Future directions in the management of soft tissue sarcomas

Adjuvant chemotherapy for adult soft tissue sarcomas of the extremities and girdles: results of the Italian randomized cooperative trial

PURPOSE

Adjuvant chemotherapy for soft tissue sarcoma is controversial because previous trials reported conflicting results. The present study was designed with restricted selection criteria and high dose-intensities of the two most active chemotherapeutic agents.

PATIENTS AND METHODS

Patients between 18 and 65 years of age with grade 3 to 4 spindle-cell sarcomas (primary diameter > or = 5 cm or any size recurrent tumor) in extremities or girdles were eligible. Stratification was by primary versus recurrent tumors and by tumor diameter greater than or equal to 10 cm versus less than 10 cm. One hundred four patients were randomized, 51 to the control group and 53 to the treatment group (five cycles of 4'-epidoxorubicin 60 mg/m(2) days 1 and 2 and ifosfamide 1.8 g/m(2) days 1 through 5, with hydration, mesna, and granulocyte colony-stimulating factor).

RESULTS

After a median follow-up of 59 months, 60 patients had relapsed and 48 died (28 and 20 in the treatment arm and 32 and 28 in the control arm, respectively). The median disease-free survival (DFS) was 48 months in the treatment group and 16 months in the control group (P =.04); and the median overall survival (OS) was 75 months for treated and 46 months for untreated patients (P =.03). For OS, the absolute benefit deriving from chemotherapy was 13% at 2 years and increased to 19% at 4 years (P =.04).

CONCLUSION

Intensified adjuvant chemotherapy had a positive impact on the DFS and OS of patients with high-risk extremity soft tissue sarcomas at a median follow-up of 59 months. Therefore, our data favor an intensified treatment in similar cases. Although cure is still difficult to achieve, a significant delay in death is worthwhile, also considering the short duration of treatment and the absence of toxic deaths.

Sarcomas and other malignancies of soft tissue, retroperitoneum, peritoneum, pleura, heart, mediastinum, and spleen

BACKGROUND

Malignant neoplasms of the structural tissues, consisting mostly of soft tissue sarcomas, are morphologically diverse and rarely treated for epidemiologic purposes as individual entities. Our understanding to date of the pattern of occurrence of sarcomas is based largely on reports of limited individual clinic experience or case-control studies, each driven by a single hypothesis, and there have been virtually no descriptions according to specific morphologic type.

METHODS

The accumulated coverage of the SEER populations offers an opportunity to correct this deficit. Each of the diagnoses has been reported and coded using a single set of rules and described in relation to the population at risk in terms of age, sex, race, calendar period, anatomic location, and outcome. In addition, each morphologic type has been compared with each of the others with respect to the pattern of occurrence and survival.

RESULTS

For most of the individual morphologic entities, the pattern of occurrence is specific and unlike other patterns. Differences according to anatomic site, age, sex, race, and period-specific survival were found. Partly because of changes in diagnostic criteria over the years, differences in secular trend, other than that for Kaposi's sarcoma, could not be verified. Although some types of sarcoma may have important genetic determinants, there is evidence of environmental causation in others; for some varieties both genetic and environmental factors may operate. There is no evidence of improvements in survival.

CONCLUSIONS

The most likely basis for the observed patterns are morphology-specific differences in etiology and growth phase. Each of the entities should be considered etiologically distinct and should be studied individually whenever possible.

Soft tissue and visceral sarcomas in Irish patients. Interim analysis of data obtained by the Dublin Soft Tissue Tumour Panel

The Dublin Soft Tissue Sarcoma Panel was established in 1989 with a view to achieving a unified approach to diagnosis and management of soft tissue and visceral sarcomas. This interim report presents data on 265 prospectively-evaluated patients and on a separate retrospective series of 126 patients. The patients in the prospective series were treated by 93 different surgical and medical specialists. Tumours presented in all anatomic sites and ranged in size from 0.2 to 60 cm. Leiomyosarcoma was the commonest tumour type. Eighty-nine tumours were inoperable at clinical presentation. There was a consensus panel diagnosis in over 90%, non-neoplastic reactive lesions and primitive round cell tumours being the most difficult cases diagnostically. Management, including onward referral for chemotherapy or radiation therapy, was inconsistent. The 2-year survival figures were: 43% (1989-91) and 37% (1980-88). These findings should provide a basis for the evaluation of coherent treatment strategies for Irish sarcoma patients.