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Hayes AJ, Nixon IF, Strauss DC, Seddon BM, Desai A, Benson C, Judson IR, Dangoor A. UK guidelines for the management of soft tissue sarcomas. Br J Cancer 2024:10.1038/s41416-024-02674-y. [PMID: 38734790 DOI: 10.1038/s41416-024-02674-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 03/24/2024] [Accepted: 03/27/2024] [Indexed: 05/13/2024] Open
Abstract
Soft tissue sarcomas (STS) are rare tumours arising in mesenchymal tissues and can occur almost anywhere in the body. Their rarity, and the heterogeneity of subtype and location, means that developing evidence-based guidelines is complicated by the limitations of the data available. This makes it more important that STS are managed by expert multidisciplinary teams, to ensure consistent and optimal treatment, recruitment to clinical trials, and the ongoing accumulation of further data and knowledge. The development of appropriate guidance, by an experienced panel referring to the evidence available, is therefore a useful foundation on which to build progress in the field. These guidelines are an update of the previous versions published in 2010 and 2016 [1, 2]. The original guidelines were drawn up by a panel of UK sarcoma specialists convened under the auspices of the British Sarcoma Group (BSG) and were intended to provide a framework for the multidisciplinary care of patients with soft tissue sarcomas. This iteration of the guidance, as well as updating the general multidisciplinary management of soft tissue sarcoma, includes specific sections relating to the management of sarcomas at defined anatomical sites: gynaecological sarcomas, retroperitoneal sarcomas, breast sarcomas, and skin sarcomas. These are generally managed collaboratively by site specific multidisciplinary teams linked to the regional sarcoma specialist team, as stipulated in the recently published sarcoma service specification [3]. In the UK, any patient with a suspected soft tissue sarcoma should be referred to a specialist regional soft tissues sarcoma service, to be managed by a specialist sarcoma multidisciplinary team. Once the diagnosis has been confirmed using appropriate imaging and a tissue biopsy, the main modality of management is usually surgical excision performed by a specialist surgeon, combined with pre- or post-operative radiotherapy for tumours at higher risk for local recurrence. Systemic anti-cancer therapy (SACT) may be utilised in cases where the histological subtype is considered more sensitive to systemic treatment. Regular follow-up is recommended to assess local control, development of metastatic disease, and any late effects of treatment.
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Affiliation(s)
- Andrew J Hayes
- The Sarcoma Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK.
- The Institute of Cancer Research, London, SM2 5NG, UK.
| | - Ioanna F Nixon
- Department of Clinical Oncology, The Beatson West of Scotland Cancer Center, Glasgow, G12 0YN, UK
| | - Dirk C Strauss
- The Sarcoma Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Beatrice M Seddon
- Department of Medical Oncology, University College London Hospital NHS Foundation Trust, London, NW1 2BU, UK
| | - Anant Desai
- The Midlands Abdominal and Retroperitoneal Sarcoma Unit, Queen Elizabeth Hospital, Birmingham, B15 2WB, UK
| | - Charlotte Benson
- The Sarcoma Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Ian R Judson
- The Institute of Cancer Research, London, SM2 5NG, UK
| | - Adam Dangoor
- Department of Medical Oncology, University Hospitals Bristol & Weston NHS Foundation Trust, Bristol, BS1 3NU, UK
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Adjuvant Radiation after Primary Resection of Atypical Lipomatous Tumors of the Extremity Reduces Local Recurrence but Increases Complications: A Multicenter Evaluation. Sarcoma 2022; 2022:2091677. [PMID: 36046749 PMCID: PMC9424010 DOI: 10.1155/2022/2091677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 07/11/2022] [Accepted: 07/15/2022] [Indexed: 11/21/2022] Open
Abstract
Background Radiation after resection of an atypical lipomatous tumor (ALT) is controversial. This study evaluates local control and complications after the first resection of ALTs of the extremity with or without adjuvant radiation. Methods A dual institution, retrospective review of patients treated from 1995 to 2020 with first-time resection of an ALT in the extremity was performed. In total, 102 patients underwent adjuvant radiation (XRT group) and 68 patients were treated with surgery alone (no-XRT group). The median follow-up time was 4.6 years (interquartile range (IQR) 2.0–7.3 years). The median radiation dose was 60 Gy (IQR 55–66 Gy). Univariable and multivariable analyses evaluated the association of patient, tumor, and treatment variables with recurrence and complications. Kaplan–Meier analysis evaluated local recurrence-free survival (LRFS) and time to complication. Results The overall incidence of local recurrence was 1% (1/102) in the XRT group and 24% (16/68) in the no-XRT group (p < 0.001). The median time-to-recurrence was 8.2 years (IQR 6.5–10.5 years). In the XRT and the no-XRT groups, 5-yr LRFS was 98% and 92% (p=0.21) and 10-yr LRFS was 98% and 41% (p < 0.001), respectively. The absence of radiation (HR = 23.63, 95% CI (3.09–180.48); p < 0.001) and R2 surgical resection margins (HR = 11.04, 95% CI (2.07–59.03); p < 0.001) incurred a 23-fold and 11-fold increased risk of local recurrence, respectively, while tumor size, depth, location, and neurovascular involvement were not found to be independent predictors of recurrence. The complication rate was 37% (38/102) in the XRT group and 10% (7/68) in the no-XRT group (p < 0.001). Eight patients (8/102, 8%) required surgical management for complication in the XRT group compared with two patients (2/68, 3%) in the no-XRT group (p=0.10). Higher radiation dose had a modest correlation with increased severity of complication (ρ=0.24; p=0.02). Conclusions Adjuvant radiation after first-time resection of an ALT of the extremity was associated with a significantly reduced risk of local recurrence but a three-fold increase in complication rate. These data support a 10-year follow-up for these patients and inform a notable clinical trade-off if considering adjuvant radiation for this tumor with recurrent potential.
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Olson CR, Suarez-Kelly LP, Ethun CG, Shelby RD, Yu PY, Hughes TM, Palettas M, Tran TB, Poultsides G, Tseng J, Roggin KK, Chouliaras K, Votanopoulos K, Krasnick BA, Fields RC, King DM, Bedi M, Pollock RE, Grignol VP, Cardona K, Howard JH. Resection Status Does Not Impact Recurrence in Well-Differentiated Liposarcoma of the Extremity. Am Surg 2021; 87:1752-1759. [PMID: 34758653 DOI: 10.1177/00031348211054536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Well-differentiated liposarcoma (WDLPS) is a low-grade soft tissue sarcoma with a propensity for local recurrence. The necessity of obtaining microscopically free surgical margins (R0) to minimize local recurrence is not clear. This study evaluates recurrence-free survival (RFS) of extremity WDLPS in relation to resection margin status. METHODS A retrospective review of adult patients with primary extremity WDLPS at seven US institutions from 2000 to 2016 was performed. Patients with recurrent tumors or incomplete resection (R2) were excluded. Clinicopathologic factors were analyzed to assess impact on local RFS. RESULTS 97 patients with primary extremity WDLPS were identified. The majority of patients had deep, lower extremity tumors. Mean tumor size was 18.2±8.9cm. Patients were treated with either radical (76.3%) or excisional (23.7%) resections; 64% had R0 and 36% had microscopically positive (R1) resection margins. Ten patients received radiation therapy with no difference in receipt of radiation between R0 vs R1 groups. Thirteen patients (13%) developed a local recurrence with no difference in RFS between R0 vs R1 resection. Five-year RFS was 59.5% for R0 vs 85.2% for R1. Only one patient died of disease after developing dedifferentiation and distant metastasis despite originally having an R0 resection. DISCUSSION In this large multi-institutional study of surgical resection of extremity WDLPS, microscopically positive margins were not associated with an increased risk of recurrence. Positive microscopic margin resection for extremity WDLPS may yield similar rates of local control while avoiding a radical approach to obtain microscopically negative margins.
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Affiliation(s)
- Chelsea R Olson
- Department of Surgery, 5557University of South Alabama, Mobile, AL, USA
| | | | - Cecilia G Ethun
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Rita D Shelby
- Department of Surgery, 10624Stanford University, Palo Alto, CA, USA
| | - Peter Y Yu
- Department of Surgery, 10624Stanford University, Palo Alto, CA, USA
| | - Tasha M Hughes
- Department of Surgery, 10624Stanford University, Palo Alto, CA, USA
| | - Marilly Palettas
- Department of Surgery, 10624Stanford University, Palo Alto, CA, USA
| | - Thuy B Tran
- Department of Surgery, Wake Forest University, Winston-Salem, NC, USA
| | - George Poultsides
- Department of Surgery, Wake Forest University, Winston-Salem, NC, USA
| | - Jennifer Tseng
- Department of Surgery, 12275Washington University School of Medicine, St. Louis, MO, USA
| | - Kevin K Roggin
- Department of Surgery, 12275Washington University School of Medicine, St. Louis, MO, USA
| | | | | | - Bradley A Krasnick
- Department of Surgery, 12306The Ohio State University, Columbus, OH, USA
| | - Ryan C Fields
- Department of Surgery, 12306The Ohio State University, Columbus, OH, USA
| | - David M King
- Department of Surgery, 23034Emory University, Atlanta, GA, USA
| | - Meena Bedi
- Department of Surgery, 23034Emory University, Atlanta, GA, USA
| | - Raphael E Pollock
- Department of Surgery, 12306The Ohio State University, Columbus, OH, USA
| | | | - Kenneth Cardona
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - J Harrison Howard
- Department of Surgery, 5557University of South Alabama, Mobile, AL, USA.,Department of Surgery, 10624Stanford University, Palo Alto, CA, USA
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Atypical Lipomatous Tumors: Does Our Inconsistent Terminology Have Patient Repercussions? Results of a Meta-Analysis. Am J Clin Oncol 2020; 42:487-492. [PMID: 30932920 DOI: 10.1097/coc.0000000000000540] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Misnaming low-grade lipomatous tumors poses a clinical and medicolegal challenge, potentially subjecting patients to expensive and unnecessary surgeries. The terms atypical lipomatous tumor (ALT) and "well-differentiated" liposarcoma (WDL) have been used interchangeably in pathology reports, scholarly works and consensus recommendations, creating vagaries between low-virulence extremity tumors and retroperitoneal disease with metastatic potential. METHODS A systematic review was performed on all studies that reported on the local recurrence rate and metastasis of ALTs and WDLs in living human subjects. Local recurrence and metastases were compared using Fisher's Exact Test. RESULTS In total, 20 studies evaluated ALTs (n=936), whereas 13 studied WDLs (n=626). Mean follow-up was 6.6±2.0 years (median, 7.0 y). No metastatic disease was observed among ALTs, whereas 15 patients with WDLs (2.7%, P<0.0001) had metastases. The local recurrence rate of ALTs was significantly lower than WDLs after both marginal (15.1%, 141/936 vs. 46.0%, 288/626, P<0.0001) and wide excisions (3.3%, 2/59 in ALT vs. 17.4%, 19/109, P=0.007). CONCLUSIONS ALT should be reserved for extremity lesions meeting appropriate histopathologic criteria that represent nonmetastatic disease, reducing over-diagnosis, over-treatment, and patient risk.
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Lali BS, Kini H, Chakraborti S, Kini J, Suresh PK. Analysis of Dedifferentiated Liposarcomas Emphasizing the Diagnostic Dilemmas. Indian J Med Paediatr Oncol 2020. [DOI: 10.4103/ijmpo.ijmpo_129_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Abstract
Introduction: Dedifferentiated liposarcoma (DDLPS) is defined as a progression of well-differentiated liposarcoma (WDLPS) to another nonlipogenic sarcoma. Since a variety of heterologous sarcomas can be encountered in dedifferentiation, clinical dilemmas arise. The present study analyzed the role of clinicopathologic and immunohistochemical (IHC) features in the diagnosis of DDLPS and its differentiation from mimics. Materials and Methods: A retrospective and prospective study was conducted wherein all cases of liposarcoma from 2012 to 2017 were reviewed. DDLPS cases were identified among pleomorphic lesions. Clinical and histopathological details for these cases were retrieved from medical records section and department archives. Histomorphology and immunohistochemistry (MDM2, S100, and Ki-67) were analyzed for these cases. Results: Among 37 cases of liposarcomas reviewed, DDLPS was diagnosed in 12 cases (32.4%). Mean age of the patients was 54.3 years with equal gender distribution (M:F =1:1.2). Two patients had recurrent tumors. Most were retroperitoneal (58.3%) with mean duration of symptoms being 8.7 months. Mean tumor dimension was 17.5 cm. High-grade dedifferentiated component was most common (83.3%) with only one case each (8.3%) of low-grade and homologous dedifferentiation. Undifferentiated pleomorphic sarcoma was the frequent nonlipogenic sarcoma. MDM2 overexpression was detected in 100%, focal S100 positivity seen in 66.6%, and mean Ki-67 labeling index was 24. Conclusion: DDLPS exhibits aggressive clinical behavior. Adequate sampling, correlation to clinical details, demonstration of transition from WDLPS to DDLPS aid in narrowing the differentials. Immunostaining with MDM2 helps in definite categorization and S100 highlights lipoblasts, when they are not easily identifiable. MDM2, CDK4, and p16 IHC panel is recommended in all cases and fluorescence in situ hybridization analysis where IHC is noncontributory.
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Affiliation(s)
- Bhagat Singh Lali
- Department of Pathology, Kasturba Medical College, Manipal Academy of Higher Education, Mangalore, Karnataka, India
| | - Hema Kini
- Department of Pathology, Kasturba Medical College, Manipal Academy of Higher Education, Mangalore, Karnataka, India
| | - Shrijeet Chakraborti
- Department of Cellular Pathology, Leighton Hospital, Mid Cheshire NHS Foundation Trust Hospitals, Crewe, England
| | - Jyoti Kini
- Department of Pathology, Kasturba Medical College, Manipal Academy of Higher Education, Mangalore, Karnataka, India
| | - Pooja K Suresh
- Department of Pathology, Kasturba Medical College, Manipal Academy of Higher Education, Mangalore, Karnataka, India
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Soft-tissue fat tumours: differentiating malignant from benign using proton density fat fraction quantification MRI. Clin Radiol 2019; 74:534-538. [DOI: 10.1016/j.crad.2019.01.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 01/15/2019] [Indexed: 12/20/2022]
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Wang J, Du YP, Li SX, Hu JH, Wang CX. Recurrent paratesticular dedifferentiated liposarcoma after contralateral radical orchiectomy. Asian J Androl 2018; 20:520-522. [PMID: 29623907 PMCID: PMC6116691 DOI: 10.4103/aja.aja_18_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Jin Wang
- Department of Urology, The First Hospital of Jilin University, Changchun 130021, China
| | - Yi-Peng Du
- Department of Anesthesiology, The First Hospital of Jilin University, Changchun 130021, China
| | - Sheng-Xian Li
- Department of Urology, The First Hospital of Jilin University, Changchun 130021, China
| | - Jing-Hai Hu
- Department of Urology, The First Hospital of Jilin University, Changchun 130021, China
| | - Chun-Xi Wang
- Department of Urology, The First Hospital of Jilin University, Changchun 130021, China
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Gundle KR, Gupta S, Kafchinski L, Griffin AM, Kandel RA, Dickson BC, Chung PW, Catton CN, O’Sullivan B, Ferguson PC, Wunder JS. An Analysis of Tumor- and Surgery-Related Factors that Contribute to Inadvertent Positive Margins Following Soft Tissue Sarcoma Resection. Ann Surg Oncol 2017; 24:2137-2144. [DOI: 10.1245/s10434-017-5848-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Indexed: 12/15/2022]
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