFS (P=0.558) or OS (P=0.126). Hence, postsurgical thermochemotherapy seems critical for local tumour control without affecting survival.
Collapse
Affiliation(s)
- C Wendtner
- Department of Internal Medicine III, Klinikum Grosshadern Medical Center (KGMC), Ludwig-Maximilians-University, D-81377, Munich, Germany.
| | | | | | | | | | | | | | | |
Collapse
|
240
|
Bauer HC, Trovik CS, Alvegård TA, Berlin O, Erlanson M, Gustafson P, Klepp R, Möller TR, Rydholm A, Saeter G, Wahlström O, Wiklund T. Monitoring referral and treatment in soft tissue sarcoma: study based on 1,851 patients from the Scandinavian Sarcoma Group Register. ACTA ACUST UNITED AC 2001; 72:150-9. [PMID: 11372946 DOI: 10.1080/000164701317323408] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
This report is based on 1.851 adult patients with soft tissue sarcoma (STS) of the extremities or trunk wall diagnosed between 1986 and 1997 and reported from all tertiary referral centers in Norway and Sweden. The median age at diagnosis was 65 years and the male-to-female ratio was 1.1:1. One third of the tumors were subcutaneous, one third deep, intramuscular and one third deep, extramuscular. The median size was 7 (1-35) cm and 75% were high grade (III-IV). Metastases at presentation were diagnosed in 8% of the patients. Two thirds of STS patients were referred before surgery and the referral practices have improved during the study. The preoperative morphologic diagnosis was made with fine-needle aspiration cytology in 81%, core-needle biopsy in 9% and incisional biopsy in 10%. The frequency of amputations has decreased from 15% in 198688 to 9% in 1995-1997. A wide surgical margin was achieved in 77% of subcutaneous and 60% of deep-seated lesions. Overall, 24% of operated STS patients had adjuvant radiotherapy. The use of such therapy at sarcoma centers increased from 20% 1986-88 to 30% in 1995-97. Follow-up has been reported in 96% of the patients. The cumulative local recurrence rate was 0.20 at 5 years and 0.24 at 10 years. The 5-year metastasis-free survival rate was 0.70.
Collapse
Affiliation(s)
- H C Bauer
- Department of Oncology Service, Karolinska Hospital, Stockholm, Sweden
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
241
|
Bonvalot S, Kolb F, Mamlouk K, Cayalcanti A, Le Pechoux C, Terrier P, Vanel D, Le Cesne A. [Free-flap reconstruction of locally advanced soft tissue sarcomas]. ANNALES DE CHIRURGIE 2001; 126:308-13. [PMID: 11413809 DOI: 10.1016/s0003-3944(01)00512-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
STUDY AIM The aim of this retrospective study was to assess the advantages of free-lap reconstruction in locally advanced soft tissue sarcomas. PATIENTS AND METHOD From October 1997 to October 2000, among 256 procedures for sarcomas, 25 were associated with free-lap reconstruction. There were 16 women and nine men (mean age: 45 years). The tumor was located on inferior limbs (n = 15), superior limbs (n = 3) and trunk (n = 7), had a mean size of 12, 10 and 12 cm respectively, and was multifocal (n = 6), or recurrent (n = 10). Ten patients received a neoadjuvant chemotherapy. Tumoral excision was associated with a complementary procedure in 10 patients. Reconstruction was performed with free-laps of the latissimus dorsi (n = 21) and transverse rectus abdominis myocutaneous (TRAM) (n = 4). Early postoperative radiotherapy was associated in 15 patients. RESULTS Median duration of the procedure was 6.5 hours. There were no postoperative deaths. Two free-laps necrotized and another free-lap was constructed. Tumoral excision was Ro (n = 20), R1 (n = 4) and R2 (n = 1). With a median follow-up of 20 months, there were no local recurrences in patients Ro. Ten patients developed pulmonary metastases and five of them died. CONCLUSION With free-lap reconstruction, tumoral excision was larger, amputation of the limb was avoided in 14 patients, and early postoperative radiotherapy was possible in 15 patients. Multidisciplinary management and collaboration of the oncologist and plastic surgeon are associated with a better prognosis of locally advanced soft tissue sarcomas.
Collapse
Affiliation(s)
- S Bonvalot
- Département de chirurgie oncologique, institut Gustave-Roussy, 39, rue Camille-Desmoulins, 94805 Villejuif, France.
| | | | | | | | | | | | | | | |
Collapse
|
242
|
Singer S, Demetri GD, Baldini EH, Fletcher CD. Management of soft-tissue sarcomas: an overview and update. Lancet Oncol 2000; 1:75-85. [PMID: 11905672 DOI: 10.1016/s1470-2045(00)00016-4] [Citation(s) in RCA: 121] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Soft-tissue sarcomas (STS) are relatively uncommon, especially when considered as individual histological subtypes (of which there are more than 50). Their incidence increases with age, although they are disproportionately common among children. When diagnosed and managed in a non-specialist environment, outcome is generally significantly poorer than if patients are managed by a multidisciplinary team in a tertiary centre of excellence. Prompt referral of patients with clinically suspicious masses is strongly advocated, before any type of intervention is attempted. This brief, opinion-based overview emphasises the team approach and provides a synopsis of the strategies used at our institution for pre-operative assessment and biopsy, surgical management, and the delivery of radiation therapy when appropriate (focusing on limb preservation and optimisation of function). Predictable variations in the natural history of these tumours, based on accurate histological subclassification, merit wider recognition. The role of systemic chemotherapy for soft-tissue sarcoma is still evolving, but at present the main aims are improved local control, disease-free survival, and quality of life. There are overall survival benefits for specific histological types, but this is a relatively small subgroup. Novel therapies, based on disease mechanisms at the molecular level, show promise for future advances.
Collapse
Affiliation(s)
- S Singer
- Division of Surgical Oncology, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA
| | | | | | | |
Collapse
|
243
|
Trovik CS, Gustafson P, Bauer HC, Saeter G, Klepp R, Berlin O, Erlanson M, Wahlström O, Raabe N. Consequences of local recurrence of soft tissue sarcoma: 205 patients from the Scandinavian Sarcoma Group Register. ACTA ORTHOPAEDICA SCANDINAVICA 2000; 71:488-95. [PMID: 11186407 DOI: 10.1080/000164700317381199] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
From the Scandinavian Sarcoma Group Register, information on 1,224 surgically-treated patients with soft tissue sarcoma (STS) of the extremity or trunk wall, diagnosed between 1987 and 1995, was collected. 205 patients, one third of whom were referred to a center with a local recurrence, had a total of 284 local recurrences. This analysis describes the treatment for these local recurrences, complications and risk of further recurrences. 169 patients were surgically treated for their first local recurrence. An intralesional or marginal margin was achieved in 110 of these patients, 59 of whom were also given radiotherapy. 54 of the 169 patients had a second local recurrence. The second local recurrence rate was 0.50 if the first local recurrence had been treated with only surgery with a marginal margin, compared to 0.28 if treated with surgery with a marginal margin and radiotherapy or with a wide margin (p = 0.0008). In extremity STS, the crude amputation rate for local recurrences was 0.22 (31 of 142)-i.e., higher than for primary tumors 0.09 (96 of 1065) (p < 0.0001). A high local recurrence rate after treatment outside of sarcoma centers has earlier been shown. We conclude that the consequences of local recurrence in terms of morbidity and costs justifies referral of STS patients for multidisciplinary evaluation and multimodality treatment.
Collapse
Affiliation(s)
- C S Trovik
- Department of Orthopedics, Haukeland Hospital, Bergen, Norway.
| | | | | | | | | | | | | | | | | |
Collapse
|
244
|
Ciaravino G, Kapp DS, Vela AM, Fulton RS, Lum BL, Teng NNH, Roberts JA. Primary leiomyosarcoma of the vagina. A case report and literature review. Int J Gynecol Cancer 2000; 10:340-347. [PMID: 11240697 DOI: 10.1046/j.1525-1438.2000.010004340.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Primary vaginal leiomyosarcoma is a rare tumor. We report a unique case of a 27-year-old woman with stage I, high-grade primary leiomyosarcoma of the vagina treated with surgical resection and adjuvant radiation therapy. She returned within 6 months with an abdominal-pelvic recurrence and lung metastases. The patient died of disease 9 months after diagnosis. A comprehensive review of primary vaginal leiomyosarcoma was performed and factors affecting survival were analyzed. A Medline search of the English-language literature revealed 66 previously reported cases. Forty-eight of these had follow-up data. Survival probabilities were calculated using the Kaplan-Meier method, and the effects of age, stage, grade, tumor location, and treatment modality were analyzed. Stage III and IV data were combined. The overall 5-year survival rate was 43%. Patients more than 50 years of age had a 5-year survival rate of 26% compared with 51% for those less than 40 years. Five-year survival for stage I and II tumors was 55% and 44%, respectively. Patients with stage III/IV disease had 25% survival at 18 months. No patient treated primarily with chemotherapy or radiation therapy survived beyond 36 months. In contrast, patients treated primarily with surgery had a 5-year survival rate of 57%. Only stage remained an independent predictor of survival on Cox regression analysis. We continue to recommend surgical resection as primary treatment. Exenteration may be an option for select patients, but ultimately management should continue on a case-by-case basis.
Collapse
Affiliation(s)
- G. Ciaravino
- Division of Gynecologic Oncology, Department of Gynecology and Obstetrics, Stanford University School of Medicine, and Departments of Radiation Oncology and Pathology, Clinical Cancer Center, Stanford University Hospital, Stanford, California
| | | | | | | | | | | | | |
Collapse
|