The influence of local recurrence of extremity soft tissue sarcoma on metastasis and survival

Local recurrence rates of superficial versus deep soft tissue sarcoma

INTRODUCTION

Soft tissue sarcomas are a group of malignancies that commonly occur in the extremities. As deep lesions may exist within the confines of the muscular fascia, we postulate that local recurrence rates are higher for superficial soft tissue sarcomas managed by the standard of care.

MATERIALS AND METHODS

A retrospective review was performed on 90 patients who underwent surgical resection of soft tissue sarcomas of the extremity from 2007 to 2015. Patients with minimum 2-year follow-up and adequate operative, pathologic, and clinical outcomes data were included.

RESULTS

Mean age was 54 ± 18 years with 49 (54.4%) patients being male. Lesions in 77.8% of cases were deep, and 22.2% were superficial to fascia. Following the index surgical resection, a total of 33 (36.7%) patients had positive margins. A total of 17 (18.9%) patients had a local recurrence. Overall, 3-year survival was 92.7%, and 5-year survival was 79.0%. Five-year recurrence-free survival of deep sarcomas was 91.1% versus 58.2% of superficial lesions (p = 0.006). Patients with higher tumor depth had lower odds of experiencing a local recurrence (HR 0.26 [95% CI 0.09-0.72]). Local recurence rates was also associated with positive surgical margins on initial resection (33.3% versus 12.3%) (p = 0.027).

CONCLUSIONS

In this series, superficial tumor depth was associated with local recurrence of soft tissue sarcomas of the extremity following surgical resection. Positive surgical margins was also associated with local recurrence.

Tumor size and surgical margins are important prognostic factors of synovial sarcoma - A retrospective study

Background

Synovial Sarcoma (SS) is a rare soft tissue sarcoma. Mean time to get a SS diagnosis from the onset of symptoms is 10 years, furthermore, SS is associated with late metastasis. Surgery is the main treatment option, whose quality deeply affects SS outcomes, and it can be associated to preoperative or post-operative radiotherapy. Chemotherapy is considered very effective in Children, while in adults its efficacy is still under debate. The aim of this study was to investigate the oncologic results in SS treatment and to identify the risk factors for local and systemic control of the disease.

Methods

From 1994 to 2018, 211 patients affected by SS were treated in 3 Referral Centres of Orthopaedic Oncology. One hundred seventy-seven patients were included in the study, the median follow-up length was 96 months (5-374).

Results

Overall Survival on the Kaplan Meier Analyses was 80%, 70% and 56% at 5, 10 and 20 years. In multivariate analyses, OS correlated with tumour size and negative surgical margins. Chemotherapy use wasn't associated with better survival although patients who underwent CT had bigger and more aggressive tumours.

Conclusions

Our findings suggests that surgery with negative margins is the most important factor in Synovial Sarcoma. Adjuvant treatments as chemotherapy and radiation therapy didn't change the disease's course.

Clinical characteristics and survival analysis of patients with limb epithelioid sarcoma

Limb epithelioid sarcoma (LES) is a rare and aggressive soft tissue sarcoma, which is scarcely reported. Therefore, the current study was performed to analyze the clinicopathologic features and risk factors of survival among patients with LES. By using the Surveillance, Epidemiology, and End Results database, data were obtained regarding patients who were diagnosed with LES for the period between 2010 and 2016. We first analyzed overall survival (OS) and cancer-specific survival (CSS) by applying univariate Cox regression analysis. Then we performed multivariate analysis to confirm independent predictors of survival. In total, we identified 475 patients with LES for survival analysis, of which 291 were males (61.3%) and 184 females (38.7%). The mean and median age at diagnosis were 38 and 36 years, respectively. The 5-year OS and CSS rates among Patients with LES were 65.4% and 69.5%, respectively. Gender, age, tumor stage, tumor size, and treatment type were significant predictors of OS on both univariate and multivariate analyses (P < .05). As for CSS, multivariable analysis revealed that age <60 years, localized stage, and tumor size <5 cm were significantly associated with increased survival (P < .05). Predictors of improved survival for LES patients include gender, age, tumor stage, tumor size, and treatment type. Surgery only was recommended for treating LES patients. Future studies are warranted to determine effective treatment types for LES patients.

Risk Factors for Occurrence and Relapse of Soft Tissue Sarcoma

The diagnosis and prognostic outcome of STS pose a therapeutic challenge in an interdisciplinary setting. The treatment protocols are still discussed controversially. This systematic meta-analysis aimed to determine prognostic factors leading to the development and recurrence of STS. Eligible studies that investigated potential risk factors such as smoking, genetic dispositions, toxins, chronic inflammation as well as prognostic relapse factors including radiation, chemotherapy and margins of resection were identified. Data from 24 studies published between 1993 and 2019 that comprised 6452 patients were pooled. A statistically significant effect developing STS was found in overall studies stating a causality between risk factors and the development of STS (p < 0.01). Although subgroup analysis did not meet statistical significances, it revealed a greater magnitude with smoking (p = 0.23), genetic predisposition (p = 0.13) chronic inflammation, (p = 0.20), and toxins (p = 0.14). Secondly, pooled analyses demonstrated a higher risk of relapse for margin of resection (p = 0.78), chemotherapy (p = 0.20) and radiation (p = 0.16); after 3 years of follow-up. Therefore, we were able to identify risk and relapse prognostic factors for STS, helping to diagnose and treat this low incidental cancer properly.

Clinical Significance and Risk Factors of Local Recurrence in Synovial Sarcoma: A Retrospective Analysis of 171 Cases

Objective: To investigate risk factors of local recurrence of synovial sarcoma and the impact of local recurrence on survival.

Methods: We retrospectively reviewed clinical data of patients with II to IIIB (AJCC8) synovial sarcoma who underwent surgery at our center between March 2005 and December 2016. Data relating clinicopathological factors, treatment and prognosis were collected. The impact of local recurrence on overall survival (OS), local recurrence-free survival (LRFS), and distant relapse-free survival (DRFS) were analyzed. The prognostic factors associated with local recurrence were also analyzed using Kaplan-Meier Curves and Cox regression analysis.

Results: A total of 171 patients were included in this analysis. After a median follow-up of 48 months, 66 patients (38.6%) experienced local recurrence. The 5-year OS, LRFS, and DRFS rates of patients with local recurrence were 37.6, 6.1, and 24.1%, respectively. Multivariate analysis showed that larger initial tumors, multiple recurrences, positive resection margins, marginal resection, and lack of adjuvant therapy were associated with higher local recurrence.

Conclusion: Local recurrence of synovial sarcoma is associated with distant metastasis and poor survival. Chemoradiation improves the prognosis of patients with local recurrence, in particular those for which recurrence occurs shortly after initial treatment.

Re-excision after unplanned excision of soft tissue sarcoma: A systematic review and metanalysis. The rationale of systematic re-excision

In Soft Tissue Sarcomas (STS) referral centre many patients have already had an incomplete tumour resection. In the majority of specimen, tumoral residual is detected and linked to a worsen prognosis. Systematic surgical re-resection of the scar tissue area is often performed. Some authors suggested to postpone re-resections until a clinically evident local recurrence is detected. A searching strategy was applied to Pubmed-Central and Ovid Medline. Odds ratio (OR) for local recurrence (LR), distant metastasis (MTS) or overall survival (OS) were calculated comparing patients who had tumour residual to people who hadn't. OR of local recurrences, distant metastasis and OS were calculated in planned vs unplanned-excisions groups. OR to develop a metastasis and OS after a local recurrences were calculated. Residual tumour led to an OR for LR of 3,56, OR of MTS was 3,42; OR of decreased OS was 3,42. Having a LR lead to a OR of 1,55 for MTS and to a OR of decreased OS of 2,32. Patients who underwent a re-excision compared to planned surgery did not have an increased OR of LR and had an OR to develop a MTS of 0,56. Our data confirm that there is a strong correlation between local recurrences, distant relapses and overall survival. Although there is a selection bias; this analysis highlights the optimal oncological outcome in patients who underwent re-resection. The rationale for systematic re-resection after unplanned excision of soft tissue sarcomas is very strong and this treatment remains the gold standard of care in these patients.

The Effect of Resection Margin on Local Recurrence and Survival in High Grade Soft Tissue Sarcoma of the Extremities: How Far Is Far Enough?

Simple Summary

In soft tissue sarcomas the width of surgical margins after resection determines the extent of surgery and the function after resection. But how far is really necessary? 305 patients with deep-seated, G2/3 soft tissue sarcomas of the extremity, the trunk wall, or the pelvis were reviewed. The 5-year local recurrence-free survival (LRFS) was 82%. Overall survival (OS) at 5 years was 66%. Positive (contaminated) margins worsened LRFS and OS. A margin of >10 mm did not improve LRFS and OS as compared to one of >5 mm. A resection margin of <1 mm showed a trend but not significantly better LRFS or OS compared to a contaminated margin. In conclusion the margin should at least be free of tumor, in sound tissue. A margin of >5 mm sound tissue seems to be sufficient. Resecting more tissue does not benefit the patient.

Abstract

Background: The significance of surgical margins after resection of soft tissue sarcomas in respect to local-recurrence-free survival and overall survival is evaluated. Methods: A total of 305 patients with deep-seated, G2/3 soft tissue sarcomas (STS) of the extremity, the trunk wall, or the pelvis were reviewed. The margin was defined according to the Fédération Nationale des Centres de Lutte Contre le Cancer (FNCLCC) classification system (R0-2), the Union Internationale Contre le Cancer (UICC) classification (R + 1 mm) for which a margin <1 mm is included into the R1 group, and in groups of <1 mm, 1–5 mm, >5 mm, or >10 mm. Results: Of these patients, 31 (10.2%) had a contaminated margin, 64 (21%) a margin of <1 mm, 123 (40.3%) a margin of 1–5 mm, 47 (15.4%) a margin of >5 mm, and 40 (13.1%) a margin of >10 mm. The 5-year local recurrence-free survival (LRFS) was 81.6%. Overall survival (OS) at 5 years was 65.9%. Positive margins worsened LRFS and OS. A margin of >10 mm did not improve LRFS and OS as compared to one of >5 mm. Conclusions: A resection margin of <1 mm showed a trend but not significantly better LRFS or OS compared to a contaminated margin. This finding supports use of the UICC classification. A margin of more than 10 mm did not improve LRFS or OS.

Extraskeletal myxoid chondrosarcoma: A high incidence of metastatic disease to lymph nodes

BACKGROUND

Extraskeletal myxoid chondrosarcoma (ESMC) is a rare type of soft-tissue sarcoma with limited series reporting outcome of treatment. Currently there is limited data on the incidence and impact on patient outcome in those with metastatic disease to lymph nodes in ESMC.

METHODS

Thirty (21 males, 9 females) patients, mean age 50 ± 16 years, with ESMC were reviewed. The tumors were most commonly located in the lower extremity (n = 23, 77%) and the mean tumor size and volume were 9 ± 5 cm and 490 ± 833 cm³ . Mean follow up was 7 ± 4 years.

RESULTS

Six (20%) patients either presented (n = 3, 10%) or developed (n = 3, 10%) lymph node metastatic disease. When comparing patients without, with lymph node metastasis and metastasis elsewhere, patients with lymph nodes metastasis had worse survival than those without metastasis, however better 10-year disease specific survival than those with metastasis elsewhere (100% vs 62% vs 0%; P < .001).

CONCLUSION

There is a high incidence of lymph node metastatic disease in patients with ESMC. Although survival in these patients is worse compared to those without metastasis, their survival is better than those with metastasis elsewhere. Due to the high incidence of lymph node metastatic disease, preoperative staging of the lymph node should be considered.

Surgical Resection Margin Classifications for High-grade Pleomorphic Soft Tissue Sarcomas of the Extremity or Trunk After Neoadjuvant Cytotoxic Therapy

Soft tissue sarcomas of the extremities or trunk are often resected after treatment with neoadjuvant radiotherapy. Adequate surgical resection margins for sarcomas after neoadjuvant cytotoxic therapy are not well characterized. Minimum surgical resection margins required for local control of primary, high-grade, pleomorphic soft tissue sarcomas treated with neoadjuvant therapy was assessed by competing risk regression in a series of 166 cases. Optimal tumor clearance was determined to be ≥1 mm. Predictive accuracy of three commonly used resection margin classification schemes (American Joint Committee on Cancer, Musculoskeletal Tumor Society, and the margin distance method) were comparable. However, diagnostic performance of a binary system (positive vs. negative) was more specific than margin distance classification (positive or <1 vs. ≥1 mm from tumor), but less sensitive in predicting local recurrence. The American Joint Committee on Cancer R classification (R0 vs. R1/R2) seems to adequately stratify patients by risk for local recurrence after neoadjuvant therapy and subsequent surgical resection. Furthermore, close but negative resection margins (<1 mm from tumor) appear sufficient for local control of high-grade pleomorphic soft tissue sarcomas of the extremity or trunk in this clinical setting, with minimal reduction in the risk of local recurrence with increasing margin width or surgical clearance.

Surgical resection margin classifications for high-grade pleomorphic soft tissue sarcomas of the extremity or trunk: definitions of adequate resection margins and recommendations for sampling margins from primary resection specimens

Adequacy of surgical resection margins for soft tissue sarcomas are poorly defined because of the various classifications and definitions used in prior studies of heterogeneous patient cohorts and inconsistent margin sampling protocols. Surgical resection margins of 166 primary, high-grade, pleomorphic sarcomas of the extremity or trunk were classified according to American Joint Committee on Cancer R and Musculoskeletal Tumor Society categories, as well as by metric distance and tissue composition. None of the cases were treated with neoadjuvant therapy. Multivariable competing risk regression models were evaluated and optimal surgical resection margins for each classification system were defined. Minimum safe tumor clearance was 5 mm without use of adjuvant radiotherapy and 1 mm with adjuvant radiotherapy. Predictive accuracy of margin classification systems was compared by area under receiver-operating characteristic curves generated from logistic regression of 2½-year local recurrence-free survival and other standard tests of diagnostic accuracy. The Musculoskeletal Tumor Society and margin distance classifications performed similarly, both of which showed higher sensitivity and negative predictive value compared to the American Joint Committee on Cancer R classification. The prognostic power of close or positive margins in prediction models significantly increased when six or more slides were submitted for assessment of surgical resection margins. Surgical resection margins for soft tissue sarcoma should be reported using the Musculoskeletal Tumor Society classification or metric distance to the closest resection margin. Musculoskeletal Tumor Society wide/radical margins or tumor clearances of 5 mm (without adjuvant radiotherapy) or 1 mm (with adjuvant radiotherapy) appear to define the minimum safe surgical resection margins necessary to decrease the likelihood of local recurrence of high-grade pleomorphic sarcomas of the extremity or trunk.

Laser thermal ablation to treat a recurrent soft-tissue sarcoma of the leg: a case report

We present the case of a 52-year-old male patient with recurrence of a soft-tissue sarcoma of the left leg treated with percutaneous laser ablation. The patient received the diagnosis of sarcoma for the first time in 2011; further local recurrences and a pulmonary metastatic spread occurred during follow-up, so the patient has been treated several times with chemotherapy, limb-sparing surgery and radiotherapy. In September 2017, a new local recurrence of sarcoma occurred, for which limb amputation was proposed but refused by the patient. Laser ablation with ultrasound guidance was performed, with complete ablation at 6 months and limb salvage.

Carbon ion radiotherapy for unresectable localized axial soft tissue sarcoma

Carbon ion radiotherapy is known for its high‐precision dose distribution and high biological effectiveness. We evaluated the results of carbon ion radiotherapy in 128 patients with unresectable localized axial soft tissue sarcoma at a single institution. The patients’ median age was 54 years, and the median follow‐up period was 49.4 (range 6.4‐146.4) months. The median tumor volume was 356 cm³. The 5‐year local control, overall survival, and disease‐free survival rates were 65%, 46%, and 39%, respectively. In the univariate analysis, tumor volume, local control, and incidences of metastases were significantly related to overall survival. In the multivariate analysis, tumor volume and local control were significantly related to overall survival. We did not find any factors related to local control. Five patients required surgical intervention because of adverse events in the bones. Carbon ion radiotherapy may be a treatment option for unresectable axial soft tissue sarcoma.

A retrospective cohort study to assess adjuvant concurrent chemoradiation (CCRT) compared to adjuvant radiation therapy (RT) in the treatment of grade 2 and 3 extremity soft tissue sarcomas

PURPOSE

To evaluate the efficacy and tolerance of adjuvant concurrent chemoradiation (CCRT) as treatment of grade 2 and 3 (G2-3) localized extremity soft tissue sarcomas (STS) by comparing CCRT with standard adjuvant radiation therapy (RT).

PATIENTS AND METHODS

This monocentric retrospective study included non-pediatric patients (>16years) treated by adjuvant RT with or without chemotherapy (CT) after conservative resection of non-recurrent G2-3 extremity STS.

RESULTS

A total of 80 patients were treated between 1990 and 2012: 51 by RT and 29 by CCRT. Of the 29 CCRT patients, 25 received doxorubicin monotherapy (75mg/m²/3weeks). The CCRT group contained a greater proportion of grade 3 extremity STS (p<0.001). Median follow up was 68months (9-284). Multivariate analysis revealed greater local control in the CCRT group (1 local recurrence vs 8 in the RT group; HR=0.082, 95% CI 0.011-0.321) and incomplete resection as the major risk factor of local recurrence (HR=25.2, 95% CI 4.767-133.226). The two groups exhibited no differences in distant failure-free survival (HR=1.469, 95% CI 0.668-3.228), disease-free survival (HR=1.096, 95% CI 0.519-2.315) or overall survival (HR=1.378, 95% CI 0.498-3.814). Grade 3 was an adverse prognostic factor for overall survival (HR=3.11, 95% CI 1.04-9.32). Our analyses also revealed that CCRT tended to increase the risk of both grade ≥3 acute dermatitis (14 events vs 6 in the RT group; OR=6.99, 95% CI 2.28-21.47) and grade ≥2 late toxicity (6 events vs 3 in the RT group; p=0.0572).

CONCLUSION

CCRT could improve local control as part of a limb-preservation strategy. However, with a limited number of patients, CCRT showed no improvement in either distant control or survival and increased toxicity.

Gross examination and reporting of soft tissue tumours: evaluation of compliance with the UK Royal College of Pathologists soft tissue sarcoma dataset

Aims

Soft tissue tumours are a heterogeneous group of neoplasms that can arise at almost every anatomical site. As they often show similar clinical and radiological findings, histology is the definitive diagnostic method and it is crucial that the surgical pathology report contains accurate, useful information for management and prognostication. The soft tissue sarcoma minimum dataset produced by the Royal College of Pathologists in the UK outlines a structure for handling and reporting soft tissue tumours, including the core data required, and aiding pathologists in forming a consistent reporting approach.

Methods

We assessed the information in surgical pathology reports for soft tissue lesions at a tertiary soft tissue centre, in 1 year prior to the development of this dataset, and 1 year after its release, to audit the comparative adequacy of macroscopic and microscopic information provided, and to assess for differences in reporting since the advent of routine ancillary molecular diagnostic testing.

Results and conclusions

We found that while essential information was always included in reports, more specific details contributing to better quality reports such as more detailed macroscopic descriptions and a higher proportion of clinical summaries with radiological correlation were included in 2011 than 2006, despite increasing workload. Specimen handling, particularly of core biopsies, was also improved, reflecting the increasing need to conserve the maximum amount of patient material for molecular investigations.

Association of short duration from initial symptoms to specialist consultation with poor survival in soft-tissue sarcomas

INTRODUCTION

The association of symptom duration with survival remains controversial in soft-tissue sarcoma (STS).

MATERIALS AND METHODS

We determined whether the length from initial symptoms to specialist consultation affects prognosis in STSs. We retrospectively reviewed 152 primary STS patients (with 142 non-small round cell sarcomas) who consulted our specialist hospital. The factors that affected the length of the period from the initial symptoms to specialist consultation and the length of the delay at the clinic before specialist hospital referral were investigated. The relation between the length of the period from symptom onset and overall survival was also analyzed.

RESULTS

Unplanned excision and superficial tumor were significantly associated with increasing duration from the initial symptoms to specialist hospital referral. Multivariate analysis revealed that tumors over 5 cm (P=0.002 and 0.005) and symptoms within 6 months (P=0.017 and 0.016) were independent poor prognostic factors of overall survival among the pretreatment factors when analyzing all and non-small round cell STSs.

CONCLUSIONS

This is a first report to show the independent prognostic role of symptom duration in STSs on multivariate analysis. Considering the impact of symptom duration on survival in these heterogenous tumors, careful follow-up and consideration of treatment are necessary for patients with short symptom duration.

Long-term local disease control in a recurrent soft-tissue sarcoma of the thigh treated by radiofrequency ablation

In 2008, we performed radiofrequency ablation (RFA) in an elderly patient with a large recurrent soft-tissue sarcoma of the thigh, previously treated with surgery and radiotherapy. After ablation, a marked shrinkage of tumor was obtained. Further local recurrences occurred during follow-up, all safely treated by RFA, with local control of the disease maintained until 6-year follow-up. RFA was safe, effective, and repeatable for soft-tissue sarcoma recurrences, and allowed long-term local control of the disease.

Prognostic significance of histological invasion in high grade soft tissue sarcomas

High grade soft tissue sarcomas often show histological invasion to adjacent compartment including bone and vessel. This study aimed to evaluate histological invasion in high grade soft tissue sarcomas, clarify its impact on prognosis and devise treatment strategies. We retrospectively reviewed 133 patients with non-small round cell high grade soft tissue sarcomas surgically treated between 2001 and 2011. Clinical and histological factors examined for prognostic value included age, gender, size, depth, location, adjuvant therapy and invasion to adjacent compartment. Study endpoints included overall survival rate, event free survival rate and local recurrence free survival rate, estimated by the Kaplan-Meier method. Univariate and multivariate analyses were performed using the log-rank test and Cox proportional hazards model. Local recurrence was recognized in 14 cases (11%). The 5-year overall survival rate and 5-year event free survival rate were 82.2% and 63.6% respectively. The metastasis-free survival rate at 5 years and local recurrence-free survival rate at 5 years were 69.8% and 86.8% respectively. Histological invasion to adjacent compartment was noted in 52 cases (39%), and was significantly correlated with histological type (p = 0.01), tumor size (p = 0.009), and depth (p < 0.05). In multivariate analyses, we showed that tumor size and histological invasion were significant independent predictors of OS (hazard ratio 8.1/2.5) and EFS (hazard ratio 5.5/2.2), while only tumor size was a significant independent predictor of LRFS (hazard ratio 4.0). We evaluated the relation between histological invasion and the oncological outcomes of high grade soft tissue sarcomas. In multivariate analyses, histological invasion was found to be an independent adverse prognostic factor with hazard ratios of 2.2-2.5, suggesting that a detailed assessment of these factors is essential. Histological invasion showed a correlation with tumor size and histological type, and the surgical margin should be decided based on these factors.

Impact of margin status and local recurrence on soft-tissue sarcoma outcomes

BACKGROUND

The impact of local recurrence and surgical resection margin status on survival in extremity soft-tissue sarcomas remains to be clearly defined. Our aim was to conduct a retrospective analysis of prospectively collected data to determine the prognostic relevance of positive resection margins and local recurrence for extremity soft-tissue sarcomas for survival.

METHODS

Three hundred and sixty-three patients who underwent resection of localized primary extremity soft-tissue sarcomas with curative intent were selected from the United States Department of Defense Automated Central Tumor Registry. Outcomes for local recurrence, distant recurrence, disease-specific survival, and overall survival were analyzed according to clinical, pathological, and treatment variables with use of the Kaplan-Meier method (log-rank test) and the multivariate Cox regression model.

RESULTS

Positive margins (hazard ratio, 1.99 [95% confidence interval, 1.15 to 3.45]), local recurrence (hazard ratio, 2.93 [95% confidence interval, 1.38 to 6.23]), and distant recurrence (hazard ratio, 12.13 [95% confidence interval, 5.97 to 24.65]) were significantly associated with overall survival on multivariate Cox regression analysis. However, for disease-specific survival, local recurrence was not significant and tumor size of >10 cm (hazard ratio, 2.83 [95% confidence interval, 1.15 to 6.95]), positive margins (hazard ratio, 1.95 [95% confidence interval, 1.05 to 3.63]), and distant recurrence (hazard ratio, 9.46 [95% confidence interval, 4.37 to 20.47]) were independent adverse prognostic factors. The disease-specific survival rate for patients with localized soft-tissue sarcomas was 89% (95% confidence interval, 85% to 92%) for five years and 75% (95% confidence interval, 70% to 81%) for ten years.

CONCLUSIONS

Positive surgical margins are consistently associated with adverse survival-related outcomes in localized soft-tissue sarcomas of the extremity. Local recurrence had a significant impact on overall survival, but not on disease-specific survival.

Resection of soft tissue tumors extending through the obturator ring

Pelvic soft tissue sarcomas are rare tumors often presenting larger than other soft tissue sarcomas and can extend into the thigh through various anatomic routes. Surgical resection is the main modality of curative treatment. En bloc tumor excision with wide, negative margins may reduce the risk of local recurrence. Soft tissue sarcomas extending through the obturator foramen create unique challenges to operative management. This case report describes 2 cases of lipomatous lesions that extend through the obturator foramen, presenting as dumbbell-shaped lesions with large intra- and extrapelvis portions. One possible surgical approach performed in both patients is detailed with long-term follow-up. Postoperatively, 1 incidence of infection was reported. Functional outcomes were acceptable, with full restoration of ambulation without assistive devices in both cases and no hernia observed. Oncologic outcomes included locoregional recurrence in 1 patient at 24 months outside the radiation field. The ideal primary treatment for all localized soft tissue sarcomas, including those extending through the obturator foramen, is resection. However, the unique subgroup of obturator ring soft tissue sarcomas has undefined outcomes and complications. The authors' goal was to achieve en bloc resection with wide negative margins while preserving ipsilateral limb function. The surgical approach described in this case study offers a description of feasibility and discussion of theoretical and observed complications.

Outcomes of isolated limb perfusion in the treatment of extremity soft tissue sarcoma: a systematic review

BACKGROUND

Isolated limb perfusion (ILP) may provide a limb salvage option for locally advanced soft tissue sarcoma (STS) not amenable to local resection.

METHODS

A systematic review was performed for studies reporting outcome of ILP for locally advanced STS performed after 1980 in patients aged ≥ 12 years old. The main endpoints were tumour response and limb salvage rates. Complication and recurrence rates were secondary endpoints.

RESULTS

Eighteen studies were included, providing outcomes for 1030 patients. Tumour necrosis factor-alpha with melphalan was the commonest chemotherapy regime. When reported, 22% of cases achieved a complete tumour response (216/964, 15 studies) with an overall response rate of 72% (660/911, 15 studies). At median follow-up times ranging between 11 and 125 months, the limb salvage rate was 81% in patients who otherwise would have been subjected to amputation. However, 27% of patients suffered local recurrence and 40% suffered distant failure. ILP was associated with severe locoregional reactions in 4% (22/603) of patients. Amputation due to complications within 30 days was necessary in 1.2% of cases (7/586, nine studies). There was insufficient evidence to determine the effect of ILP on survival.

CONCLUSION

ILP induces a high tumour response rate, leads to a high limb salvage rate but is associated with a high recurrence rate. It provides a limb salvage alternative to amputation when local control is necessary.

Risk factors for local recurrence and metastasis in soft tissue sarcomas of the extremity

OBJECTIVES

We reviewed our institution's experience in treating soft tissue sarcomas of the extremity to identify factors associated with local recurrence, metastasis, and overall survival, to identify patients who may benefit from intensification of therapy.

METHODS

A retrospective analysis was performed for patients who underwent both limb-sparing surgery and external beam radiotherapy for extremity sarcoma. Those who had gross residual disease or who presented with recurrent or metastatic disease were excluded. The Kaplan-Meier product limit and multivariate Cox regression were used to estimate local failure-free probability, distant failure-free probability, and overall survival along with associations with patient, tumor, and treatment characteristics.

RESULTS

One hundred eighty-eight patients were included in the analysis. Twenty-five (13%) and 46 (24%) experienced local and distant recurrence, respectively. Patients with high/intermediate-grade tumors [hazard ratio (HR)=5.63, 95% confidence interval (CI): 1.27-24.89, P=0.023] or with multifocally positive margins (HR=4.27, 95% CI: 1.20-15.24, P=0.026) were more likely to fail locally. Those with a preceding local recurrence (HR=8.58, 95% CI: 3.87-19.04, P<0.0001), high/intermediate-grade tumors (HR=5.68, 95% CI: 1.28-25.25, P=0.023), or no secondary reexcision (HR=2.5, 95% CI: 1.09-5.74, P=0.031) were more likely to develop metastasis. Patients with local recurrence (HR=3.6, 95% CI: 1.77-7.29, P<0.001), metastasis (HR=16.0, 95% CI: 7.93-32.31, P<0.0001), or without secondary reexcision (HR=3.2, 95% CI: 1.27-8.09, P=0.014) had decreased overall survival.

CONCLUSIONS

Patients whose tumor grade or margin status put them at high risk for local failure should be considered for intensification of therapy. Those with a local recurrence should be considered for increased surveillance or systemic therapy, as local failure is associated with subsequent metastasis and decreased survival.

Long-term results of tumor necrosis factor alpha- and melphalan-based isolated limb perfusion in locally advanced extremity soft tissue sarcomas

PURPOSE

Because there is no survival benefit of amputation for extremity soft tissue sarcomas (STSs), limb-sparing surgery has become the gold standard. Tumor size reduction by induction therapy to render nonresectable tumors resectable or facilitate function-preserving surgery can be achieved by tumor necrosis factor α (TNF) -based and melphalan-based isolated limb perfusion (TM-ILP). This study reports the long-term results of 231 TM-ILPs for locally advanced extremity STS.

PATIENTS AND METHODS

We analyzed 231 TM-ILPs in 208 consecutive patients (1991 to 2005), who were all candidates for functional or anatomic amputation for locally advanced extremity STS. All patients had a potential follow-up of up to 5 years. TM-ILP was performed under mild hyperthermic conditions with 1 to 4 mg of TNF and 10 to 13 mg/L of limb-volume melphalan. Almost all patients (85%) had intermediate- or high-grade tumors.

RESULTS

The overall response rate (ORR) was 71% (complete response, 18%; partial response, 53%). Multifocal sarcomas had a significantly better ORR of 83% (P = .008). The local recurrence rate was 30% (n = 70); local recurrence rates were highest for multifocal tumors (54%; P = .001) and after previous radiotherapy (54%; P < .001). Five-year overall survival rate was 42%. Survival was poorest in patients with large tumors (P = .01) and with leiomyosarcomas (P < .001). Limb salvage rate was 81%.

CONCLUSION

We demonstrated that TM-ILP results in a limb salvage rate of 81% in patients with locally advanced extremity STS who would otherwise have undergone amputation. Whenever an amputation is deemed necessary to obtain local control of an extremity STS, TM-ILP should be considered.

Factors Influencing Prognosis After Initial Inadequate Excision (IIE) for Soft Tissue Sarcoma

Purpose. The influence of initial inadequate excision (IIE) of soft tissue sarcoma (STS) on local control and overall survival is not well established. It is generally believed that an IIE may have a negative impact on both, despite subsequent treatment by radical surgery and radiotherapy. However, data on local recurrence-free survival/overall survival are conflicting and there are no data on the effect of IIE on overall survival.Patients and methods. A retrospective analysis was made of 86 patients with soft tissue sarcoma of the extremities and trunk after an IIE had been performed due to inappropriate work-up. The minimal follow-up was 7 years. Specimens of the subsequent radical resection were evaluated for residual tumor, grade of tumor and complications of IIE. Endpoints were recurrence-free survival and overall survival.Results. Specimens of the subsequent radical resection showed residual tumor in 66 patients (77%). The most common complication after IIE was hematoma. In both univariate and multivariate analyses, grade II/III tumors and complications after IIE are significant negative prognostic factors for local recurrence-free survival (P = 0.008 and P = 0.002, respectively, in the Cox model). For this survival, three prognostic groups could be formed based on grade, or presence or absence of complications. Adjuvant radiotherapy did not change the rate of local recurrence-free survival. For overall survival, only tumor grade is a significant factor (log-rank test).Conclusion. This retrospective study shows that complications associated with an IIE have a significant negative effect on local control, but not on overall survival, because IIE is often the result of inappropriate work-up before surgery. For better diagnosis and therapy STS should be treated in specialized centers.

Clinical features, treatment, and outcome in 102 adult and pediatric patients with localized high-grade synovial sarcoma

Background. There remains controversy on the routine use of chemotherapy in localized SS. Methods. The records of 87 adult (AP) and 15 pediatric (PP) patients with localized SS diagnosed between 1986 and 2007 at 2 centres in Toronto were reviewed. Results. Median age for AP and PP was 37.6 (range 15–76) and 14 (range 0.4–18) years, respectively. 65 (64%) patients had large tumours (>5 cm). All patients underwent en bloc surgical resection resulting in 94 (92.2%) negative and 8 (7.8%) microscopically positive surgical margins. 72 (82.8%) AP and 8 (53%) PP received radiotherapy. Chemotherapy was administered to 12 (13.8%) AP and 13 (87%) PP. 10 AP and 5 PP were evaluable for response to neoadjuvant chemotherapy, with response rate of 10% and 40%, respectively. 5-year EFS and OS was 69.3 ± 4.8% and 80.3 ± 4.3%, respectively, and was similar for AP and PP, In patients with tumors >5 cm, in whom chemotherapy might be considered most appropriate, relapse occurred in 9/19 (47%) with chemotherapy, compared to 17/46 (37%) In those without. Conclusions. Patients with localized SS have a good chance of cure with surgery and RT. Evidence for a well-defined role of chemotherapy to improve survival In localized SS remains elusive.

Factors predicting local recurrence, metastasis, and survival in pediatric soft tissue sarcoma in extremities

BACKGROUND

Pediatric soft tissue sarcomas are rare and differ from those in adults regarding the spectrum of diagnoses and treatment. Sarcomas in extremities may have different prognoses from those located elsewhere.

QUESTIONS/PURPOSES

We sought risk factors predicting local recurrence, metastasis, and overall survival and asked whether radiation and chemotherapy influenced local recurrence, metastasis, and overall survival.

METHODS

We retrospectively reviewed all 98 patients aged 18 years or younger diagnosed with soft tissue sarcomas in extremities from 1990 to 2008. Age, tumor size, depth, location, bone or neurovascular involvement, histologic subtypes, unplanned excision, surgical margins, metastasis at diagnosis, and adjuvant treatments were reviewed for each patient. We determined the effect of each prognostic variable on local recurrence, metastasis, and overall survival.

RESULTS

Ninety-four patients underwent surgical excision and seven patients had local recurrence at a median time of 18.6 months. Radiation therapy reduced the rate of local recurrence. Fourteen patients had metastasis at diagnosis and seven patients later developed metastasis. The median time to metastasis was 20.9 months. Six patients died and the median time to death was 28.0 months. Metastasis at diagnosis was a predictive factor for death.

CONCLUSIONS

When limited to extremities, radiation therapy reduced the rate of local recurrence in pediatric soft tissue sarcomas. Metastases at diagnosis predict death.

Management of adult soft-tissue sarcoma of the extremities and trunk

Soft-tissue sarcomas are a heterogeneous group of tumors consisting of approximately 100 distinct diagnoses. Management requires a multimodality approach with the input of pathologists, surgeons, radiation oncologists, medical oncologists and radiologists. In localized disease, the primary modality of treatment is wide-resection surgery, and the use of radiation therapy has improved local control rates for high-grade tumors. Currently, most localized tumors can be managed with limb-sparing treatment, and local control rates of 80-90% can be seen with appropriate management. Improvements in classification and diagnosis of these tumors have led to the current idea that the specific histology is an important consideration when developing a treatment plan and may affect prognosis, although existing staging systems have not yet incorporated this parameter. Treatment of metastatic disease continues to be difficult, but current research focuses on clarifying molecular mechanisms of disease and identifying new potential targets for medical therapy. This review focuses on the current status of management of these tumors including a review of epidemiology, initial evaluation, and treatment including surgical, radiation, and medical aspects.

Space sarcomas: extra compartmental soft tissue tumors of the lower extremities a systematic approach to sarcomas of the femoral triangle, sartorial canal, and popliteal space

BACKGROUND

Extra-compartmental soft tissue sarcomas may grow in virtual spaces in close proximity to major neurovascular structures and thus, require a complex resection. We analyzed the general principles by which these resections are planned.

METHODS

We retrospectively analyzed 53 patients with sarcomas located in the femoral triangle (15), sartorial canal (16), and the popliteal fossa (22). These lesions were grouped into three categories based on involvement of spatial structure; neurovascular involvement = 13, musculofascial involvement = 19 and no involvement = 11.

RESULTS

Limb sparing surgery was feasible in lesions that had either no structural or musculofascial involvement. Amputation, however, was required in 3 of 13 patients with neurovascular involvement because of gross involvement of the surrounding tissues. Overall, limb sparing was feasible in 94% (50 of 53 patients). The 2- and 5-year local recurrence rates were 10% and 14%, respectively. Five-year survival was 88%.

CONCLUSIONS

Limb sparing resection of space sarcomas is feasible in the majority of extra-compartmental sarcomas by utilizing a systematic approach which emphasizes specific planes of resection.

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.

Treatment of soft tissue sarcoma: a European approach

This article discusses the treatment of adult soft tissue sarcoma (excluding gastrointestinal stromal tumor), analyzing the principles underlying treatment and the results of surgery, radiotherapy, and chemotherapy. The focus is on the European approach in particular, and ongoing studies are summarized.

Analysis of prognostic factors associated with injection-site sarcomas in cats: 57 cases (2001-2007)

OBJECTIVE

To identify prognostic factors in cats with injection-site sarcomas (ISSs).

DESIGN

Retrospective case series.

ANIMALS

57 cats with ISSs.

PROCEDURES

Medical records of cats were reviewed with regard to sex, age, anatomic site of tumor, tumor size, histologic grade, excision of a primary tumor versus excision of a recurrent ISS, use of excision alone versus excision plus adjuvant therapy, local tumor recurrence, and development of distant metastasis to predict overall survival time (ie, time from tumor excision to death).

RESULTS

In univariate analyses, local recurrence and development of distant metastasis were significantly associated with survival time in cats. On multivariate analysis, development of distant metastasis remained a significant prognostic factor. Histologic grade was associated with distant metastasis, with cats having grade 3 tumors being significantly more likely to develop metastasis than cats with grade 1 and 2 tumors. Factors associated with local recurrence of ISSs were not identified.

CONCLUSIONS AND CLINICAL RELEVANCE

The development of distant metastasis, which may occur later during the course of the disease, was identified as a prognostic factor for overall survival time in cats with ISSs. In addition, cats with histologic grade 3 ISSs should be considered for further interventional studies with chemotherapy to prevent the high rate of distant metastasis.

Radiotherapy to improve local control regardless of surgical margin and malignancy grade in extremity and trunk wall soft tissue sarcoma: a Scandinavian sarcoma group study

PURPOSE

Adjuvant radiotherapy has during the past decades become increasingly used in the treatment of localized soft tissue sarcoma. We evaluated the effect of radiotherapy (RT) on local recurrence rates (LRRs) in Scandinavia between 1986 and 2005.

METHODS AND MATERIALS

A total of 1,093 adult patients with extremity or trunk wall soft tissue sarcoma treated at four Scandinavian sarcoma centers were stratified according to the treatment period (1986-1991, 1992-1997, and 1998-2005). The use of adjuvant RT, quality of the surgical margin, interval between surgery and RT, and LRR were analyzed. The median follow-up was 5 years.

RESULTS

The use of RT (77% treated postoperatively) increased from 28% to 53%, and the 5-year LRR decreased from 27% to 15%. The rate of wide surgical margins did not increase. The risk factors for local recurrence were histologic high-grade malignancy (hazard ratio [HR], 5), an intralesional (HR, 6) or marginal (HR, 3) surgical margin, and no RT (HR, 3). The effect of RT on the LRR was also significant after a wide margin resection and in low-grade malignant tumors. The LRR was the same after preoperative and postoperative RT. The median interval from surgery to the start of RT was 7 weeks, and 98% started RT within 4 months. The LRR was the same in patients who started treatment before and after 7 weeks.

CONCLUSION

The results of our study have shown that adjuvant RT effectively prevents local recurrence in soft tissue sarcoma, irrespective of the tumor depth, malignancy grade, and surgical margin status. The effect was most pronounced in deep-seated, high-grade tumors, even when removed with a wide surgical margin.

Isolated limb perfusion with melphalan and TNF-alpha in the treatment of extremity sarcoma

Isolated limb perfusion (ILP) with chemotherapy alone has uniformly failed in the treatment of irresectable extremity soft tissue sarcomas. The addition of tumor necrosis factor-alpha (TNF-α) to this treatment approach contributed to a major step forward in the treatment of locally advanced extremity soft tissue sarcoma (STS). High response rates and limb salvage rates have been reported in multicenter trials, which combined ILP with TNF-α plus melphalan, which resulted in the approval of TNF-α for this indication in Europe in 1998. Subsequently a series of confirmatory single institution reports on the efficacy of the procedure have now been published. TNF-α has an early and a late effect; it enhances tumor-selective drug uptake during the perfusion and plays an essential role in the subsequent selective destruction of the tumor vasculature. These effects result in a high response rate in high-grade soft tissue sarcomas. This induction therapy thus allows for resection of tumor remnants some 3 months after ILP and thus avoidance of limb amputation. TNF-α-based ILP is a well-established treatment to avoid amputations. It represents an important example of tumor vasculatory-modulating combination therapy and should be offered in large volume tertiary referral centers.

Clinical significance of margin status in postoperative radiotherapy for extremity and truncal soft-tissue sarcoma

PURPOSE

To evaluate whether adjuvant radiotherapy (RT) in extremity and truncal soft-tissue sarcoma (STS) patients with microscopically positive or close margins after excision can achieve comparable local control to that of excision with negative margin plus RT.

METHODS AND MATERIALS

A total of 150 patients (111 extremity and 39 trunk cases) treated with conserving surgery and adjuvant RT was analyzed. All surgical margins were classified as being a negative margin or a positive or close margin based on pathologic margin width. RT was delivered with a shrinking-field technique in 150 patients (median, 63 Gy).

RESULTS

All patients were divided into two groups: (A) excision with negative margins plus RT (n = 56) and (B) excision with positive or close margins plus RT (n = 94). Overall, the 5-year local failure-free survival in all patients was 72.9%, and no significant differences were found between the two groups (Group A, 74.7%; Group B, 71.6%). High tumor grade was found to be a significant predictor of local failure. However, Group A was superior to Group B in distant metastasis-free survival (p = 0.02). No significant differences were shown in overall survival between the two groups.

CONCLUSIONS

In our series, margin status did not predict for LF when adjuvant RT was used. We believe that when adjuvant RT is used, re-resection may not be necessary for selected patients with positive or close pathologic margins in the management of extremity and truncal STS patients.

[Epithelioid sarcoma: a retrospective study of conservative treatment with initial surgery and radiotherapy]

INTRODUCTION

Epithelioid sarcoma is a rare type of soft tissue sarcomas with a high risk of recurrence both local and distant. The place of surgical conservative treatment and the role of radiation therapy remain controversial.

PATIENTS AND METHODS

A serie of 9 consecutive patients treated with initial conservative surgery and postoperative radiotherapy (median dose of 52.8 Gy) from 1987 to 2006 in the same institution was analyzed.

RESULTS

With a median follow-up of 40 months (range 15-153 months), the rate of local, nodal and distant relapse is respectively 56%, 11% and 33%. The rate of death is 44.5%. No imputation has been performed.

CONCLUSION

Even with a high rate of local relapse observed, a conservative treatment doesn't seem to influence badly the overall survival (55.5% alive at 40 months). Indeed the rate of distant relapse and death are comparable with those found in the literature. Moreover relapse occurred almost within the irradiated volumes. An improvement of dose could be also discussed.

[Diagnosis and treatment of soft-tissue tumors]

The diagnostic and therapeutic management of patients with soft-tissue tumors would be similar to the approach used for bone tumors if it were not for one crucial factor: the absolute necessity to recognize a sarcoma. The predominant features are the size of the tumor and its superficial or deep localization. If the tumor is small and superficial, biopsy can be associated with immediate resection without risk of dissemination to the deep tissues: this is the biopsy-resection approach. If the tumor is deep or superficial but large sized, search for locoregional spread with MRI is necessary before undertaking any surgical procedure. MRI can help guide the biopsy and plan resection if the tumor is a sarcoma. A first biopsy is necessary to establish the histological diagnosis and elaborate the therapeutic strategy. Samples should be sent immediately to the pathology lab which should examine sterile fresh tissue. Experience has demonstrated that proper rules for diagnosis and treatment are not necessarily applied initially in approximately one-fourth of all subjects with a malignant soft-tissue tumor. Besides the medical problems caused by this situation, the patient loses a chance for cure. When the tumor is a sarcoma, surgery is the basis of treatment. Complementary radiation therapy may be necessary, particularly for high-grade tumors or if the surgical margin was insufficient. Systemic or locoregional chemotherapy can also be used for high-grade or non-resectable tumors.

Preoperative chemoradiation and flap reconstruction provide high local control and low wound complication rates for patients undergoing limb salvage surgery for upper extremity tumors

BACKGROUND AND OBJECTIVES

Neoadjuvant protocols in the management of upper extremity sarcoma have improved local control rates but have been associated with high complication rates. We present a refinement of the Eilber protocol using judicious preoperative chemoradiation, limb salvage surgery, and flap coverage to achieve high local control rates with acceptable wound healing complications.

METHODS

Patients presenting with upper extremity neoplasms from 1986 to 2002 were treated with a modified Eilber protocol, consisting of 3 days of adriamycin (30 mg/day) and sequential radiotherapy (300 cGy/day for 10 days). Limb salvage surgery with flap coverage where needed was performed 4-8 weeks later. Patients were followed prospectively for recurrence.

RESULTS

Fifty-three consecutive patients with upper extremity tumors were treated and followed for a mean of 6.1 years. This cohort included 44 sarcomas and nine non-metastasizing, locally aggressive tumors. There were two local recurrences (3.8%). Limb salvage was achieved in all patients. Flaps were required in 43.4% of patients. Major complications occurred in 11%, were all flap related (partial flap loss, venous congestion), and went on to heal promptly with treatment.

CONCLUSION

This modified Eilber protocol achieved 96% local control for upper extremity tumors with a wound complication rate of 11%. The liberal use of flaps of resulted in healed, stable wounds in all patients.