Predictive factors for complete removal in soft tissue sarcomas: a retrospective analysis in a series of 592 cases

Evaluating surgery quality in soft tissue sarcoma

To identify pertinent indicators for oncologic outcomes in assessing surgery in soft tissue sarcomas, only local recurrences are considered here. Functional outcomes and treatment morbidity, equally important end-points for evaluating surgery quality, are less frequently reported and are not taken into account in this review. Herein, we review recent publications reporting indicators of surgery quality in soft tissue sarcoma treatment. Local recurrence-free interval is the major end-point in evaluating the quality of surgery. Disease-free survival should not be used because the risk factors for metastases are different from those for local recurrence. Five-year local recurrence-free estimations for limb and trunk wall sarcoma should be below 20%, and best approach 10%. The risk of local recurrence depends on tumour biology (i.e. grade) and quality of surgery as defined by the quality of margins. Better than margin width as measured on the tumour specimen, margin quality determined consensually between surgeons and pathologists is the best indicator for local outcome. Quality of margin should be expressed according the UICC residual disease definitions (R0: in sano, R1: microscopic residual disease, R2: macroscopic residual disease). Other important indicators for surgery quality are treatment in specialised centres, a planned, organised surgery, and treatment within a multidisciplinary team. Soft tissue sarcoma should also be treated in specialised centres. Surgery quality depends on obtained margins that are determined best by close collaboration between the surgeon and the pathologist.

Soft tissue sarcomas of the trunk wall (STS-TW): a study of 343 patients from the French Sarcoma Group (FSG) database

BACKGROUND

Soft tissue sarcomas of the trunk wall (STS-TW) are usually studied together with soft tissue sarcomas of other locations. We report a study on STS-TW forming part of the French Sarcoma Group database.

PATIENTS AND METHODS

Three hundred and forty-three adults were included. We carried out univariate and multivariate analysis for overall survival (OS), metastasis-free survival (MFS) and local recurrence-free survival (LRFS).

RESULTS

Tumor locations were as follows: thoracic wall, 82.5%; abdominal wall, 12.3% and pelvic wall, 5.2%. Median tumor size was 6.0 cm. The most frequent tumor types were unclassified sarcoma (27.7%) and myogenic sarcoma (19.2%). A total of 44.6% of cases were grade 3. In all, 21.9% of patients had a previous medical history of radiotherapy (PHR). Median follow-up was 7.6 years. The 5-year OS, MFS and LRFS rates were 60.4%, 68.9% and 58.4%, respectively. Multivariate analysis retained PHR and grade for predicting LRFS and PHR, size and grade as prognostic factors of MFS. Factors influencing OS were age, size, PHR, depth, grade and surgical margins. The predictive factors of incomplete response were PHR, size and T3.

CONCLUSIONS

Our results suggest similar classical prognostic factors as compared with sarcomas of other locations. However, a separate analysis of STS-TW revealed a significant poor prognosis subgroup of patients with PHR.

Infiltrative MRI pattern and incomplete initial surgery compromise local control of myxofibrosarcoma

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).

Sarcomes des tissus mous : données anatomopathologiques actuelles

Over the last fifteen years, pathology underwent significant changes in the field of soft tissue tumours. They were related to considerable advances in molecular biology and genetics. New data led to the revision of the WHO classification. Malignant fibrous histiocytoma is no longer considered as an entity. It has split up into several subgroups belonging to liposarcomas, leiomyosarcomas or undifferentiated sarcomas. Haemangiopericytoma underwent reappraisal and was put in the same category as solitary fibrous tumour. Many tools have improved. Immunohistochemistry performed with new antibodies had its specificity increased, and became appropriate for the prediction of therapeutic response in some cases, e.g. CD117 detecting mutations of the c-kit proto-oncogen in gastro-intestinal stromal tumours. Refinement of the techniques allows accurate diagnoses from core needle biopsies. Surgical specimens are collegially examined by surgeons and pathologists with special attention paid to resection margins. Although bound by some limitations, the grading system of the French Federation of Cancer Centers has currently remained the best predictor of metastasis-free survival and overall survival of patients. It is based on an assessment of three parameters: differentiation, amount of necrosis, and mitotic count of tumours. The pathologist sets up a diagnosis, and actively takes part in the prediction of the prognosis and therapeutic response. He is one of the major participants in decision making for multimodal treatment of sarcomas.

Sarcomes des tissus mous des extrémités. Rôle de l'imagerie dans la prise en charge initiale

Soft tissue sarcomas are uncommon heterogeneous group of tumour derived from mesenchym. The most common location is the lower extremity, but they can occur in the upper extremity, and abdominal and chest walls. The first radiological evaluation may include plain films and ultrasonography in viewing to assess the probability of soft tissue sarcomas. MRI with contrast is the main modality to evaluate these lesions and choose which part of tumour must be biopsied. Computer tomography (CT) is secondary used to perform core needle biopsy and detect lung metastases. The role of PET begins to be more clear in case of need global assessment before radical surgery. A multidisciplinary approach is essential to perform rational treatment planning and avoid partial surgery.

Brachytherapy for locally recurrent soft-tissue sarcoma

Radiation is used to reduce potential risk of local recurrence from microscopic residual disease after surgical resection. Brachytherapy is a clinically established means of providing radiation for soft-tissue sarcomas that recur after surgical resection alone or surgical resection and radiation. Although the total dose of radiation that is prescribed is approximately the same for patients undergoing external beam radiation or brachytherapy, the radiobiologic characteristics of brachytherapy, based on the inverse-square law, provide higher doses of radiation to the surgical bed. This provides a theoretical advantage for the use of brachytherapy as compared with external beam radiation among patients with recurrence after surgical resection. When soft-tissue sarcomas recur in a previously irradiated area, further external beam radiation generally is not possible; therefore, brachytherapy allows a radiotherapeutic alternative in an attempt to reduce the risk of further local recurrence. Recommendations for patient selection, the total dose of radiation, and the radiation dose-rate are outlined. Standard grading systems for response, symptoms, and severity of complications should be used.

Treatment-induced pathologic necrosis: a predictor of local recurrence and survival in patients receiving neoadjuvant therapy for high-grade extremity soft tissue sarcomas

PURPOSE

To determine whether treatment-induced pathologic necrosis correlates with local recurrence and overall survival in patients who receive neoadjuvant therapy for high-grade extremity soft tissue sarcomas.

PATIENTS AND METHODS

Four hundred ninety-six patients with intermediate- to high-grade extremity soft tissue sarcomas received protocol neoadjuvant therapy. All patients underwent surgical resection after neoadjuvant therapy and had pathologic assessment of tumor necrosis in the resected specimens.

RESULTS

The 5- and 10-year local recurrence rates for patients with > or = 95% pathologic necrosis were significantly lower (6% and 11%, respectively) than the local recurrence rates for patients with less than 95% pathologic necrosis (17% and 23%, respectively). The 5- and 10-year survival rates for the patients with > or = 95% pathologic necrosis were significantly higher (80% and 71%, respectively) than the survival rates for the patients with less than 95% pathologic necrosis (62% and 55%, respectively). Patients with less than 95% pathologic necrosis were 2.51 times more likely to develop a local recurrence and 1.86 times more likely to die of their disease as compared with patients with > or = 95% pathologic necrosis. The percentage of patients who achieved > or /= 95% pathologic necrosis increased to 48% with the addition of ifosfamide as compared with 13% of the patients in all the other protocols combined.

CONCLUSION

Treatment-induced pathologic necrosis is an independent predictor of both local recurrence and overall survival in patients who receive neoadjuvant therapy for high-grade extremity soft tissue sarcomas. A complete pathologic response (> or = 95% pathologic necrosis) correlated with a significantly lower rate of local recurrence and improved overall survival.

Prognostic factors in localized primary synovial sarcoma: a multicenter study of 128 adult patients

PURPOSE

To identify most significant and therapeutically relevant prognostic factors in adults with localized primary synovial sarcomas (SS) and to confirm the usefulness of the French Federation of Cancer Centers (FNCLCC) grading system, the prognostic impact of which has been already proven in soft tissue sarcomas.

PATIENTS AND METHODS

Data on 128 patients with nonmetastatic SS collected from a cooperative database by the FNCLCC Sarcoma Group between 1980 and 1994 were studied retrospectively. Immunohistochemistry was performed at diagnosis in 77 cases (61%). The tumors were classified as biphasic (n = 45), monophasic fibrous (n = 72), and poorly differentiated (n = 10) subtypes. Histologic grade was determined according to the FNCLCC method, and vascular invasion was assessed in every case.

RESULTS

The 5-year disease-specific survival (DSS) rate for this series of patients with localized SS was 62.9% (+/- 9.6% [SD]) with a median follow-up time of 37 months (range, 8 to 141 months). In multivariate analysis, the adverse risk factors associated with decreased DSS were International Union Against Cancer/American Joint Committee on Cancer stage III/IVA disease, male sex, and truncal tumor locations. For metastasis-free survival (MFS), disease stage III/IVA, tumor necrosis, and monophasic subtypes were the major factors associated with a less favorable prognosis. Separately, when not using disease stage, tumor necrosis, and mitotic activity, histologic grade became the most significant prognostic factor for both DSS and MFS. In addition, larger tumors and older patients become associated with a significantly worse prognosis. Independent adverse risk factors for local recurrence-free survival included histologic grade 3 and truncal tumor location.

CONCLUSION

These data confirm that not all SS present the same severe outcome. High-risk patients identified on the basis of these parameters may qualify for an aggressive treatment approach.