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Seldon C, Grossman JG, Shrivastava G, Fernandez M, Jin W, Conaway S, Rosenberg A, Livingstone A, Franceschi D, Jonczak E, Trent J, Subhawong T, Studenski MT, Yechieli R. CivaSheet® use for soft tissue sarcoma: A single institution experience. Brachytherapy 2023; 22:649-654. [PMID: 37271655 DOI: 10.1016/j.brachy.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 02/28/2023] [Accepted: 03/05/2023] [Indexed: 06/06/2023]
Abstract
OBJECTIVE CivaSheet is a palladium-103, implantable, intraoperative radiation therapy device which emits unidirectional radiation that enables boost doses in patients who have otherwise received the maximum radiation dose. Here, we present our initial clinical experience with the first 10 cases using this new technology. METHODS AND MATERIALS A retrospective chart review of all patients with STS treated with surgical resection and CivaSheet placement at the University of Miami Hospital, a tertiary care center, from January 2018 to December 2019, was performed. Adjuvant radiation was administered by a palladium-103 implant, which delivered an average of 47 Gy (35-55) to a depth of 5 mm. RESULTS Nine patients underwent CivaSheet placement from January 2018 until December 2019 for a total of 10 CivaSheets placed (1 patient had 2 CivaSheets inserted) and followed for a mean of 27 months (4-45 months). Four tumors were located in the retroperitoneum, two in the chest, two in the groin, and two within the lower extremity. At the time of tumor resection and CivaSheet placement, tumor sizes ranged from 2.5 cm to 13.8 cm with an average of 7.6 cm. Four patients necessitated musculocutaneous tissue flaps for closure and reconstruction. All patients with Grade 4 complications had flap reconstruction and prior radiation. Four patients' tumors recurred locally for a local recurrence rate of 40%. Three patients had modified accordion Grade 4 complications necessitating additional surgery for CivaSheet removal. Extremity tumors unanimously developed modified accordion Grade 4 adverse events. CONCLUSIONS CivaSheet may be an acceptable alternative treatment modality compared to prior brachytherapy methods.
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Affiliation(s)
- Crystal Seldon
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL
| | - Julie G Grossman
- Department of Surgical Oncology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL
| | - Gautam Shrivastava
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL
| | - Melanie Fernandez
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL
| | - William Jin
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL
| | - Sheila Conaway
- Department of Orthopedic Surgery, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL
| | - Andrew Rosenberg
- Department of Pathology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL
| | - Alan Livingstone
- Department of Surgical Oncology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL
| | - Dido Franceschi
- Department of Surgical Oncology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL
| | - Emily Jonczak
- Department of Hematology Oncology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL
| | - Jonathan Trent
- Department of Hematology Oncology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL
| | - Ty Subhawong
- Department of Radiology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL
| | - Matthew T Studenski
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL
| | - Raphael Yechieli
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL.
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Abstract
➤ Soft-tissue sarcomas (STS) in adults comprise a heterogeneous group of tumors of mesenchymal origin that share similar biological patterns of local tumor growth and metastatic dissemination. ➤ The judicious use of imaging studies, biopsy techniques, and pathological evaluations is essential for accurate diagnosis and for planning treatment strategy. ➤ Wide local resection and radiation therapy form the cornerstone of management of high-grade STS. The role of adjuvant radiation therapy is questionable in the management of small (≤5 cm) superficial lesions that can be resected with negative margins. Chemotherapy given to patients who have nonmetastatic, high-grade STS results in varying benefit in terms of local tumor control and overall survival. ➤ Coordinated care by a multidisciplinary team of trained surgeons, medical oncologists, radiologists, radiation oncologists, and pathologists has been documented to improve local tumor control and the overall survival of patients with STS. ➤ Although considerable progress in tumor diagnostics and targeted therapies has been made over the past 2 decades, recommendations and controversies relating to tumor imaging and margins of resection have not changed.
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Affiliation(s)
- Jacob Bickels
- Unit of Orthopedic Oncology, Orthopedic Division, Hillel-Yaffe Medical Center, Hadera, Israel, affiliated with the Rappaport Faculty of Medicine, The Technion, Haifa, Israel
| | - Martin M Malawer
- Department of Orthopedic Surgery, Georgetown University School of Medicine, Washington, DC
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Shelby RD, Suarez-Kelly LP, Yu PY, Hughes TM, Ethun CG, Tran TB, Poultsides G, King DM, Bedi M, Mogal H, Clarke C, Tseng J, Roggin KK, Chouliaras K, Votanopoulos K, Krasnick BA, Fields RC, Pollock RE, Howard JH, Cardona K, Grignol V. Neoadjuvant radiation improves margin-negative resection rates in extremity sarcoma but not survival. J Surg Oncol 2020; 121:1249-1258. [PMID: 32232871 DOI: 10.1002/jso.25905] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 02/16/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND OBJECTIVES Radiation improves limb salvage in extremity sarcomas. Timing of radiation therapy remains under investigation. We sought to evaluate the effects of neoadjuvant radiation (NAR) on surgery and survival of patients with extremity sarcomas. MATERIALS AND METHODS A multi-institutional database was used to identify patients with extremity sarcomas undergoing surgical resection from 2000-2016. Patients were categorized by treatment strategy: surgery alone, adjuvant radiation (AR), or NAR. Survival, recurrence, limb salvage, and surgical margin status was analyzed. RESULTS A total of 1483 patients were identified. Most patients receiving radiotherapy had high-grade tumors (82% NAR vs 81% AR vs 60% surgery; P < .001). The radiotherapy groups had more limb-sparing operations (98% AR vs 94% NAR vs 87% surgery; P < .001). NAR resulted in negative margin resections (90% NAR vs 79% surgery vs 75% AR; P < .0001). There were fewer local recurrences in the radiation groups (14% NAR vs 17% AR vs 27% surgery; P = .001). There was no difference in overall or recurrence-free survival between the three groups (OS, P = .132; RFS, P = .227). CONCLUSION In this large study, radiotherapy improved limb salvage rates and decreased local recurrences. Receipt of NAR achieves more margin-negative resections however this did not improve local recurrence or survival rates over.
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Affiliation(s)
- Rita D Shelby
- Department of Surgery, The Ohio State University, Columbus, Ohio
| | | | - Peter Y Yu
- Department of Surgery, The Ohio State University, Columbus, Ohio
| | - Tasha M Hughes
- Department of Surgery, The Ohio State University, Columbus, Ohio
| | - Cecilia G Ethun
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Thuy B Tran
- Department of Surgery, Stanford University, Palo Alto, California
| | | | - David M King
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Meena Bedi
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Harveshp Mogal
- Department of Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - Callisia Clarke
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jennifer Tseng
- Department of Surgery, University of Chicago Medicine, Chicago, Illinois
| | - Kevin K Roggin
- Department of Surgery, University of Chicago Medicine, Chicago, Illinois
| | | | | | - Bradley A Krasnick
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | | | | | - Kenneth Cardona
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Valerie Grignol
- Department of Surgery, The Ohio State University, Columbus, Ohio
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Kang J, Xu M, Wang B, Yu X. Wide resection of soft tissue sarcomas after unplanned primary procedures: A long-term follow-up study. Medicine (Baltimore) 2020; 99:e19067. [PMID: 32080080 PMCID: PMC7034676 DOI: 10.1097/md.0000000000019067] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Unplanned resection of soft-tissue sarcomas (STS) predispose the patients to recurrences and metastases, secondary wide resection is usually warranted.To investigate the outcomes of re-excision of STS after unplanned initial resection.The records of 39 patients undergoing re-excision of STS after unplanned initial resection from January 2006 through December 2015 were retrospectively investigated.There were 17 males and 22 females, the mean age was 45.7 years. Most initial unplanned resections were performed in rural hospitals by surgeons from general surgery department, dermatology department, plastic surgery department, and orthopedic department. Thirty-five patients underwent secondary wide resections in our department. Histopathological findings indicated positive margins after primary surgeries in 18 patients. Until the conclusion of 37.2-month follow-up, 7 patients developed metastasis, 3 had local recurrence, and 7 were dead. Positive margins were associated with increased metastases and lower survival rates (P < .05). There was no significant difference in recurrences between the 2 groups.Unplanned initial resection of STS often lead to unfavorable prognosis. Primary wide resections are warranted for this disease entity.
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A Meta-Analysis of the Association Between Radiation Therapy and Survival for Surgically Resected Soft-Tissue Sarcoma. Am J Clin Oncol 2019; 41:348-356. [PMID: 26886948 DOI: 10.1097/coc.0000000000000274] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Radiotherapy for soft-tissue sarcoma (STS) has been shown to reduce local recurrence, but without clear improvement in survival. We conducted a meta-analysis to study the association between radiotherapy and survival in patients undergoing surgery for STS. METHODS A systematic review was conducted from PubMed, EMBASE, Web of Science, and Cochrane databases. Our population of interest consisted of adults with primary extremity, chest wall, trunk, or back STS. Our metameters were either an odds or hazard ratio for mortality. A bias score was generated for each study based on margin status and grade. RESULTS Of 1044 studies, 30 met inclusion criteria for final analysis. The pooled odds ratio in patients receiving radiation was 0.94 (95% confidence interval [CI], 0.78-1.14). The pooled estimate of the hazards ratio in patients receiving radiation was 0.87 (95% CI, 0.73-1.03) overall and 0.65 (95% CI, 0.52-0.82) for studies judged to be at low risk of bias. Significant publication bias was not seen. CONCLUSIONS High-quality studies reporting adjusted hazard ratios are associated with improved survival in patients receiving radiotherapy for STS. Studies in which odds ratios are calculated from event data and those that do not report adjusted outcomes do not show the same association, likely due to confounding by indication.
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Crompton JG, Ogura K, Bernthal NM, Kawai A, Eilber FC. Local Control of Soft Tissue and Bone Sarcomas. J Clin Oncol 2018; 36:111-117. [DOI: 10.1200/jco.2017.75.2717] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Sarcomas of soft tissue and bone are mesenchymal malignancies that can arise in any anatomic location, most commonly the extremity, retroperitoneum, and trunk. Even for lower grade histologic subtypes, local recurrence can cause significant morbidity and even disease-related death. Although surgery remains the cornerstone of local control, perioperative radiation and systemic therapy are often important adjuvants. This review will summarize the current therapeutic approaches for local control of soft tissue and bone sarcomas.
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Affiliation(s)
- Joseph G. Crompton
- Joseph G. Crompton, Nicholas M. Bernthal, and Fritz C. Eilber, University of California Los Angeles, Los Angeles, CA; and Koichi Ogura and Akira Kawai, National Cancer Center Hospital, Tokyo, Japan
| | - Koichi Ogura
- Joseph G. Crompton, Nicholas M. Bernthal, and Fritz C. Eilber, University of California Los Angeles, Los Angeles, CA; and Koichi Ogura and Akira Kawai, National Cancer Center Hospital, Tokyo, Japan
| | - Nicholas M. Bernthal
- Joseph G. Crompton, Nicholas M. Bernthal, and Fritz C. Eilber, University of California Los Angeles, Los Angeles, CA; and Koichi Ogura and Akira Kawai, National Cancer Center Hospital, Tokyo, Japan
| | - Akira Kawai
- Joseph G. Crompton, Nicholas M. Bernthal, and Fritz C. Eilber, University of California Los Angeles, Los Angeles, CA; and Koichi Ogura and Akira Kawai, National Cancer Center Hospital, Tokyo, Japan
| | - Fritz C. Eilber
- Joseph G. Crompton, Nicholas M. Bernthal, and Fritz C. Eilber, University of California Los Angeles, Los Angeles, CA; and Koichi Ogura and Akira Kawai, National Cancer Center Hospital, Tokyo, Japan
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Multidisciplinary Approach to Salvage of Unplanned Sarcoma Resections. Sarcoma 2017. [DOI: 10.1007/978-3-319-43121-5_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Shurell E, Vergara-Lluri ME, Li Y, Crompton JG, Singh A, Bernthal N, Wu H, Eilber FC, Dry SM. Comprehensive adipocytic and neurogenic tissue microarray analysis of NY-ESO-1 expression - a promising immunotherapy target in malignant peripheral nerve sheath tumor and liposarcoma. Oncotarget 2016; 7:72860-72867. [PMID: 27655679 PMCID: PMC5341949 DOI: 10.18632/oncotarget.12096] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 09/09/2016] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Immunotherapy targeting cancer-testis antigen NY-ESO-1 shows promise for tumors with poor response to chemoradiation. Malignant peripheral nerve sheath tumors (MPNSTs) and liposarcomas (LPS) are chemoresistant and have few effective treatment options. Materials Methods: Using a comprehensive tissue microarray (TMA) of both benign and malignant tumors in primary, recurrent, and metastatic samples, we examined NY-ESO-1 expression in peripheral nerve sheath tumor (PNST) and adipocytic tumors. The PNST TMA included 42 MPNSTs (spontaneous n = 26, NF1-associated n = 16), 35 neurofibromas (spontaneous n = 22, NF-1 associated n = 13), 11 schwannomas, and 18 normal nerves. The LPS TMA included 48 well-differentiated/dedifferentiated (WD/DD) LPS, 13 myxoid/round cell LPS, 3 pleomorphic LPS, 8 lipomas, 1 myelolipoma, and 3 normal adipocytic tissue samples. Stained in triplicate, NY-ESO-1 intensity and density were scored. RESULTS NY-ESO-1 expression was exclusive to malignant tumors. 100% of myxoid/round cell LPS demonstrated NY-ESO-1 expression, while only 6% of WD/DD LPS showed protein expression, one of which was WD LPS. Of MPNST, 4/26 (15%) spontaneous and 2/16 (12%) NF1-associated MPNSTs demonstrated NY-ESO-1 expression. Strong NY-ESO-1 expression was observed in myxoid/round cell and dedifferentiated LPS, and MPNST in primary, neoadjuvant, and metastatic settings. CONCLUSIONS We found higher prevalence of NY-ESO-1 expression in MPNSTs than previously reported, highlighting a subset of MPNST patients who may benefit from immunotherapy. This study expands our understanding of NY-ESO-1 in WD/DD LPS and is the first demonstration of staining in a WD LPS and metastatic/recurrent myxoid/round cell LPS. These results suggest immunotherapy targeting NY-ESO-1 may benefit patients with aggressive tumors resistant to conventional therapy.
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Affiliation(s)
- Elizabeth Shurell
- Division of Surgical Oncology, University of California, Los Angeles, CA 90095, USA
| | - Maria E. Vergara-Lluri
- Department of Pathology and Laboratory Medicine, University of California, Los Angeles, CA 90095, USA
| | - Yunfeng Li
- Department of Molecular and Medical Pharmacology, University of California, Los Angeles, CA 90095, USA
| | - Joseph G. Crompton
- Division of Surgical Oncology, University of California, Los Angeles, CA 90095, USA
| | - Arun Singh
- Department of Hematology/Oncology, University of California, Los Angeles, CA 90095, USA
| | - Nicholas Bernthal
- Department of Orthopaedic Surgery, University of California, Los Angeles, CA 90095, USA
| | - Hong Wu
- Department of Molecular and Medical Pharmacology, University of California, Los Angeles, CA 90095, USA
| | - Fritz C. Eilber
- Division of Surgical Oncology, University of California, Los Angeles, CA 90095, USA
| | - Sarah M. Dry
- Department of Pathology and Laboratory Medicine, University of California, Los Angeles, CA 90095, USA
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Harati K, Kirchhoff P, Behr B, Daigeler A, Goertz O, Hirsch T, Lehnhardt M, Ring A. Soft tissue sarcomas of the distal lower extremities: A single-institutional analysis of the prognostic significance of surgical margins in 120 patients. Oncol Rep 2016; 36:863-70. [DOI: 10.3892/or.2016.4862] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Accepted: 05/23/2016] [Indexed: 11/06/2022] Open
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Koulaxouzidis G, Schwarzkopf E, Bannasch H, Stark GB. Is revisional surgery mandatory when an unexpected sarcoma diagnosis is made following primary surgery? World J Surg Oncol 2015; 13:306. [PMID: 26499785 PMCID: PMC4619444 DOI: 10.1186/s12957-015-0719-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 10/12/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Soft tissue sarcomas (STS) are often diagnosed unexpectedly after surgery, and many excisions are incomplete. As histopathological assessments are challenging, patients later referred to comprehensive cancer centers (CCC) often come with an unclear status. This can make treatment planning problematic. We investigated the reliability of primary histopathological assessments, whether revisional surgery improved resection status, and the prognostic value of residual tumor at re-excision. METHODS We analyzed the demographic and clinical characteristics of all patients referred to our CCC between 2003 and 2013. We compared patients treated exclusively at our CCC with those who had primary surgery elsewhere, and focused on resection margins, re-excision type, residual tumor, resection status after re-excision, and oncological outcome. RESULTS Over half (n = 110) of all patients (n = 204) were referred from elsewhere. Seventy-one had undergone an excision without suspicion of malignancy. Resection status in referred patients was significantly inferior to the CCC group (p < 0.0001), although the latter had significantly more serious tumors and advanced disease stages (p < 0.05). The residual tumor rate was 53.13%, with a significantly higher probability in an upper extremity (p = 0.001). Initial histopathological classification was misleading in 46.9% of cases. Re-excision improved resection status in 69% of cases. Residual tumor presumably leads to higher rates of local recurrence (p = 0.057) and significantly shorter times to recurrence (p < 0.05). CONCLUSIONS Re-excision should always follow unplanned STS excisions. Resection margins and histopathological assessments from referring institutions are often unreliable and unsuitable for treatment planning. Residual tumor is a risk factor for earlier and more likely local recurrence.
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Affiliation(s)
- Georgios Koulaxouzidis
- Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Freiburg, Germany.
| | - Eugenia Schwarzkopf
- Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Freiburg, Germany
| | - Holger Bannasch
- Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Freiburg, Germany.,Comprehensive Cancer Center Freiburg (CCCF), Section Plastic and Reconstructive Tumour Surgery, University of Freiburg Medical Center, Freiburg, Germany
| | - G Björn Stark
- Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Freiburg, Germany
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Abstract
Sarcomas are uncommon malignancies accounting for about 1% of all adult malignancies. Sarcomas are a heterogeneous group of tumors which includes more than 100 different subtypes. Surgery is the mainstay therapy for localized disease. In selected patients the combination of surgery with radiotherapy achieves better local control and offers the best chance of cure. Systemic treatment including cytotoxic chemotherapy or targeted therapies remains the mainstay therapy for most patients with advanced disease. There are a wide variety of clinical situations, such that an individualized treatment plan must be defined by a multidisciplinary tumor board. Treatment decisions should take into consideration the histology, site of disease, stage, performance status, treatment goals, and the patient’s wishes. The management of patients should be carried out in a center with expertise in the treatment of sarcomas for optimal outcome. This review will cover the different treatment modalities of adult soft tissue sarcomas.
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Cipriano CA, Wunder JS, Ferguson PC. Surgical Management of Soft Tissue Sarcomas of the Extremities. ACTA ACUST UNITED AC 2014. [DOI: 10.1053/j.oto.2014.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Long-term outcome after local recurrence of soft tissue sarcoma: a retrospective analysis of factors predictive of survival in 135 patients with locally recurrent soft tissue sarcoma. Br J Cancer 2014; 110:1456-64. [PMID: 24481401 PMCID: PMC3960604 DOI: 10.1038/bjc.2014.21] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Revised: 12/08/2013] [Accepted: 01/06/2014] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The aim of this study was to identify prognostic indicators of survival in patients with locally recurrent soft tissue sarcoma (STS) through a long-term follow-up. METHODS We retrospectively assessed the relationship between post-recurrence survival (PRS) and potential prognostic factors in 135 patients who had experienced local recurrence, which was suitable for further surgical treatment. The median follow-up time after initial recurrence was 12.3 years (95% confidence interval (CI): 10.4-14.2 years). RESULTS The 5-year estimate of the PRS rate was 53.1% (95% CI: 44.3-61.2%) for the entire series. Patients with negative margins after the final surgery experienced improved survival compared with patients with positive margins (5-year survival: 46.7% (35.2-57.5%) vs 35.5% (23.4-47.8%); P=0.01). In a multivariate analysis, the significant prognostic indicators for PRS were histologic grade, tumour site, time to initial recurrence, the number of recurrences and the surgical margin status attained at the last resection. CONCLUSIONS Complete surgical resection with microscopically clear margins is desirable in patients with locally recurrent STS. However, when achieving clear surgical margins will require major functional impairment of the extremity, a radical surgical approach should be weighed for the patient in each case.
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Abstract
Soft tissue sarcomas are a diverse and rare group of neoplasms often found in the extremities. Treatment is best carried out in regional cancer centers by a multidisciplinary group with a common interest in these disorders. Treatment is usually surgical, with radiation used in select cases to try to reduce the risk of local recurrence. The role of chemotherapy is controversial, but it may be useful in patients at highest risk of developing metastatic disease. The development of newer forms of targeted systemic therapy and techniques to reduce the morbidity from local treatment to the extremity are areas of intense research interest.
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Affiliation(s)
- Paul Clarkson
- University of Toronto, Mount Sinai Hospital, 600 University Ave, Suite 476G, Toronto, ON, M5G 1X5, Canada.
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Khandekar MJ, Raut CP, Hornick JL, Wang Q, Alexander BM, Baldini EH. Paratesticular liposarcoma: unusual patterns of recurrence and importance of margins. Ann Surg Oncol 2013; 20:2148-55. [PMID: 23591942 DOI: 10.1245/s10434-013-2963-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND Paratesticular liposarcoma (LPS) is a rare entity for which optimal treatment has not been defined. We sought to determine recurrence patterns and prognostic factors. METHODS A total of 25 patients with localized paratesticular LPS between 1987 and 2009 were reviewed. Actuarial local-recurrence-free survival (LRFS), disease-free-survival (DFS), and overall survival (OS) were determined using the Kaplan-Meier method. RESULTS LPS histology was well differentiated for 10 patients (40 %), de-differentiated for 14 (56 %), and pleomorphic for 1 (4 %). Final margins were positive in 8 patients (32 %). Radiation therapy (RT) was given to 10 patients; fields included inguinal canal ± scrotum and low pelvis. LRFS rates at 3 and 5 years were 76 and 67 %. The 3-year LRFS rates were lower in patients with positive margins compared with those with negative margins (29 vs 100 %, p = .0005) and in patients with recurrent versus primary disease (38 vs 83 %, p = .04). Among patients who received surgery and RT, margins remained a significant predictor of local recurrence (p = .009). Interestingly, recurrences in 4 patients tracked along gonadal vessels, and only 1 patient had a distant recurrence. OS at 5 years was 100 %. CONCLUSIONS For patients with localized paratesticular LPS, positive margins and presentation with recurrent disease are adverse prognostic factors for LRFS. LR for patients with positive margins is still high despite RT; thus aggressive surgery to attain negative margins should be attempted in all cases. The finding of regional recurrences along gonadal vessels should be validated, and imaging studies should be tailored to reflect potential patterns of disease at presentation and subsequent recurrence.
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Affiliation(s)
- Melin J Khandekar
- Harvard Radiation Oncology Program, Brigham and Women's Hospital, Boston, MA, USA
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Compartmental resection for subfascial extremity soft tissue sarcoma and quality of life in long-term survivors. Wien Klin Wochenschr 2011; 123:488-95. [DOI: 10.1007/s00508-011-1592-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Accepted: 03/28/2011] [Indexed: 11/12/2022]
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Retrospective trial of complete decongestive physical therapy for lower extremity secondary lymphedema in melanoma patients. Support Care Cancer 2010; 19:141-7. [DOI: 10.1007/s00520-009-0803-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2009] [Accepted: 12/15/2009] [Indexed: 10/20/2022]
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Reexcision of Soft Tissue Sarcoma: Sufficient Local Control but Increased Rate of Metastasis. World J Surg 2009; 33:2599-605. [DOI: 10.1007/s00268-009-0262-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Trovik CS, Bauer HC, Berlin O, Tukiainen E, Erlanson M, Gustafson P, Klepp R, Saeter G, Wahlström O. Local recurrence of deep-seated, high-grade, soft tissue sarcoma: 459 patients from the Scandinavian Sarcoma Group Register. ACTA ACUST UNITED AC 2009; 72:160-6. [PMID: 11372947 DOI: 10.1080/000164701317323417] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
This study was based on 459 adult patients with deep, high-grade, soft tissue sarcoma of extremities or trunk wall reported to the Scandinavian Sarcoma Group Register (1986-1993). All patients had their definitive surgery for primary tumor at a sarcoma center. The median follow-up was 7.5 (3-12) years. 204 patients are still alive. 68 patients had amputations and 391 underwent limb-sparing surgery. Among 183 patients with intralesional or marginal margins after limb-sparing surgery, 65% had postoperative radiotherapy and 9% of the 198 patients with wide margins. The local recurrence rate after limb-sparing surgery was 26%. The rate with an intralesional or marginal margin was 39% without postoperative radiotherapy versus 24% when radiotherapy was given. It was 25% after a wide margin, and no recurrences were noted among the 10 patients with a compartmental surgical margin. Among patients with a wide margin, a subset fulfilling criteria for a myectomy was defined. The local recurrence rate was 26% among these 62 and there was no advantage of myectomy over other wide margins. More radical surgical margins would improve the local recurrence rate, but this can hardly be achieved in center-operated patients without increasing the amputation rate. Instead, increased use of radiotherapy in all patients with inadequate margins, and to a larger extent in those with wide margins will improve local control.
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Affiliation(s)
- C S Trovik
- Department of Orthopedics, Haukeland University Hospital, Bergen, Norway.
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22
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Cahlon O, Spierer M, Brennan MF, Singer S, Alektiar KM. Long-term outcomes in extremity soft tissue sarcoma after a pathologically negative re-resection and without radiotherapy. Cancer 2008; 112:2774-9. [PMID: 18429001 DOI: 10.1002/cncr.23493] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The purpose was to define the rate of local recurrence (LR) and identify prognostic factors for LR in patients with extremity soft-tissue sarcoma (STS) treated with limb-sparing surgery and a pathologically negative re-resection specimen without radiotherapy (RT). METHODS A review of the prospective sarcoma database identified 200 patients with primary, nonmetastatic, extremity STS treated with limb-sparing surgery between June 1982 and December 2002 who had a pathologically confirmed negative re-resection. None of the patients had adjuvant RT. Univariate and multivariate analyses were performed to determine clinicopathologic factors associated with LR. RESULTS With a median follow-up of 82 months the 5-year actuarial LR rate was 9%. Factors associated with higher LR rates on univariate and multivariate analysis were older age, stage III presentation, and histology. The 5-year LR rate was 5% for those<50 compared with 15% for those>or=50 (P=.001). For patients with stage III the LR rate was 26% versus 7% for those with stage I/II (P<.001). On multivariate analysis only age>or=50 (relative risk [RR] 3.3; P=.02) and stage III disease (RR 3.4; P=.01) remained significant predictors for LR. When the cohort of patients was divided into 3 groups based on the number of risk factors present, the 5-year LRs were as follows: no risk factors (stage I/II and<50 years old) 4%, 1 risk factor (stage III or>or=50) 12%, and 2 risk factors (stage III and>or=50) 31% (P<.01). CONCLUSIONS Patients with a pathologically negative re-excision represent a heterogeneous group. Whereas the overall rate of local recurrence at 5 years was 9% for the entire cohort, patients with older age and/or stage III disease had a higher rate of LR. Therefore, treatment decisions especially with regard to adjuvant RT should be individualized and not be based solely on the finding of a negative re-resection.
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Affiliation(s)
- Oren Cahlon
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
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23
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Kretschmer T, Antoniadis G, Heinen C, Börm W, Scheller C, Richter HP, Koenig RW. Nerve sheath tumor surgery: case-guided discussion of ambiguous findings, appropriateness of removal, repeated surgery, and nerve repairs. Neurosurg Focus 2007; 22:E19. [PMID: 17613210 DOI: 10.3171/foc.2007.22.6.20] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
✓In this article the authors attempt to raise awareness of the pitfalls and controversial issues in nerve tumor surgery. In a case-guided format, examples of ambiguous findings, inappropriate tumor removal, repeated surgery, and nerve repairs are provided. The authors also discuss the need to establish a correct diagnosis preoperatively and to avoid the erroneous identification of malignant peripheral nerve sheath tumors (MPNSTs). They emphasize that not all of the principles of soft tissue sarcoma treatment protocols are applicable to MPNST. A situation of repeated surgery for supposedly malignant tumor is described, and an outline of the indications for, and an approach to, repair after lesion removal is given.
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Efstathopoulos N, Lazarettos J, Nikolaou V, Chronopoulos E. Inflammatory leiomyosarcoma of the ankle: a case report and review of the literature. J Foot Ankle Surg 2006; 45:127-30. [PMID: 16513508 DOI: 10.1053/j.jfas.2005.12.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Inflammatory leiomyosarcoma is a rare morphologic expression of smooth muscle tumor, which is more often found in the trunk, extremities, and retroperitoneoum. We present a case of inflammatory leiomyosarcoma arising near the ankle joint, superior to the medial malleolus, in a 55-year-old man. Immunohistochemistry, electron microscopy, and cytogenetics were used in the differentiation of this rare morphologic expression of leiomyosarcoma. As in all soft tissue leiomyosarcomas, the accurate prediction of the clinical behavior of this morphologic expression often proves to be difficult. Age, vascular invasion, depth, grade, tumor disruption, size, and stage have prognostic value. Nevertheless, prognosis of inflammatory leiomyosarcoma seems to be favorable when treated early with wide excision of the tumor as in the case presented. Sixteen months after excision of the tumor the patient is doing well with no signs of recurrence.
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Affiliation(s)
- Nicolas Efstathopoulos
- 2nd Orthopaedic Department, Athens University, Agia Olga Hospital, 45 Spefsippou Str., 106 76 Kolonaki, Athens, Greece.
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25
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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.
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Affiliation(s)
- Marco Fiore
- Department of Surgery, Istituto Nazionale per lo Studio e la Cura dei Tumori, Via Venezian, 1, Milan, 20133, Italy
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26
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Grunhagen DJ, de Wilt JHW, Graveland WJ, Verhoef C, van Geel AN, Eggermont AMM. Outcome and prognostic factor analysis of 217 consecutive isolated limb perfusions with tumor necrosis factor-α and melphalan for limb-threatening soft tissue sarcoma. Cancer 2006; 106:1776-84. [PMID: 16541435 DOI: 10.1002/cncr.21802] [Citation(s) in RCA: 115] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Extensive and mutilating surgery is often required for locally advanced soft tissue sarcoma (STS) of the limb. As it has become apparent that amputation for STS does not improve survival rates, the interest in limb-preserving approaches has increased. Isolated limb perfusion (ILP) with tumor necrosis factor-alpha (TNF) and melphalan is successful in providing local tumor control and enables limb-preserving surgery in a majority of cases. A mature, large, single-institution experience with 217 consecutive ILPs for STS of the extremity is reported. METHODS At a prospectively maintained database at a tertiary referral center, 217 ILPs were performed from July 1991 to July 2003 in 197 patients with locally advanced STS of the extremity. ILPs were performed at mild hyperthermic conditions with 1-4 mg of TNF and 10-13 mg/L limb-volume melphalan (M) for leg and arm perfusions, respectively. RESULTS The overall response rate was 75%. Limb salvage was achieved in 87% of the perfused limbs. Median survival post-ILP was 57 months and prognostic factors for survival were Trojani grade of the tumor and ILP for single versus multiple STS. The procedure could be performed safely, with a perioperative mortality of 0.5% in all patients with no age limit (median age, 54 yrs; range, 12-91). Systemic and locoregional toxicity were modest and easily manageable. CONCLUSION TNF+M-based ILP can provide limb salvage in a significant percentage of patients with locally advanced STS and has therefore gained a permanent place in the multimodality treatment of STS.
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Affiliation(s)
- Dirk J Grunhagen
- Department of Surgical Oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, The Netherlands
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27
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ATALAY C, CETIN B, ZARALI O, ALTINOK M. The impact of re-excision on survival after unplanned resection in extremity soft tissue sarcomas. Asia Pac J Clin Oncol 2005. [DOI: 10.1111/j.1743-7563.2005.00013.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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28
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Höckel M, Dornhöfer N. The hydra phenomenon of cancer: why tumors recur locally after microscopically complete resection. Cancer Res 2005; 65:2997-3002. [PMID: 15833823 DOI: 10.1158/0008-5472.can-04-3868] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
After surgical resection with microscopically clear margins, solid malignant tumors recur locally in up to 50%. Although the effect of a local tumor recurrence on the overall survival may be low in common cancers such as carcinoma of the breast or prostate, the affected patients suffer from exacerbated fear and the burden of the secondary treatment. With some tumor entities such as carcinoma of the uterine cervix or carcinoma of the head and neck, a local recurrence indicates incurability in the majority of cases. The pathomechanisms of local tumor spread and relapse formation are still unclear and comparatively little research has been devoted to their elucidation. Through the analysis of clinical and molecular data, we propose the concept of two pathogenetically and prognostically different local relapse types (i) in situ recurrences that arise in the residual organ/organ system not involved in the surgery for the primary tumor and (ii) scar recurrences that develop at the site of previous tumor resection. Whereas field cancerization, the monoclonal or multiclonal displacement of normal epithelium by a genetically altered but microscopically undistinguishable homologue, may explain the origin of in situ recurrences, most scar recurrences are regarded as the result of the interaction of minimal residual microscopically occult cancer with the surgical wound environment inside a developmentally defined tissue or organ compartment. The therapeutic implications derived from these concepts and areas of future research aimed to reduce local relapses are discussed in this perspective.
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Affiliation(s)
- Michael Höckel
- Department of Obstetrics and Gynecology, University of Leipzig, Philipp-Rosenthal-Str. 55, 04103F, Leipzig, Germany.
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29
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Clarkson P, Ferguson PC. Primary multidisciplinary management of extremity soft tissue sarcomas. Curr Treat Options Oncol 2005; 5:451-62. [PMID: 15509479 DOI: 10.1007/s11864-004-0034-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Soft tissue sarcomas (STS) are a rare and heterogeneous group of malignancies that most commonly present as large painless masses deep in the muscular compartments of the extremities. Investigation and treatment of these patients must be undertaken at a tertiary referral unit. Staging studies must include a high-quality magnetic resonance imaging (MRI) scan of the local site and a computed tomography (CT) scan of the chest to investigate for possible metastatic disease. Review of biopsy material must be undertaken by an experienced musculoskeletal pathologist. Currently, histologic diagnosis and grade are assigned to the tumor, but in tumors such as synovial sarcoma and Ewing's family of tumors, molecular evaluation is becoming crucial for diagnostic, prognostic, and therapeutic reasons. Surgical resection of sarcomas with negative surgical margins remains the mainstay of treatment. Surgical treatment alone is indicated for small superficial masses that are not adjacent to bone or neurovascular structures. However, in large deep masses where surgical margins are likely to be close in order to preserve important neurovascular structures and bone, combined treatment using surgical resection and radiation results in acceptable local control rates and reasonable patient function. It is incumbent on the management team to decide on timing of radiotherapy as a practice. This decision is based on several factors but potential complications must be taken into account. In this regard the long-term effects on normal tissues must be considered. Functional outcome has become an essential consideration when recommending treatment. If promising techniques become available to reduce the incidence of wound complications or to decrease the dose of radiation to normal tissue, preoperative radiation should be considered in light of its lower incidence of long-term effects that result in reduction in patient function.
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Affiliation(s)
- Paul Clarkson
- Department of Surgery, Mount Sinai Hospital and University of Toronto, Ontario, Canada
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30
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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.
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Affiliation(s)
- Thomas F DeLaney
- Northeast Proton Therapy Center, Massachusetts General Hospital, 30 Fruit Street, Boston, MA 02114, USA.
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31
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Manoso MW, Frassica DA, Deune EG, Frassica FJ. Outcomes of re-excision after unplanned excisions of soft-tissue sarcomas. J Surg Oncol 2005; 91:153-8. [PMID: 16118773 DOI: 10.1002/jso.20323] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND AND OBJECTIVES Unplanned excisions of soft-tissue sarcomas of the extremities occur commonly. Our goal was to evaluate the presence of residual disease, the treatment outcomes as they relate to local and distant recurrence and 5-year survival, and the limb functional outcomes in patients with unplanned sarcoma excision who were treated with re-excision and adjuvant therapy. METHODS Between 1993 and 1999, 42 patients presented to our institution after unplanned excision of soft-tissue sarcomas. Of those 42 patients, 38 without gross residual disease or metastatic lesions formed the basis of this review. All 38 patients underwent revision wide excision; most (31) also received adjuvant therapy (radiation and/or chemotherapy). Clinical data were obtained from analysis of patient records and radiographic studies. Univariate analysis was performed with logistical regression, and multivariate analysis was performed with Cox modeling. RESULTS The overall 5-year survival rate was 91.3% and the disease-free 5-year survival rate was 82.2%. Univariate analysis showed that stage-III disease (American Joint Committee on Cancer classification of soft-tissue sarcomas), lesions below the fascia, a histologic high-grade, and the development of organ metastasis were statistically significant factors for mortality. Stage-III disease also was significant for mortality on multivariate analysis. Only stage-III disease was significant for the development of local recurrence. Eighty-four percent of the patients had good to excellent functional outcomes. CONCLUSIONS Re-excision with adjuvant therapy proved to be a safe and effective method for treating the disease and preserving limb function.
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Affiliation(s)
- Mark W Manoso
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD 21224, USA
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32
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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.
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Affiliation(s)
- Michelle A Ghert
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, 600 University Avenue, Suite 476E, Toronto, Ontario, M5G 1X5, Canada
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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.
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Affiliation(s)
- Peter C Ferguson
- University of Toronto and Mount Sinai Hospital, 600 University Ave., Suite 476G, Toronto, Ont., Canada.
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Massi D, Beltrami G, Mela MM, Pertici M, Capanna R, Franchi A. Prognostic factors in soft tissue leiomyosarcoma of the extremities: a retrospective analysis of 42 cases. Eur J Surg Oncol 2004; 30:565-72. [PMID: 15135488 DOI: 10.1016/j.ejso.2004.03.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2004] [Indexed: 01/15/2023] Open
Abstract
AIMS Soft tissue leiomyosarcomas (LMS) are rare tumours which are associated with a poor prognosis. The goals of the present study were to describe the clinico-pathological and prognostic features of 42 patients affected by soft tissue LMS of the extremities. METHODS The following clinical and pathological parameters were analysed: age, sex, site, size, depth, previous surgical procedures, stage, histological type, nuclear atypia, grade, mitotic activity, necrosis, surgical margins, therapy. Disease-free survival rates were calculated. RESULTS The overall 2-year and 5-year disease free survival rates were 42.3% and 32.6%, respectively. By univariate analysis, tumour size (< or =10 cm vs. >10 cm; p = 0.01), average mitotic rate (< or =19/10 HPF vs. >19/10 HPF; p = 0.05), type of excision (wide vs. marginal or intralesional; p = 0.001) and adjuvant radiotherapy (none vs. brachytherapy+external beam radiotherapy vs. external beam radiotherapy; p = 0.02) were significantly correlated with disease progression. By multivariate analysis, the only factor that was found to be an independent predictor of disease relapse was type of excision (p = 0.001). CONCLUSIONS Large tumour size and high mitotic rate resulted adverse prognostic factors. Adjuvant radiation therapy, in combination with wide surgical excision, allowed the best chance of cure.
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Affiliation(s)
- D Massi
- Department of Human Pathology and Oncology, University of Florence, Viale Morgagni, 85, 50134 Firenze, Italy
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Khanfir K, Alzieu L, Terrier P, Le Péchoux C, Bonvalot S, Vanel D, Le Cesne A. Does adjuvant radiation therapy increase loco-regional control after optimal resection of soft-tissue sarcoma of the extremities? Eur J Cancer 2003; 39:1872-80. [PMID: 12932665 DOI: 10.1016/s0959-8049(03)00426-x] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Adjuvant radiotherapy (RT) is routinely recommended for most soft-tissue sarcomas (STS) of the extremities. However, its impact on local control is not clearly established after wide complete excision. We performed a retrospective analysis of patients who underwent wide resection in our institution (first or second resection in cases of incomplete surgery) and either did or did not receive adjuvant RT. All histological specimens of patients operated upon between 1975 and 1996 were carefully analysed and only patients with free tumour margins (ftm) were retained for the analysis. The histopathological classification was as follows: minimal resection (mR) (ftm<10 mm) and optimal resection (oR) (ftm >/=10 mm). There were 133 patients with a median age of 44 years (range 16-88 years). The median tumour size was 6 cm (range 1-20 cm) with 28, 44 and 28% of stage I, II and III lesions, respectively. 93 patients (70%) were reoperated upon and residual tumour was found in 55% of the patients (51/93). 69 patients (17 oR and 52 mR) received adjuvant RT and 64 patients did not (54 oR and 10 mR). Other patient characteristics (age, tumour size, stage, deep-seated lesion, histoprognostic grade, adjuvant chemotherapy) were similar in both the RT and no-RT groups. Median follow-up was 10 years (3-25 years). The 5- and 10-year local relapse-free survival rates were 78 and 71%, respectively. 33 patients relapsed locally: 11 in the RT group and 22 patients in the control group (P=0.01). In the univariate analysis, adjuvant RT was correlated with relapse-free survival, while tumour grade and tumour margin status were correlated with overall survival. The multivariate analysis demonstrated a favourable impact of RT and negative influence of malignant fibrous histiocytoma (MFH) on local relapse-free survival; the tumour grade was correlated with overall survival. RT had a positive influence on local control exclusively in patients with mR resection (P=0.005) and in patients with residual tumour cells after re-excision (P=0.001). RT had no influence on 5- and 10-year overall survival. The 5- and 10-year overall survival for the entire population were 77 and 67%, respectively. Optimal resection seems to be the best predictive parameter for a favourable outcome in localised STS. Adjuvant RT is indicated after mR resection and for residual tumour after definitive surgery, but its role after oR resection (primary resection or no residual tumour after re-excision) should be evaluated in a prospective randomised trial.
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Affiliation(s)
- K Khanfir
- Department of Radiotherapy, Institut Gustave Roussy, 94805 Villejuif, France
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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.
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Karakousis CP, Zografos GC. Radiation therapy for high grade soft tissue sarcomas of the extremities treated with limb-preserving surgery. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2002; 28:431-6. [PMID: 12099655 DOI: 10.1053/ejso.2002.1264] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM It is common to use either pre- or post-operative radiation for high grade sarcomas undergoing limb-conserving surgery. Since 1977, we have adopted a selective policy of post-operative radiation, given only in patients with inadequate surgical margins. METHODS A retrospective review of 114 patients (1977-1995) with high grade adult soft tissue sarcomas of the extremities was carried out. Amputation was required in 10 (9%). Patients with a minimum surgical margin <2 cm (n=33) received adjuvant radiation (29%). RESULTS No complications occurred in 81/114. Wound complications were infection (14%), seroma (6%), haematoma (4%), dehiscence (4%) and skin edge necrosis (2%). Remedial operations were required in four (3%). Overall, the local recurrence rate was 23/114. Patients with surgery only (n=57) or surgery plus systemic chemotherapy (n=24) manifested local recurrence in 15/81 (19%) and those with surgery plus radiation (n=21) or surgery and radiation and chemotherapy (n=12) suffered local recurrence in 8/33. The local recurrence rate for tumours < or =5 cm was 6/32 and for those >5 cm 17/82, P=1.0. The 5 year survival rate was 60% for tumours < or =5 cm (n=32) and 46% for tumours > or =5 cm (n=82) (P=0.009). CONCLUSIONS (1) Limb preservation was feasible in 91% of patients. (2) When the local treatment modality was surgery alone ('wide' margins) the local recurrence rate was 19%, and when it was surgery plus radiation (narrow margins) it was 24%. (3) Selective use of radiation (in patients with narrow margins) and reliance on surgery alone in cases amenable to wide resection may be a legitimate alternative to universal application of radiation with conservative resection.
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Affiliation(s)
- C P Karakousis
- State University of New York at Buffalo, School of Medicine and Biomedical Sciences, Kaleida Health, Millard Fillmore Gates Hospital, Buffalo, NY, 14209, USA.
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Sugiura H, Takahashi M, Katagiri H, Nishida Y, Nakashima H, Yonekawa M, Iwata H. Additional wide resection of malignant soft tissue tumors. Clin Orthop Relat Res 2002:201-10. [PMID: 11795735 DOI: 10.1097/00003086-200201000-00024] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Forty-five patients with soft tissue sarcomas received additional wide resections after they were treated with simple excision by a primary physician. Of the patients in the current study, 26 were male and 19 were female; all were treated between 1986 and 1998 for malignant soft tissue tumors. The mean followup was 7.1 +/- 3.4 years. The mean time from first excision to additional wide resection was 8 weeks, and for 90% of the patients it was within 12 weeks. In deciding the surgical margin for an additional operation, enhanced computed tomography scans and magnetic resonance images were done. Four (8.8%) patients had local recurrences that required a second resection and had no evidence of disease at latest followup. Four (8.8%) patients had distant metastases but did not have local recurrences. Three patients died of lung metastases. The overall 5-year survival rate of the patients was 93%, and the overall 5-year disease-free rate was 84%. It seems that tumors treated adequately by wide resection in an additional operation have results as good as tumors treated with a primary wide resection.
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Affiliation(s)
- Hideshi Sugiura
- Nagoya University School of Medicine, Department of Orthopaedic Surgery, Japan
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Ramanathan RC, A'Hern R, Fisher C, Thomas JM. Prognostic index for extremity soft tissue sarcomas with isolated local recurrence. Ann Surg Oncol 2001; 8:278-89. [PMID: 11352300 DOI: 10.1007/s10434-001-0278-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Local recurrence occurs in 10% to 20% of patients with extremity soft tissue sarcomas despite optimal treatment. The association of local recurrence with subsequent survival is controversial and conflicting. There is a need for a staging system to predict outcome in this subset of patients and also to plan optimal treatment, including adjuvant systemic therapy. METHODS Data collected from 110 patients with locally recurrent extremity soft tissue sarcomas were studied. The influence of clinical and pathologic factors on local recurrence, distant metastasis, and disease-specific survival were analyzed by univariate and multivariate techniques. RESULTS Of the 110 patients who presented with local recurrence, 92 had an isolated local recurrence and 18 had prior or concomitant distant metastases. The 5-year disease-specific survival for all patients was 63% and for those with isolated local recurrence, it was 69%. Histologic grade, malignant fibrous histiocytoma histology, pathologic margins, previous local recurrence, and prior radiotherapy were independent prognostic factors for subsequent local recurrence. Tumor size, histologic grade, and time to local recurrence were independent prognostic factors for distant metastasis and disease-specific survival. A prognostic index was calculated by assigning a score of 1 to 3 for each of the three independent prognostic factors for survival and added to give the prognostic index for each patient. As the prognostic index increased from 3 to 9, there was a progressive increase in the hazard ratios and a corresponding deterioration in survival. The patients were then categorized into three prognostic groups based on the hazard ratios for disease specific survival. The differences in the survival curves were highly statistically significant (P < .0001). CONCLUSIONS Tumor size, histologic grade, and time to local recurrence are the primary determinants of distant metastases and survival in locally recurrent extremity soft tissue sarcomas. The impact of local recurrence on survival varies considerably. The nature of the local recurrence, rather than its presence per se, is a more useful guide to prognosis. We propose a simple staging system based on size, grade, and time to recurrence that correlates extremely well with prognosis and may serve as a guide to make therapeutic decisions in patients with locally recurrent extremity soft tissue sarcomas.
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Choong PF, Petersen IA, Nascimento AG, Sim FH. Is radiotherapy important for low-grade soft tissue sarcoma of the extremity? Clin Orthop Relat Res 2001:191-9. [PMID: 11400883 DOI: 10.1097/00003086-200106000-00026] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Radiotherapy and limb-preserving surgery has replaced amputation and compartmental resection for treatment of soft tissue sarcomas. However, the role of radiotherapy in low-grade tumors remains unclear. This study reviews the outcomes of 132 patients who received multimodality treatment for low-grade soft tissue sarcoma. Large primary tumors (> 5 cm) and the absence of radiotherapy correlated with local recurrence. Radiotherapy was most effective in patients operated on with marginal margins. Patients who were treated with wide surgical margins or had small tumors (< or =5 cm) showed no benefit with adjuvant radiotherapy. Size greater than 5 cm and local recurrence correlated with metastasis. Radiotherapy appears to be important in the management of low-grade soft tissue sarcoma. The principles of local treatment for low-grade soft tissue sarcoma should be the same as for high-grade tumors with a combination of surgery and adjuvant radiotherapy. In a subset of patients with small and widely excised tumors, consideration may be given to withholding radiotherapy. Local recurrence and metastasis from low-grade soft tissue sarcoma may occur as long as 1 decade after primary tumor resection. Long-term review of patients with low-grade tumors may be indicated.
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Affiliation(s)
- P F Choong
- Department of Orthopedics, Mayo Clinic and Mayo Foundation, Rochester, MN, USA
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Abstract
Due to the peculiar characteristics of sarcomas, which include classification problems, heterogeneity of presentation, and treatment, no consensus exists regarding the best strategies to follow. In particular, there is no consensus on the use of chemotherapy in localized high-grade sarcomas, with contradictory results reported in medical literature. Moreover, in the last 2 years no papers reporting new data have been published. Consequently, the updated results of the Rizzoli randomized study performed in the 1980s, together with the results of the new Italian randomized study closed in November 1996, are reported in this paper. Both studies confirm the advantage of adjuvant chemotherapy in disease-free and overall surivall in very select groups of high-grade sarcomas of the extremities.
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Affiliation(s)
- P Picci
- Laboratory of Oncologic Research, Rizzoli Orthopaedic Institute, Via di Barbiano 1/10, 40136 Bologna, Italy.
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