Surgery quality and tumor status impact on survival and local control of resectable liposarcomas of extremities or the trunk wall

Unplanned Resections of Soft Tissue Sarcomas-Necessity of Re-Resection?

BACKGROUND

In soft tissue sarcomas, unplanned resections, or so-called Whoops procedures, do occur quite frequently, thus primarily owing to the abundant presence of benign lesions. Whether re-resection reduces local recurrence or improves overall survival remains a topic of ongoing debate. The principle objective of this study was to analyze the outcomes of patients with soft tissue sarcomas of the extremities or trunk wall after an incidental marginal resection by comparing re-resections to individuals who declined the procedure.

METHODS

A total of 185 patients who underwent unplanned resection were included. These patients were stratified into two groups: Group A (n = 156) underwent re-excision, while Group B (n = 29) was treated conservatively. Depending on the clinical scenario, radio- or chemotherapy was either administered in a neoadjuvant or an adjuvant setting. The presence of residual tumor and metastatic disease was documented. Clinical outcomes, specifically local recurrence (LR), local recurrence-free survival (LRFS) and overall survival (OS), were utilized for evaluation.

RESULTS

Group B exhibited significantly larger tumors (p < 0.0001) and a higher mean age than Group A. Among the patients in Group A, 11 (5.9%) had contaminated resection margins (R1), and residual disease (RD) was observed in 93 (59.6%) of the resected specimens. In group B, 10 patients received adjuvant radiotherapy alone, 5 received chemotherapy alone, and 13 underwent a combined approach consisting of both radio- and chemotherapy. In Group A, 8% (n = 12) of the patients developed local recurrence (LR) during the observation period. Conversely, in Group B, this amount was 14% (n = 4) (n.s.). Of the 12 LR in Group A, 10 were found in the subgroup with residual disease. Overall survival and local recurrence-free survival were not significantly different between the groups. A total of 15% (n = 24) of the patients in Group A developed metastatic disease, while 10% (n = 3) in Group B developed metastatic disease (n.s.).

CONCLUSIONS

Following the reresection of unplanned resected STS, there was no statistically significant difference observed in overall survival or LR compared to patients who did not undergo re-resection. However, within the subgroup of patients with residual disease in the re-resected specimen, the OS was compromised, and the LR rate was higher. Particularly for low-grade lesions, adopting a more conservative approach seems to be justified.

High fibrinogen levels are associated with poor survival in patients with liposarcoma

The aim of this study was to evaluate whether (preoperative) plasma levels of fibrinogen, an essential clotting and acute phase protein, are associated with the prognosis of patients with a liposarcoma, a subtype of sarcoma derived from adipose tissue. We performed a retrospective cohort study of 158 patients with liposarcoma treated at the Department of Orthopaedics of the Medical University of Vienna in Austria from May 1994 to October 2021. Kaplan-Meier curves as well as uni- and multivariable Cox proportional hazard models were performed to evaluate the association between fibrinogen levels and overall survival. Elevated fibrinogen was associated with adverse overall survival in cause specific hazards analysis of mortality (hazard ratio [HR] per 10 mg/dL increase: 1.04; 95% CI 1.02-1.06; p < 0.001). This association prevailed in multivariable analysis after adjustment for AJCC tumor stage (HR 1.03; 95% CI 1.01-1.05; p = 0.013). Increasing levels of fibrinogen, a routinely available and inexpensive parameter, predicts the risk of mortality in patients with liposarcoma.

Multiple well-differentiated retroperitoneal liposarcomas with different patterns of appearance on computed tomography: A case report

BACKGROUND

Primary retroperitoneal liposarcoma (PRPLS) is a rare soft tissue tumor with nonspecific clinical symptoms; it has different computed tomography (CT) image features according to pathological types. Some patients with a single tumor have been previously reported in the literature. We present an exceptional case of a PRPLS patient with multiple large tumors exhibiting different patterns of appearance on CT and confirmed as atypical lipomatous tumor/well-differentiated liposarcoma by postoperative pathology.

CASE SUMMARY

A 64-year-old man presented with abdominal distension for 1 year. The patient was diagnosed with PRPLS based on physical examination, laparotomy, ultrasonography, CT scan, and surgery. Both of the tumors were completely resected through surgery and confirmed as atypical lipomatous tumor/well-differentiated liposarcoma by postoperative pathology. The postoperative course was uneventful without recurrence or metastasis, as demonstrated by abdominal-pelvic CT during an 18 mo follow-up.

CONCLUSION

Multiple large Well-differentiated liposarcomas with different patterns of appearance on CT image can occur simultaneously in the same patient, to which more attention should be paid to make an effective differential diagnosis.

Impact of primary tumor location on outcome of liposarcoma patients, a retrospective cohort study

BACKGROUND

Tumor location as a prognostic factor for patients with liposarcoma (LPS) has been studied modestly with varying outcomes. The aim was to establish the impact of tumor location on recurrence and survival of LPS patients.

METHODS

A retrospective database of patients treated for LPS until December 2017 was used to assess 5-year local recurrence-free survival (LRFS), distant metastasis-free survival (DMFS) and disease-specific survival (DSS) per tumor location using the Kaplan-Meier method and log-rank test. A multivariable Cox regression analysis was performed to adjust for other prognostic factors.

RESULTS

In total, 518 patients were identified with a median follow-up of 68 months (interquartile range 31-138). Patients with retroperitoneal/intrathoracic WDLPS or DDLPS (p = 0.014), or testicular WDLPS (p = 0.026) developed a local recurrence more often than patients with other tumor locations. No differences between LPS subtypes and tumor location in the development of metastases (p = 0.600) was observed. Five-year LRFS differed significantly between tumor locations (p < 0.001) as well as 5y-DSS (p < 0.001), but 5y-DMFS did not (p = 0.241), with retroperitoneal/intrathoracic LPS having a worse prognosis. Patients with WDLPS in the extremity, trunk or testicular region did not die of disease, except for the rare occasion of dedifferentiation upon recurrence. After adjustment for other prognostic factors, tumor location was only of prognostic value for DSS (retroperitoneal/intrathoracic vs. extremity: HR 5.08, 95% CI 2.41-10.71, p < 0.001).

CONCLUSION

For all tumor locations, DSS mimicked DMFS except for retroperitoneal/intrathoracic LPS, where DSS mimicked LRFS and where DSS was worse than DMFS. This implies that these patients die of local disease instead of metastatic disease.

Natural history of well-differentiated liposarcoma of the extremity compared to patients treated with surgery

BACKGROUND

Patients with well-differentiated liposarcoma (WDLPS) of the extremity are mostly treated surgically, thereby possibly inducing severe morbidities. Despite the excellent prognosis, the natural history is barely studied. The aim of this study was to evaluate the natural history of extremity WDLPS by evaluating the outcome of patients treated with active surveillance (AS), who thereby exhibited the natural history of extremity WDLPS, and of patients treated surgically.

METHODS

A large retrospective database of patients with extremity WDLPS was assessed to evaluate treatment, dedifferentiation and disease-specific survival. Lastly, our experience with patients treated with AS was explored.

RESULTS

Distant metastases (5/191 patients, 2.6%) were mainly seen after a dedifferentiated local recurrence. Death of disease occurred in 4/191 patients (2.1%); two patients died from metastatic disease (although not pathologically proven), two patients died of treatment-related complications. In our center, 24 patients are treated with AS. Time of AS varied from 0.1 to 8.9 years (median 1.8). Four patients eventually underwent surgery after a period of AS (range 14-52 months) because of symptoms and/or tumor growth. No areas of dedifferentiation were found in these resection specimens. The other patients are still under active surveillance.

CONCLUSION

Since surgical treatment might induce morbidity and even mortality, there might be overtreatment of these patients. Evaluation of the natural history of extremity WDLPS showed that AS could be a reasonable option for selected patients. Prospective studies in patients with extremity WDLPS are needed to assess the safety of AS as a treatment option.

Prognostic factors of patients with extremity myxoid liposarcomas after surgery

Background

Extremity myxoid liposarcoma (MLS) is a rare soft tissue sarcoma in adults. We performed this study to define distinctive clinical features of extremity MLS by assessing prognostic factors.

Methods

Between 1973 and 2015, 1756 patients with extremity MLS who underwent surgical resection were retrieved from the Surveillance, Epidemiology, and End Results (SEER) database of the US National Cancer Institute. Both overall survival (OS) and cancer-specific survival (CSS) were assessed using the Kaplan–Meier method (to obtain OS and CSS curves) and a Cox proportional hazards regression model.

Results

Of the 1756 patients with extremity MLS, the mean and median patient age at diagnosis were 47 and 45 years, respectively. More than half (n = 1027, 58.5%) of the patients were male. In terms of location, 10.5% tumors were located in the upper limbs and 89.5% in lower limbs. All patients received local surgery, and about half of the patients (57.2%) received radiation treatment. The 5- and 10-year OS rates of the entire cohort were 86.4% and 75.9%, respectively. The 5- and 10-year CSS rates were 90.5% and 85.2%, respectively. On multivariate analysis, older age, male gender, high tumor grade, and tumor size > 10 cm were found to be independent risk factors of both decreased OS and CSS. Year of diagnosis ≥ year 2000 was significantly associated with an increased CSS. In addition, radiation treatment failed to become an independent risk factor for either OS or CSS.

Conclusion

We identified age, gender, tumor grade, year of diagnosis, and tumor size as independent prognostic factors for OS and CSS in patients with extremity MLS.

Defining Tumor Rupture in Gastrointestinal Stromal Tumor

Tumor rupture is an important risk factor predictive of recurrence after macroscopically complete resection of gastrointestinal stromal tumors (GISTs), and an indication for defined interval or even lifelong adjuvant therapy with imatinib according to guidelines. However, there is no consensus or universally accepted definition of the term ‘tumor rupture’, and, consequently, its incidence varies greatly across reported series. Without predefined criteria, the clinical significance of rupture has also been difficult to assess on multivariate analysis of retrospective data. We reviewed the relevant literature and international guidelines, and, based on the Oslo criteria, proposed the following six definitions for ‘tumor rupture’: (1) tumor fracture or spillage; (2) blood-stained ascites; (3) gastrointestinal perforation at the tumor site; (4) microscopic infiltration of an adjacent organ; (5) intralesional dissection or piecemeal resection; or (6) incisional biopsy. Not all minor defects of tumor integrity should not be classified as rupture, i.e. mucosal defects or spillage contained within the gastrointestinal lumen, microscopic tumor penetration of the peritoneum or iatrogenic damage only to the peritoneal lining, uncomplicated transperitoneal needle biopsy, and R1 resection. This broad definition identifies GIST patients at particularly high risk of recurrence in population-based cohorts; however, its applicability in other sarcomas has not been investigated. As the proposed definition of tumor rupture in GIST has limited evidence based on the small number of patients with rupture in each retrospective study, we recommend validating the proposed definition of tumor rupture in GIST in prospective studies and considering it in clinical practice.

Prognostic Factors in Indian Patients Operated for Soft Tissue Sarcomas-a Retrospective Cross-sectional Analysis

Soft tissue sarcomas are a rare entity. While surgery is established as the mainstay of treatment, the exact role and sequencing of adjuvant therapy is not well defined. Literature on Indian patients with soft tissue sarcoma with respect to clinical profile and prognostic factors is scarce. We retrospectively analysed the data of 112 patients operated for soft tissue sarcoma of extremity or trunk (excluding retroperitoneal and mediastinal sarcomas, round cell histology) at our institute from 1 January 2009 to 31 December 2013. Around half the patients were less than 50 years of age and around a third had size more than 10 cm. Oncological outcome was correlated with various demographic, tumour-related and treatment-related factors using SPSS 22. Overall survival at 5 years was 73.2 % and event-free survival at 5 years was 42.2 %. At final follow-up (mean of 44.85 ± 4.64 months), local recurrence was seen in 31.9 % and distant metastasis was seen in 30.1 % of the patients. Using both univariate and multivariate analysis, younger age (<50 years), larger size (>10 cm, but not >5 cm) and pathologically positive lymph nodes were the only factors found significantly affecting overall survival. The clinical profile and prognosis of Indian patients with soft tissue sarcoma were found to be different from that reported in Western literature. The impact of established prognostic indicators for soft tissue sarcoma also differed in Indian patients, which may have both prognostic and therapeutic implications.

Elevated serum creatinine and low albumin are associated with poor outcomes in patients with liposarcoma

Low serum albumin levels and impaired kidney function have been associated with decreased survival in patients with a variety of cancer types. In a retrospective cohort study, we analyzed 84 patients with liposarcoma treated at from May 1994 to October 2011. Uni- and multivariable Cox proportional hazard models and competing risk analyses were performed to evaluate the association between putative biomarkers with disease-specific and overall survival. The median age of the study population was 51.7 (range 19.6-83.8) years. In multivariable analysis adjusted for AJCC tumor stage, serum creatinine was highly associated with disease-specific survival (Subdistribution Hazard ratio (SHR) per 1 mg/dl increase = 2.94; 95%CI 1.39-6.23; p = 0.005). High albumin was associated with improved overall and disease-specific survival (Hazard Ratio (HR) per 10 units increase = 0.50; 95%CI 0.26-0.95; p = 0.033 and SHR = 0.64; 95%CI 0.42-1.00; p = 0.049). The serum albumin-creatinine-ratio emerged to be associated with both overall and disease-specific survival after adjusting for AJCC tumor stage (HR = 0.95; 95%CI 0.92-0.99; p = 0.011 and SHR = 0.96; 95%CI 0.93-0.99; p = 0.08). Our study provides evidence for a tumor-stage-independent association between higher creatinine and lower albumin with worse disease-specific survival. Low albumin and a high albumin-creatinine-ratio independently predict poor overall survival. Our work identified novel prognostic biomarkers for prognosis of patients with liposarcoma.

Surgical resection of massive liposarcomas at the extremities: a 10-year experience in a referral musculoskeletal sarcoma unit

Background

There is still no consensus regarding the management of patients with massive liposarcomas located in the extremities. Several discrepancies related to the aggressiveness of the surgery and the application of concomitant radiotherapy and chemotherapy treatments remain controversial. The purpose of this study was to analyse the clinicopathological characteristics, prognostic factors and outcomes of a series of patients with massive liposarcomas of the extremities who were treated at a referral hospital specializing in musculoskeletal oncology.

Methods

This was an observational, descriptive and retrospective case series covering 10 years of clinical practice. The records of 26 adults, 14 men and 12 women, with localized massive liposarcomas in the extremities were studied. The average age was 53 years. The patients were treated from January 2003 until January 2012. Wide surgical resections with limb-sparing surgeries were performed for most patients (96.2 %).

Results

The average tumour size was 15.1 ± 6.8 cm in the greatest dimension. Regarding the histological subtypes, there were 11 well-differentiated or atypical lipomatous tumours (42.3 %), 10 myxoid (38.5 %) and 5 (19.2 %) round cell and pleomorphic liposarcomas. Regarding the malignancy grades, 19 cases (73 %) were classified as low grade. Among these low-grade tumours predominated the well-differentiated subtype (57.9 %). Within high-grade tumours, the round cell and pleomorphic subtype was most frequent (57.1 %; p = 0.011). Radiotherapy was additionally applied to 12 patients (46.2 %) and adjuvant chemotherapy to 5 (19.3 %). Tumour recurrence was observed in only 2 cases (7.7 %). Only 1 of these cases developed lung metastatic dissemination.

Conclusions

Across the entire series, these massive tumours did not compromise the survival of the patients. The histologic subtype and the malignancy degree were closely related. Proper and early diagnosis and therapeutic management of these patients via the application of wide-margin surgical excision are essential to ensure long-term survival.

Preoperative hypofractionated radiotherapy in the treatment of localized soft tissue sarcomas

BACKGROUND

The primary treatment of soft tissue sarcomas (STS) is a radical resection of the tumor with adjuvant radiotherapy. Conventional fractionation of preoperative radiotherapy is 50 Gy in fraction of 2 Gy a day. The purpose of the conducted study was to assess the efficacy and safety of hypofractionated radiotherapy in preoperative setting in STS patients.

METHODS

272 patients participated in this prospective study conducted from 2006 till 2011. Tumors were localized on the extremities or trunk wall. Median tumor size was 8.5 cm, 42% of the patients had tumor larger than 10 cm, whereas 170 patients (64.6%) had high grade (G3) tumors. 167 patients (61.4%) had primary tumors. Patients were treated with preoperative radiotherapy for five consecutive days in 5 Gy per fraction, with an immediate surgery. Median follow up is 35 months.

RESULTS

79 patients died at the time of the analysis, the 3-year overall survival was 72%. Local recurrences were observed in 19.1 % of the patients. Factors that had a significant adverse impact on local recurrence were tumor size of 10 cm or more and G3 grade. 114 patients (42%) had any kind of treatment toxicity, vast majority with tumors located on lower limbs. 7% (21) of the patients required surgery for treatment of the complications.

CONCLUSION

In this non-selected group of locally advanced STS use of hypofractionated preoperative radiotherapy was associated with similar local control (81%) when compared to previously published studies. The early toxicity is tolerable, with small rate of late complications. Presented results warrant further evaluation.