Role of radiation therapy for non-extremity soft tissue sarcomas

Giant bleeding post-traumatic thoracic sarcoma management: A case report

The heterogeneity of thoracic wall tumors often represents challenging clinical entities for surgeons due to diagnostic and treatment complexities. The primary tumors, metastases, or direct invasion from intrathoracic structures comprise almost half of all cases on average that are proved to be malignant. Surgery treatment usually leaves large chest defects that require further extensive reconstruction and multimodal management including radiotherapy and chemotherapy. We report a rare case of a giant (30 cm) post-traumatic bleeding thoracic sarcoma treatment in a 70-year-old female. The use of our modified Verneuil technique to close the extensive postoperative skin defect optimized surgical wound management and provided good functional and aesthetic results. Four-year follow-up outcomes after surgical and adjuvant radiation therapy reported a high level of tumor control and showed no evidence of postoperative disease recurrence.

Radiation Therapy in Primary Soft Tissue Sarcoma of the Superficial Trunk

PURPOSE

Despite anatomical differences, truncal soft tissue sarcomas (STS) often are grouped with extremity sarcomas. We evaluated the clinical outcome of patients with truncal STS who underwent gross total resection (GTR) and radiation therapy (RT), with special emphasis on those treated with intensity modulated radiation therapy (IMRT).

METHODS

From January 1, 2001 to December 31, 2018, 64 patients received GTR and RT, where 48 patients were male, 35 patients were aged ≤ 60 years, and 48 patients had tumors ≤ 10 cm. Sixty-two tumors were high grade, 36 were in the chest wall, 7 in the abdominal wall, and 21 were paraspinal. During surgery, 7 received mesh reconstruction, and 6 received flap closure. R0 resection was achieved in 53 patients. Thirteen patients received chemotherapy.

RESULTS

With a median follow-up of 57 months, the 5-year actuarial local control (LC) was 71%. In the IMRT subset (50/64, 78%), the 5-year LC for the chest/abdominal wall was 84%, and 69% for the paraspinal subsite. Grade 2+ radiation dermatitis was seen in 21 of 64 (33%) patients, 5 of 64 (8%) developed noninfectious wound complications, 5 of 64 (8%) developed infectious wound complications, and 1 of 64 (2%) developed grade 2 chest wall pain. No additional grade 2+ late toxicity was observed.

CONCLUSIONS

Based on this study, achieving LC in truncal STS treated with GTR and RT remains challenging even with IMRT (5-year LC: 78%). While the use of IMRT was more promising for tumors of the chest/abdominal wall with 5-year LC of 84%, it was 69% for those located in the paraspinal subsite, indicating a need for further improvement.

Hypofractionated radiotherapy for non-metastatic bone and soft tissue sarcomas

PURPOSE

To evaluate the efficacy and toxicity of hypofractionated radiotherapy in non-metastatic soft tissue and bone sarcomas.

PATIENTS AND METHODS

Thirty patients underwent hypofractionated radiotherapy between 2007 and 2015. Overall, 17 patients underwent primary hypofractionated radiotherapy, nine underwent hypofractionated radiotherapy for reirradiation, and four received a boost dose via hypofractionated radiotherapy after external beam radiotherapy. Most common disease sites were head and neck and retroperitoneum. Hypofractionated radiotherapy was administered with a definitive, adjuvant, or neoadjuvant intent.

RESULTS

Median age was 37 years (range: 11-82 years). Median hypofractionated radiotherapy dose was 35Gy (range: 20-50Gy) in three to five fractions. Median follow-up was 21 months (range: 1-108 months). One- and 2-year overall survival rate was 75% and 52%, respectively. One- and 2-year local recurrence-free survival rate was 59% and 48%, with local recurrence rates of 16% and 33% in 1 and 2 years, respectively. Univariate analysis revealed tumour size (P=0.04), hypofractionated radiotherapy intent (P=0.016) and reirradiation (P=0.001) as prognostic factors for local recurrence-free survival. Severe late toxicity was observed in one patient as grade 3 trismus.

CONCLUSION

Hypofractionated radiotherapy as the primary treatment or for reirradiation has been shown to be safe in the treatment of bone and soft tissue sarcomas. It can provide relatively good local control and survival rates.

Utilization pattern and survival outcomes of adjuvant therapies in high-grade nonretroperitoneal abdominal soft tissue sarcoma: A population-based study

BACKGROUND

Nonretroperitoneal abdominal soft tissue sarcoma (NRA-STS) is a rare disease with limited data supporting its management. Our study aimed to reveal the utilization patterns of adjuvant therapy and its potential survival benefits using the National Cancer Data Base.

MATERIALS

The analysis included patients with resected high-grade NRA-STS. Chi-square analysis was used to evaluate distribution of patient and tumor-related factors within treatment groups. The Kaplan-Meier and Cox proportional hazards model were utilized to evaluate overall survival according to treatment approach. Multivariate analysis was used to determine the impact of these factors on patients' outcome. Matched propensity score analysis was implemented to control for imbalance of confounding variables.

RESULTS

At median follow-up of 49 months, 5-year overall survival improved from 46% without adjuvant radiation therapy to 52% (P = 0.009) with radiotherapy delivery with a 30% reduction in hazard of death (95% confidence interval = 0.58-0.84). On multivariate analysis, age <50, tumor <8 cm, negative margins and radiotherapy delivery were significant predictors of improved survival. Chemotherapy was not associated with significant survival improvement (Hazard Ratios [HR]: 0.89, P = 0.28).

CONCLUSION

Adjuvant radiotherapy was associated with improved survival in high-grade NRA-STS. Chemotherapy was not associated with a survival improvement; however, further studies are needed to refine treatment strategies.

A multidisciplinary approach to giant soft tissue sarcoma of the chest wall: A case report

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Chest wall sarcomas most commonly present as painless slow growing masses.

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Resection is often precarious due to involvement of important structures.

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The multidisciplinary approach is crucial for the optimal management of this tumor.

Introduction

Soft tissue sarcomas of the chest wall are exceptionally rare entities that present as painless slow growing masses. Resection is often precarious due to involvement of vital structures, and patients are left with large chest wall defects postoperatively requiring extensive reconstruction.

Presentation of case

We present a case report of a 29 year-old man who presented with a giant soft tissue sarcoma of the chest that had been growing slowly for one year prior to presentation. The patient had a biopsy that was positive for sarcoma, and PET CT demonstrated a large lobulated mass in the left chest wall with an SUV of 6.7. He received 50 Gy of radiation therapy; however, the mass continued to grow in size. He subsequently underwent an en-bloc resection of the mass with latissimus and serratus muscle primary reconstruction. Final pathology showed a 27 cm high-grade fibrosarcoma with prominent myxoid component. To our knowledge, this is the largest soft tissue sarcoma of the chest wall reported in the literature. Postoperatively, the patient received 6 cycles of adjuvant chemotherapy.

Discussion

Surgery is the mainstay of treatment, and chemotherapy and radiation are used in specific circumstances. Risk of recurrence is dependent on many factors, including histologic subtype, grade, and size of tumor. Long term surveillance with physical exam and imaging is recommended.

Conclusion

We feel that the multidisciplinary approach is crucial for optimal management of large soft tissue sarcomas. We recommend this approach to all patients with chest wall sarcomas.

Clinical outcomes of tissue expanders on adjuvant radiotherapy of resected retroperitoneal sarcoma

We investigated the efficacy and safety of a tissue expander (TE) for adjuvant radiotherapy (RT) of resected retroperitoneal sarcoma (RPS).This study was conducted with 37 patients with RPS who received resection with or without TE insertion followed by RT from August 2006 to June 2012 at Samsung Medical Center. Among the 37 patients, TE was inserted in 19. The quality of TE insertion was evaluated according to the correlation of clinical target volume and retroperitoneal surface volume covered by TE and was defined as follows: excellent, ≥85%; good, 70% to 85%; fair, 50% to 70%; and poor, <50%. The median follow-up period after surgery was 47.9 months (range, 5.5-85.5 months).The quality of TE insertion was excellent in 7 (36.8%), good in 5 (26.3%), fair in 4 (21.0%), and poor in 3 (16.7%) patients. A significantly higher biologically equivalent dose (BED, α/β = 10) was used in patients who had TE insertion (median, 64.8 vs. 60.0 Gy, P = 0.01). Local control was 39.7%, and overall survival was 76.4% at 5 years. Local control was significantly higher in patients who received ≥65 Gy of BED, 100.0% in contrast to 22.8% (P = 0.01). One patient with a history of multiple tumor resections showed abdominal infection with duodenal perforation of uncertain cause but had the potential of being related to TE and/or RT. Otherwise there were no ≥grade III acute or late toxicities.TE for adjuvant RT in RPS is feasible for delivering a higher RT dose with acceptable toxicity.

[Complex pelvic and sarcoma surgery with vascular replacement]

Due to optimization of surgical techniques in surgical oncology and vascular surgery, the most modern approaches of anesthesia and intensive care medicine and effective multimodal therapeutic strategies, locally advanced malignant tumors are resected more frequently with a potentially curative intent. In the case of extensive tumors with infiltration of vital vascular structures or of structures which are crucial for extremity preservation, the necessary surgical procedure for complete tumor removal poses a major challenge for the surgeon and incorporates a high risk of perioperative morbidity for the patient. The decision to attempt tumor resection should therefore always be based on a concept considering all aspects of the malignant disease. The treating team should be highly experienced in this complex field of surgery, not only with respect to the surgical approach but also regarding the management of postoperative complications. In this article relevant aspects of decision making, surgical technique and postoperative outcome for malignant tumors involving vascular structures of the retroperitoneum and pelvis are presented.