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Brachytherapy in the Treatment of Soft-Tissue Sarcomas of the Extremities-A Current Concept and Systematic Review of the Literature. Cancers (Basel) 2023; 15:cancers15041133. [PMID: 36831476 PMCID: PMC9954233 DOI: 10.3390/cancers15041133] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/02/2023] [Accepted: 02/06/2023] [Indexed: 02/12/2023] Open
Abstract
INTRODUCTION Evidence on the use of brachytherapy in soft-tissue sarcoma (STS) is sparse. Therapy regimens are determined more by local interdisciplinary tumor conferences than by standardized protocols. Patient-specific factors complicate the standardized application of therapy protocols. The individuality of the treatment makes it difficult to compare results. MATERIALS AND METHODS A comprehensive literature search was conducted, whereby the literature from a period of almost 44 years (1977-2021) was graded and included in this systematic review. For this purpose, PubMed was used as the primary database. Search string included "soft-tissue sarcoma", "brachytherapy", and "extremity." Four independent researchers reviewed the literature. Only full-text articles written in English or German were included. RESULTS Of the 175 identified studies, 70 were eligible for analysis based on the inclusion and exclusion criteria. The key points to compare were local complications, recurrence rate and correlation with margins of resection, and the use of brachytherapy regarding tumor grading. CONCLUSION Brachytherapy represents an important subset of radiotherapy techniques used in STSs, whose indications and applications are constantly evolving, and for which a local control rate of 50% to 96% has been reported as monotherapy, depending on risk factors. However, the best benefit is seen in the combination of further resection and brachytherapy, and most authors at many other centers agree with this treatment strategy.
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Bray J, Eward W, Breen M. Defining the relevance of surgical margins. Part two: Strategies to improve prediction of recurrence risk. Vet Comp Oncol 2023; 21:145-158. [PMID: 36745110 DOI: 10.1111/vco.12881] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 12/03/2022] [Accepted: 02/03/2023] [Indexed: 02/07/2023]
Abstract
Due to the complex nature of tumour biology and the integration between host tissues and molecular processes of the tumour cells, a continued reliance on the status of the microscopic cellular margin should not remain our only determinant of the success of a curative-intent surgery for patients with cancer. Based on current evidence, relying on a purely cellular focus to provide a binary indication of treatment success can provide an incomplete interpretation of potential outcome. A more holistic analysis of the cancer margin may be required. If we are to move ahead from our current situation - and allow treatment plans to be more intelligently tailored to meet the requirements of each individual tumour - we need to improve our utilisation of techniques that either improve recognition of residual tumour cells within the surgical field or enable a more comprehensive interrogation of tumour biology that identifies a risk of recurrence. In the second article in this series on defining the relevance of surgical margins, the authors discuss possible alternative strategies for margin assessment and evaluation in the canine and feline cancer patient. These strategies include considering adoption of the residual tumour classification scheme; intra-operative imaging systems including fluorescence-guided surgery, optical coherence tomography and Raman spectroscopy; molecular analysis and whole transcriptome analysis of tissues; and the development of a biologic index (nomogram). These techniques may allow evaluation of individual tumour biology and the status of the resection margin in ways that are different to our current techniques. Ultimately, these techniques seek to better define the risk of tumour recurrence following surgery and provide the surgeon and patient with more confidence in margin assessment.
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Affiliation(s)
| | - Will Eward
- Orthopedic Surgical Oncologist, Duke Cancer Center, Durham, North Carolina, USA
| | - Matthew Breen
- Oscar J. Fletcher Distinguished Professor of Comparative Oncology Genetics, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
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Surgical Excision of Intramuscular Sarcomas: Description of Three Cases in Dogs. Animals (Basel) 2023; 13:ani13020218. [PMID: 36670758 PMCID: PMC9854821 DOI: 10.3390/ani13020218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/20/2022] [Accepted: 01/04/2023] [Indexed: 01/11/2023] Open
Abstract
Compartmental excision consists of the complete resection of an anatomic district in which specific structures act as a barrier to local tumour invasion. It is a well-established procedure in human medicine, while only a few reports are available in veterinary medicine. The aim of this study was to describe complete muscle resection in 3 dogs affected by different intramuscular sarcomas. The clinical outcome was also reported. Medical records were searched, including preoperative diagnostic findings, compartmental excision, histologic diagnosis, and outcome. Three dogs fit the inclusion criteria, which had a sarcoma confined to a single muscular belly (semitendinosus, biceps, and splenius capitis muscles). Complete excision of the affected muscle was performed in all cases. One dog showed moderate lameness in the immediate postoperative period, resulting from the dorsal lifting of the scapula due to serratus ventralis tenotomy performed to remove the caudal insertion of the splenius capitis muscle. All the dogs recovered fully within one month, experiencing good clinical function. Histopathology showed complete tumour removal with no neoplastic fascial disruption in all cases. Compartmental excision provides effective local tumour control, representing an alternative to limb amputation or more radical excision if adjuvant radiotherapy is not an option for owners.
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Stiles ZE, Lohman RF, Mann GN. Plastic Surgery Reconstruction of Sarcoma Resection Defects. Surg Clin North Am 2022; 102:583-599. [DOI: 10.1016/j.suc.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Mohamed R, Shuja M, Al-Hazienh A, Aly M. A retrospective comparison of two different immobilization systems for radiotherapy of extremity soft tissue sarcomas and its influence on CTV-PTV margin. J Egypt Natl Canc Inst 2021; 33:27. [PMID: 34568989 DOI: 10.1186/s43046-021-00076-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 07/16/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND On account of extremity wide range of movements and difficulty of reproducibility during irradiation of extremity sarcomas, assorted immobilization strategies are employed to eliminate setup errors. The study purpose was to compare the setup errors of the commonly used immobilization tools and to define planning target volume (PTV) margins for each device. METHODS A retrospective review comparing Vac-Loc™ and thermoplastic cast (Tcast) was conducted. On radiotherapy treatment, portal imaging was matched with the pre-treatment simulation imaging for both fixation tools. The isocenter shifts and total vector error (TVE) were compared. Random (σ) and systemic errors (Σ) were computed and PTV margins were defined. RESULTS Three hundred seven shifts in each direction measured in 14 patients. Mean displacements for the Vac-Loc™ and Tcast, respectively, were as follow: vertical; -0.01 cm vs. 0.02 cm, longitudinal; 0.03 cm vs. 0.04; lateral; 0.04 cm vs. 0.00 cm and TVE; 0.15 cm vs. 0.17 cm with no significant statistical difference. Random and systemic errors were comparable for both devices. The lateral displacement and rotational random errors were higher Vac-Loc™ compared to Tcast. Overall measured PTV margins were marginally lower for Tcast compared to Vac-Loc™. CONCLUSION Vac-Loc™ and Tcast are valid options for immobilization with no clear superiority of either device. The marginal advantage of Tcast warrants further prospective studies.
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Affiliation(s)
- Reham Mohamed
- Radiotherapy and Nuclear Medicine Department, Cairo University, National Cancer Institute, Cairo, Egypt. .,King Fahad Medical City, Radiation Oncology Department, Riyadh, Saudi Arabia.
| | - Muhammad Shuja
- Radiation Oncology Department, Mayo Clinic, Rochester, USA
| | - Asaad Al-Hazienh
- King Fahad Medical City, Radiation Oncology Department, Radiation therapy unit, Riyadh, Saudi Arabia
| | - Moamen Aly
- King Fahad Medical City, Medical Physics Department, Riyadh, Saudi Arabia.,South Egypt Cancer Institute, Medical Physics Unit, Radiotherapy and Nuclear Medicine Department, Assiut University, Assiut, Egypt
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Chiti LE, Ferrari R, Roccabianca P, Boracchi P, Godizzi F, Busca GA, Stefanello D. Surgical Margins in Canine Cutaneous Soft-Tissue Sarcomas: A Dichotomous Classification System Does Not Accurately Predict the Risk of Local Recurrence. Animals (Basel) 2021; 11:ani11082367. [PMID: 34438827 PMCID: PMC8388623 DOI: 10.3390/ani11082367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/02/2021] [Accepted: 08/09/2021] [Indexed: 12/18/2022] Open
Abstract
Simple Summary Histological evaluation of surgical margins is crucial for correct prognostication and adjuvant treatment recommendation after excision of soft tissue sarcoma (STS) in dogs. Incompletely excised STS have a high risk of local recurrence (LR), while completely excised STS without other negative prognostic factors are generally associated with a good prognosis. However, guidelines are lacking on how to manage STS excised with clean but close margins (CbCM), although some authors advocated their inclusion in the tumor-free margin group. This retrospective study investigates the impact of CbCM on LR of canine STS. Ninety-eight surgical excised canine STS at first presentation were included. Cumulative incidence of LR was estimated for each category of margins (tumor-free, infiltrated, CbCM), and after grouping CbCM alternatively in the tumor-free and infiltrated category. Cumulative incidence of LR at three years differed significantly between the three categories, and it was estimated to be 42% with infiltrated margins, 23% with CbCM, 7% with tumor-free margins. Both when CbCM were grouped with infiltrated margins or with tumor-free margins, the incidence of LR was statistically different. The rate of LR with CbCm was greater than with tumor-free margins. The category CbCM may be considered as a separate prognostic category. Abstract Adjuvant treatments are recommended in dogs with incompletely excised cutaneous soft-tissue sarcoma (STS) to reduce the risk of local recurrence (LR), although guidelines are lacking on how to manage clean but close margins (CbCM). This retrospective study investigates the impact of CbCM on LR of canine STS. Ninety-eight surgically excised canine STS at first presentation were included. Tissue samples were routinely trimmed and analyzed. Cumulative incidence of LR was estimated for each category of margins (tumor-free, infiltrated, CbCM), and included CbCM in the tumor-free and infiltrated category, respectively. The prognostic impact on LR was then adjusted for relevant prognostic factors. Cumulative incidence of LR at three years differed significantly between the three categories (p = 0.016), and was estimated to be 42% with infiltrated margins, 23% with CbCM, 7% with tumor-free margins. Both when CbCM were grouped with infiltrated margins (p = 0.033; HR = 5.05), and when CbCM were grouped with tumor-free margins (p = 0.011; HR = 3.13), a significant difference between groups was found. STS excised with infiltrated margins had the greatest risk of LR. The rate of LR with CbCm was greater than recurrence rate of tumor-free margins. The category CbCM may be considered as a separate prognostic category.
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Affiliation(s)
- Lavinia Elena Chiti
- Dipartimento di Medicina Veterinaria, Università degli Studi di Milano, 26900 Lodi, Italy; (L.E.C.); (P.R.); (F.G.); (D.S.)
| | - Roberta Ferrari
- Dipartimento di Medicina Veterinaria, Università degli Studi di Milano, 26900 Lodi, Italy; (L.E.C.); (P.R.); (F.G.); (D.S.)
- Correspondence:
| | - Paola Roccabianca
- Dipartimento di Medicina Veterinaria, Università degli Studi di Milano, 26900 Lodi, Italy; (L.E.C.); (P.R.); (F.G.); (D.S.)
| | - Patrizia Boracchi
- Laboratorio di Statistica Medica, Biometrica ed Epidemiologia “A. Maccaro”, Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, 20122 Milan, Italy;
| | - Francesco Godizzi
- Dipartimento di Medicina Veterinaria, Università degli Studi di Milano, 26900 Lodi, Italy; (L.E.C.); (P.R.); (F.G.); (D.S.)
| | | | - Damiano Stefanello
- Dipartimento di Medicina Veterinaria, Università degli Studi di Milano, 26900 Lodi, Italy; (L.E.C.); (P.R.); (F.G.); (D.S.)
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Collier CD, Kim CY, Liu RW, Getty PJ. The Interval Between Preoperative Radiation and Surgery Is Not Associated with Overall Survival for Soft-tissue Sarcomas: An Analysis of the National Cancer Database. Clin Orthop Relat Res 2021; 479:506-517. [PMID: 32401002 PMCID: PMC7899587 DOI: 10.1097/corr.0000000000001287] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 04/14/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Most cancer centers prefer preoperative radiation therapy (preRT) over postoperative therapy to treat soft-tissue sarcoma (STS) to limit long-term fibrosis, joint stiffness, and edema. Surgery is often delayed after preRT to allow for tissue recovery and to reduce wound complications. However, the association between the time interval between preRT and surgery and survival is unknown. QUESTIONS/PURPOSES (1) What factors are associated with the preRT-surgery interval in patients with STS? (2) Is the preRT-surgery interval associated with overall survival? METHODS The National Cancer Database, a nationwide registry that includes 70% of all new cancers in the United States with 90% follow-up, was reviewed to identify 6378 patients who underwent preRT and surgical resection for a localized extremity or pelvic STS from 2004 to 2014. Patients were excluded if they had lymphatic or metastatic disease at diagnosis (23%; n = 1438), underwent neoadjuvant chemotherapy (24%; 1531), were missing vital status (8%; 487), had chemosensitive histologies (9%; 603), underwent radiation other than external beam (1%; 92), were missing preRT-surgery interval (1%; 45), or had a preRT-surgery interval greater than 120 days (< 1%; 6). A total of 2176 patients were included for analysis, with a mean preRT-surgery interval of 35 ± 16 days. A multiple linear regression model was generated to assess demographic, clinicopathologic, and treatment characteristics associated with the preRT-surgery interval. A Kaplan-Meier survival analysis was then conducted, stratified by the preRT-surgery interval, to assess survival over 10 years. Finally, a multivariate Cox regression analysis model was constructed to further evaluate the association between the preRT-surgery interval and overall survival, adjusted for demographic, clinicopathologic, and treatment characteristics. RESULTS A longer preRT-surgery interval was associated with higher age (β = 0.002 per year [95% CI 0.0 to 0.004]; p = 0.026), tumor location in the pelvis (compared with the lower extremity; β = 0.15 [95% CI 0.082 to 0.22]; p < 0.001), and malignant peripheral nerve sheath tumor subtype (compared with undifferentiated pleomorphic sarcoma; β = 0.17 [95% CI 0.044 to 0.29]; p = 0.008). A shorter preRT-surgery interval was associated with higher facility volume (β = -0.002 per case [95% CI -0.003 to -0.002]; p = 0.026) and higher tumor stage (compared with Stage I; β = -0.066 [95% CI -0.13 to -0.006]; p = 0.03 for Stage II; β = -0.12 [95% CI -0.17 to -0.065]; p < 0.001 for Stage III). The 5-year overall survival rates were similar across all preRT-surgery interval groups: less than 3 weeks (66% [95% CI 60 to 72]), 3 to 4 weeks (65% [95% CI 60 to 71]), 4 to 5 weeks (65% [95% CI 60 to 71]), 5 to 6 weeks (66% [95% CI 60 to 72]), 6 to 7 weeks (63% [95% CI 54 to 72]), 7 to 9 weeks (66% [95% CI 58 to 74]), and more than 9 weeks (59% [95% CI 48 to 69]). Over 10 years, no difference in overall survival was observed when stratified by the preRT-surgery interval (p = 0.74). After controlling for potentially confounding variables, including age, sex, Charlson/Deyo comorbidity score, histology, tumor size, stage and surgery type, the preRT-surgery interval was not associated with survival (hazard ratio = 1 per day [95% CI 1 to 1]; p = 0.88). CONCLUSION With the numbers available, this study demonstrates that a delay in surgery up to 120 days after radiation is not associated with poorer survival. Therefore, clinicians may be able to delay surgery to minimize the risks of wound complications and modifiable comorbidities without affecting overall survival.Level of Evidence Level III, therapeutic study.
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Affiliation(s)
- Christopher D Collier
- C. D. Collier, C.-Y. Kim, R. W. Liu, P. J. Getty, Department of Orthopaedics, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
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Six-Week Interval Between Preoperative Radiation and Surgery Is Associated With Fewer Major Wound Complications in Soft Tissue Sarcoma. Am J Clin Oncol 2020; 43:491-495. [PMID: 32217853 DOI: 10.1097/coc.0000000000000692] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES A total of 30% to 40% of soft tissue sarcoma (STS) patients develop major wound complications (MWCs) after preoperative radiation (preRT). The optimal preRT-surgery interval and its association with MWCs is unknown. This study investigated whether a longer preRT-surgery interval is associated with fewer MWCs compared with historical controls. METHODS All patients treated by a single surgeon after preRT with limb-sparing wide resection for extremity and trunk STS were retrospectively reviewed from 2004 to 2014. The primary outcome was MWCs defined as a secondary operation, invasive procedure, wound packing, or readmission for wound care. Secondary outcomes of local recurrence and survival were followed and independent variables were analyzed for an association with MWCs. RESULTS Fifty-four patients were included with a median follow-up of 32 months and age of 61 years. The majority of tumors were deep (91%), large (median size of 11 cm), high grade (78%) and within the lower extremity (78%). The median preRT-surgery interval was 43 days and 80% of patients received surgery 35 to 49 days after radiation. MWCs were observed in 15% of patients and 88% occurred within 40 days. Predictors for MWCs on multivariate analysis were peripheral vascular disease (P=0.03), location in the medial compartment of the thigh (P=0.03), and neurovascular involvement (P=0.03). CONCLUSIONS This study presents a cohort of STS patients with an extended preRT-surgery interval of ~6 weeks. MWCs in this population occurred at a lower rate than historical controls. Overall these findings support the exploration of a longer interval to reduce MWCs and their associated morbidity.
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9
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Bray J. Histologic margins and the residual tumour classification scheme. Vet Comp Oncol 2020; 18:445-446. [PMID: 32378307 DOI: 10.1111/vco.12607] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 04/30/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Jonathan Bray
- Fitzpatrick Referrals Oncology and Soft Tissue, Guildford, UK
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Götzl R, Sterzinger S, Semrau S, Vassos N, Hohenberger W, Grützmann R, Agaimy A, Arkudas A, Horch RE, Beier JP. Patient's quality of life after surgery and radiotherapy for extremity soft tissue sarcoma - a retrospective single-center study over ten years. Health Qual Life Outcomes 2019; 17:170. [PMID: 31703704 PMCID: PMC6842193 DOI: 10.1186/s12955-019-1236-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 10/22/2019] [Indexed: 01/12/2023] Open
Abstract
Background and objectives The purpose of this study is to analyze major complication rates and different aspects of health-related quality of life (HRQoL) in extremity soft tissue sarcoma (STS) patients treated with or without radio (chemo) therapy and surgery. Methods We performed a retrospective analysis of all patients who underwent Extremity STS excision from 2004 to 2014 (182 patients included). Patients’ data were collected from patients’ records. HRQoL was assessed by using EORTC QLQ-C30. Results A total of 182 patients underwent sarcoma resection. After neoadjuvant radiochemotherapy (RCT), the major-complication rate amounted to 28% (vs. 7%, no radiotherapy, p < 0.001). Major-complication rates after adjuvant radiotherapy (RT) occurred in 8% (vs. 7%, no radiotherapy, p = 0.265). Comparison QoL scores between treating with neoadjuvant RCT or without RT revealed significant worse scores with neoadjuvant RCT. Further stratification of disease control of these patients showed significant reduced scores in the group of disease-free patients with neoadjuvant RCT compared to irradiated disease-free patients. Discussion To date, there have only been a few investigations of QoL in STS. Retrospective study on quality of life have limitations, like a lack of baseline evaluation of QoL. Patient candidated to radiation therapy could have had worse QoL baseline due to more advanced disease. Disease status of the patients who answered the questionnaires could have been an influence of QoL and we could show reduced scores in the group of disease-free patients with neoadjuvant RCT, but not for the patients with recurrence or metastasis, so it is very hard to discriminate whether radiation therapy could really have an impact or not. Conclusion This study might assist in further improving the understanding of QoL in STS patients and may animate for prospective studies examining the oncological therapies impact on HRQoL.
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Affiliation(s)
- Rebekka Götzl
- Department of Plastic and Hand Surgery, Comprehensive Cancer Center, Universitiy Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany. .,Present Address: Department of Plastic Surgery, Hand and Burn Surgery, University Hospital of Aachen, RWTH University of Aachen, Aachen, Germany.
| | - Sebastian Sterzinger
- Department of Plastic and Hand Surgery, Comprehensive Cancer Center, Universitiy Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Sabine Semrau
- Department of Radiation Oncology, Comprehensive Cancer Center, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Nikolaos Vassos
- Department of Surgery, Comprehensive Cancer Center, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Werner Hohenberger
- Department of Surgery, Comprehensive Cancer Center, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Robert Grützmann
- Department of Surgery, Comprehensive Cancer Center, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Abbas Agaimy
- Department of Pathology, Comprehensive Cancer Center, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Andreas Arkudas
- Department of Plastic and Hand Surgery, Comprehensive Cancer Center, Universitiy Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Raymund E Horch
- Department of Plastic and Hand Surgery, Comprehensive Cancer Center, Universitiy Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Justus P Beier
- Department of Plastic and Hand Surgery, Comprehensive Cancer Center, Universitiy Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany.,Present Address: Department of Plastic Surgery, Hand and Burn Surgery, University Hospital of Aachen, RWTH University of Aachen, Aachen, Germany
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Haas RL, Gronchi A, van de Sande MA, Baldini EH, Gelderblom H, Messiou C, Wardelmann E, Le Cesne A. Perioperative Management of Extremity Soft Tissue Sarcomas. J Clin Oncol 2018; 36:118-124. [DOI: 10.1200/jco.2017.74.7527] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Surgery is potentially curative for primary nonmetastatic extremity soft tissue sarcomas. After surgery alone, patients may remain at risk for local recurrences and/or metastatic disease. To reduce the likelihood of a local relapse, the addition of radiotherapy (RT) to limb-sparing surgery may result in higher local control rates of at least 85%. Generally, it can be stated that local control after both preoperative and postoperative RT is comparable, but that preoperative RT comes with a more favorable toxicity profile after prolonged follow-up, albeit at the cost of a higher wound complication rate. Furthermore, recent data suggest that preoperative RT is more cost effective. To reduce the risk of subsequent metastatic disease, systemic chemotherapy can be introduced early during the primary management of these patients. These systemic chemotherapy regimens can also be applied both preoperatively and postoperatively. Finally, with the aim of increasing the antitumor response of perioperative RT, these agents may even be combined with RT, concurrently and sequentially. While designing new preoperative combination regimens, responses should be carefully monitored by both sophisticated radiologic and pathologic evaluations. This article reviews all these aspects, in addition to limb-sparing surgery.
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Affiliation(s)
- Rick L. Haas
- Rick L. Haas, The Netherlands Cancer Institute, Amsterdam; Rick L. Haas, Michiel A.J. van de Sande, and Hans Gelderblom, Leiden University Medical Centre, Leiden, the Netherlands; Alessandro Gronchi, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy; Elizabeth H. Baldini, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA; Christina Messiou, The Royal Marsden Hospital and The Institute of Cancer Research, London, United Kingdom; Eva Wardelmann, University Hospital
| | - Alessandro Gronchi
- Rick L. Haas, The Netherlands Cancer Institute, Amsterdam; Rick L. Haas, Michiel A.J. van de Sande, and Hans Gelderblom, Leiden University Medical Centre, Leiden, the Netherlands; Alessandro Gronchi, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy; Elizabeth H. Baldini, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA; Christina Messiou, The Royal Marsden Hospital and The Institute of Cancer Research, London, United Kingdom; Eva Wardelmann, University Hospital
| | - Michiel A.J. van de Sande
- Rick L. Haas, The Netherlands Cancer Institute, Amsterdam; Rick L. Haas, Michiel A.J. van de Sande, and Hans Gelderblom, Leiden University Medical Centre, Leiden, the Netherlands; Alessandro Gronchi, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy; Elizabeth H. Baldini, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA; Christina Messiou, The Royal Marsden Hospital and The Institute of Cancer Research, London, United Kingdom; Eva Wardelmann, University Hospital
| | - Elizabeth H. Baldini
- Rick L. Haas, The Netherlands Cancer Institute, Amsterdam; Rick L. Haas, Michiel A.J. van de Sande, and Hans Gelderblom, Leiden University Medical Centre, Leiden, the Netherlands; Alessandro Gronchi, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy; Elizabeth H. Baldini, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA; Christina Messiou, The Royal Marsden Hospital and The Institute of Cancer Research, London, United Kingdom; Eva Wardelmann, University Hospital
| | - Hans Gelderblom
- Rick L. Haas, The Netherlands Cancer Institute, Amsterdam; Rick L. Haas, Michiel A.J. van de Sande, and Hans Gelderblom, Leiden University Medical Centre, Leiden, the Netherlands; Alessandro Gronchi, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy; Elizabeth H. Baldini, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA; Christina Messiou, The Royal Marsden Hospital and The Institute of Cancer Research, London, United Kingdom; Eva Wardelmann, University Hospital
| | - Christina Messiou
- Rick L. Haas, The Netherlands Cancer Institute, Amsterdam; Rick L. Haas, Michiel A.J. van de Sande, and Hans Gelderblom, Leiden University Medical Centre, Leiden, the Netherlands; Alessandro Gronchi, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy; Elizabeth H. Baldini, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA; Christina Messiou, The Royal Marsden Hospital and The Institute of Cancer Research, London, United Kingdom; Eva Wardelmann, University Hospital
| | - Eva Wardelmann
- Rick L. Haas, The Netherlands Cancer Institute, Amsterdam; Rick L. Haas, Michiel A.J. van de Sande, and Hans Gelderblom, Leiden University Medical Centre, Leiden, the Netherlands; Alessandro Gronchi, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy; Elizabeth H. Baldini, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA; Christina Messiou, The Royal Marsden Hospital and The Institute of Cancer Research, London, United Kingdom; Eva Wardelmann, University Hospital
| | - Axel Le Cesne
- Rick L. Haas, The Netherlands Cancer Institute, Amsterdam; Rick L. Haas, Michiel A.J. van de Sande, and Hans Gelderblom, Leiden University Medical Centre, Leiden, the Netherlands; Alessandro Gronchi, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy; Elizabeth H. Baldini, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA; Christina Messiou, The Royal Marsden Hospital and The Institute of Cancer Research, London, United Kingdom; Eva Wardelmann, University Hospital
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Broecker JS, Ethun CG, Monson DK, Lopez-Aguiar AG, Le N, McInnis M, Godette K, Reimer NB, Oskouei SV, Delman KA, Staley CA, Maithel SK, Cardona K. The Oncologic Impact of Postoperative Complications Following Resection of Truncal and Extremity Soft Tissue Sarcomas. Ann Surg Oncol 2017; 24:3574-3586. [DOI: 10.1245/s10434-017-6034-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Indexed: 12/28/2022]
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14
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Carbó-Laso E, Sanz-Ruiz P, Calvo-Haro JA, Cuervo-Dehesa M, Pérez-Mañanes R, Mediavilla-Santos L, Sánchez-Pérez C, Álvarez-González A, Vaquero-Martín J. Intraoperative radiotherapy for extremity soft-tissue sarcomas: can long-term local control be achieved? Int J Clin Oncol 2017; 22:1094-1102. [PMID: 28717856 DOI: 10.1007/s10147-017-1162-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 07/08/2017] [Indexed: 01/20/2023]
Abstract
BACKGROUND Intraoperative electron-beam radiation therapy (IOERT) during limb-sparing surgery has the advantage of delivering a single high boost dose to sarcoma residues and surgical bed area near to radiosensitive structures with limited toxicity. Retrospective studies have suggested that IOERT may improve local control compared to standard radiotherapy and we aimed to demonstrate this theory. Therefore, we performed an observational prospective study to determine (1) if it is possible to achieve high local control by adding IOERT to external-beam radiation therapy (EBRT) in extremity soft-tissue sarcomas (STS), (2) if it is possible to improve long-term survival rates, and (3) if toxicity could be reduced with IOERT MATERIALS AND METHODS: From 1995-2003, 39 patients with extremity STS were treated with IOERT and postoperative radiotherapy. The median follow-up time was 13.2 years (0.7-19). Complications, locoregional control and survival rates were collected. RESULTS Actuarial local control was attained in 32 of 39 patients (82%). Control was achieved in 88% of patients with primary disease and in 50% of those with recurrent tumors (p = 0.01). Local control was shown in 93% of patients with negative margins and in 50% of those with positive margins (p = 0.002). Limb-sparing was achieved in 32 patients (82%). The overall survival rate was 64%. 13% of patients had grade ≥3 acute toxicity, and 12% developed grade ≥3 chronic toxicity. CONCLUSION IOERT used as a boost to EBRT provides high local control and limb-sparing rates in patients with STS of the extremities, with less toxicity than EBRT alone.
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Affiliation(s)
- Esther Carbó-Laso
- Department of Traumatology and Orthopaedic Surgery, General Hospital Gregorio Marañón, Dr. Esquerdo, 46, 28007, Madrid, Spain.
| | - Pablo Sanz-Ruiz
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
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15
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Bray JP. Soft tissue sarcoma in the dog - Part 2: surgical margins, controversies and a comparative review. J Small Anim Pract 2017; 58:63-72. [DOI: 10.1111/jsap.12629] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 07/07/2016] [Accepted: 08/08/2016] [Indexed: 12/12/2022]
Affiliation(s)
- J. P. Bray
- Companion Animal Clinical Studies, Head of Companion Animal Group, IVABS; Massey University; Palmerston North 4442 New Zealand
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16
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Cai A, Boos AM, Arkudas A, Horch RE. Management of extremely hard-to-heal extremity wounds with severe life-threatening complications. Int Wound J 2016; 14:708-715. [PMID: 27778451 DOI: 10.1111/iwj.12681] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Revised: 08/31/2016] [Accepted: 09/12/2016] [Indexed: 12/11/2022] Open
Abstract
The introduction of neoadjuvant radiotherapy has allowed limb-preserving surgical treatment in patients with extremity soft tissue sarcoma, and the overall prognosis of this approach is similar to that of limb amputation. The benefits of this treatment, however, are often accompanied with a higher risk of major complications and blood vessel damage because of radiation-induced inflammation and necrosis of the vessel wall. In particular, it is associated with the rupture of large vessels like the femoral artery and more severe complications of wounds located in the proximal lower extremity. We present a series of four patients with soft tissue sarcoma of the thigh undergoing tumour removal and reconstruction of the defect after neoadjuvant radiotherapy. The post-operative outcome depended on the total dose of radiation used as well as the closing technique of the resulting wound. Major wound complications occurred when the irradiated skin was closed directly over the resection cavity or when local skin flaps were used. In one case, severe radiation-induced life-threatening multiple bleeding events occurred, which led to multiple flap failures. Even if the skin cover is not a problem, we propose a combined interdisciplinary approach involving immediate plastic surgical transfer of healthy, well-vascularised tissue into a defect resulting from oncological resection of sarcoma of the lower extremity following neoadjuvant radiotherapy in order to avoid secondary wound breakdown and severe bleeding complications.
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Affiliation(s)
- Aijia Cai
- Department of Plastic and Hand Surgery and Laboratory for Tissue Engineering and Regenerative Medicine, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nuernberg (FAU), Erlangen, Germany
| | - Anja M Boos
- Department of Plastic and Hand Surgery and Laboratory for Tissue Engineering and Regenerative Medicine, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nuernberg (FAU), Erlangen, Germany
| | - Andreas Arkudas
- Department of Plastic and Hand Surgery and Laboratory for Tissue Engineering and Regenerative Medicine, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nuernberg (FAU), Erlangen, Germany
| | - Raymund E Horch
- Department of Plastic and Hand Surgery and Laboratory for Tissue Engineering and Regenerative Medicine, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nuernberg (FAU), Erlangen, Germany
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17
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Bray JP. Soft tissue sarcoma in the dog - part 1: a current review. J Small Anim Pract 2016; 57:510-519. [PMID: 27624929 DOI: 10.1111/jsap.12556] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 07/07/2016] [Accepted: 08/08/2016] [Indexed: 12/24/2022]
Abstract
Soft tissue sarcomas are derived from tissues of mesenchymal origin. Although local recurrence following surgical resection is the characteristic challenge in their management, 40% dogs with high-grade tumours may also develop metastatic disease, despite successful local control. Soft tissue sarcoma is a complex disease and there are many uncertainties regarding the biology and optimal clinical management. There are currently no diagnostic tests that can reliably predict the amount of surgical margin required for a particular tumour, so there can be a mismatch between treatment and disease. Historically, the tendency has been to always recommend wide excision margins but this is not fully supported by recent evidence. A selection bias for less aggressive soft tissue sarcomas in primary care practice can account for good outcomes that are achieved despite narrow surgical excision margins. On the other hand, inappropriately conservative treatment will adversely affect outcomes for patients with more aggressive disease. This review provides an update on the current understanding of management of canine soft tissue sarcomas.
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Affiliation(s)
- J P Bray
- Veterinary Teaching Hospital, Institute for Veterinary, Animal and Biomedical Sciences, Massey University, Palmerston North 4442, New Zealand.
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18
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Matsumine A, Tsujii M, Nakamura T, Asanuma K, Matsubara T, Kakimoto T, Yada Y, Takada A, Ii N, Nomoto Y, Sudo A. Minimally invasive surgery using intraoperative electron-beam radiotherapy for the treatment of soft tissue sarcoma of the extremities with tendon involvement. World J Surg Oncol 2016; 14:214. [PMID: 27514518 PMCID: PMC4982423 DOI: 10.1186/s12957-016-0968-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 08/02/2016] [Indexed: 11/21/2022] Open
Abstract
Background When a soft tissue sarcoma (STS) is located at the distal part of an extremity and involves the tendon, a wide excision usually causes severe functional disability. We therefore developed a minimally invasive surgical technique using intraoperative electron-beam radiotherapy (IOERT) to reduce the incidence of post-operative functional disability in patients with peri-/intra-tendinous STS. We assessed the clinical outcomes of the novel minimally invasive surgery. Methods The study population included five patients who received treatment for distal extremity STSs. After elevating the tumor mass, including the tendon and nerve from the tumor bed with a wide margin, a lead board was inserted beneath the tumor mass to shield the normal tissue. IOERT (25–50 Gy) was then applied, and the tumor excised with care taken to maintain the continuity of the tendon. Results In a desmoid patient, local recurrence was observed outside the irradiated field. No cases of neuropathy or bone necrosis were observed. The mean limb function score was excellent in all patients. None of the high-grade sarcoma patients had local recurrence or distant metastasis. Conclusions Although the current study is only a pilot study with a small number of patients, it shows that this minimally invasive procedure has the potential to become a standard treatment option for selected patients. Trial registration H17-250 (registered 2 November 2005) and H25-250 (modified from H17-250, registered 5 December 2013)
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Affiliation(s)
- Akihiko Matsumine
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan.
| | - Masaya Tsujii
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Tomoki Nakamura
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Kunihiro Asanuma
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Takao Matsubara
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Takuya Kakimoto
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Yuki Yada
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Akinori Takada
- Department of Radiology, Mie University School of Medicine, 2-174 Edobashi, Tsu city, Mie, 514-8507, Japan
| | - Noriko Ii
- Department of Radiology, Mie University School of Medicine, 2-174 Edobashi, Tsu city, Mie, 514-8507, Japan
| | - Yoshihito Nomoto
- Department of Radiology, Mie University School of Medicine, 2-174 Edobashi, Tsu city, Mie, 514-8507, Japan
| | - Akihiro Sudo
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
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Mejia Oneto JM, Khan I, Seebald L, Royzen M. In Vivo Bioorthogonal Chemistry Enables Local Hydrogel and Systemic Pro-Drug To Treat Soft Tissue Sarcoma. ACS CENTRAL SCIENCE 2016; 2:476-82. [PMID: 27504494 PMCID: PMC4965853 DOI: 10.1021/acscentsci.6b00150] [Citation(s) in RCA: 135] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Indexed: 05/18/2023]
Abstract
The ability to activate drugs only at desired locations avoiding systemic immunosuppression and other dose limiting toxicities is highly desirable. Here we present a new approach, named local drug activation, that uses bioorthogonal chemistry to concentrate and activate systemic small molecules at a location of choice. This method is independent of endogenous cellular or environmental markers and only depends on the presence of a preimplanted biomaterial near a desired site (e.g., tumor). We demonstrate the clear therapeutic benefit with minimal side effects of this approach in mice over systemic therapy using a doxorubicin pro-drug against xenograft tumors of a type of soft tissue sarcoma (HT1080).
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Affiliation(s)
- Jose M. Mejia Oneto
- Shasqi Inc., 665 Third Street, Suite 250, San Francisco, California 94107, United States
- E-mail:
| | - Irfan Khan
- University
at Albany, Department of Chemistry, 1400 Washington Avenue, Albany, New York 12222, United States
| | - Leah Seebald
- University
at Albany, Department of Chemistry, 1400 Washington Avenue, Albany, New York 12222, United States
| | - Maksim Royzen
- University
at Albany, Department of Chemistry, 1400 Washington Avenue, Albany, New York 12222, United States
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20
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Ho AL, Lyonel Carre A, Patel KM. Oncologic reconstruction: General principles and techniques. J Surg Oncol 2016; 113:852-64. [PMID: 26939879 DOI: 10.1002/jso.24206] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 02/06/2016] [Indexed: 02/06/2023]
Abstract
Halsted's principle of radical mastectomy influenced cancer treatment for decades. Randomized controlled trials resulted in a paradigm shift to less radical surgery and the use of adjuvant therapies. Oncologic reconstruction performed by plastic surgeons has evolved, ranging from skin grafts and local flaps for smaller defects to pedicled flaps and free flaps for larger and more complex defects. Immediate reconstruction facilitates resection is oncologically safe and contributes to meaningful improvements in quality of life. J. Surg. Oncol. 2016;113:852-864. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Adelyn L Ho
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Antoine Lyonel Carre
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Ketan M Patel
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
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21
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Illuminati G, Pizzardi G, Calio' F, Pacilè MA, Masci F, Vietri F. Outcome of inferior vena cava and noncaval venous leiomyosarcomas. Surgery 2016; 159:613-20. [DOI: 10.1016/j.surg.2015.08.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 08/26/2015] [Accepted: 08/26/2015] [Indexed: 01/22/2023]
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