SEOM Clinical Guideline of management of soft-tissue sarcoma (2016)

Assessing the methodological strengths and limitations of the Spanish Society of Medical Oncology (SEOM) guidelines: a critical appraisal using AGREE II and AGREE-REX tool

BACKGROUND

The Spanish Society of Medical Oncology (SEOM) has provided open-access guidelines for cancer since 2014. However, no independent assessment of their quality has been conducted to date. This study aimed to critically evaluate the quality of SEOM guidelines on cancer treatment.

METHODS

Appraisal of Guidelines for Research and Evaluation II (AGREE II) and AGREE-REX tool was used to evaluate the qualities of the guidelines.

RESULTS

We assessed 33 guidelines, with 84.8% rated as "high quality". The highest median standardized scores (96.3) were observed in the domain "clarity of presentation", whereas "applicability" was distinctively low (31.4), with only one guideline scoring above 60%. SEOM guidelines did not include the views and preferences of the target population, nor did specify updating methods.

CONCLUSIONS

Although developed with acceptable methodological rigor, SEOM guidelines could be improved in the future, particularly in terms of clinical applicability and patient perspectives.

Myxoid liposarcoma: MRI features with histological correlation

BACKGROUND AND AIMS

Myxoid liposarcoma is classified in the group of sarcomas with adipose differentiation, which is the second most common group of sarcomas. However, myxoid liposarcoma is not a homogeneous entity, because the behavior and clinical course of these tumours can vary widely. This study aimed to describe the magnetic resonance imaging (MRI) features of myxoid liposarcomas and to determine whether the MRI features are associated with the histologic grade and can differentiate between low-grade and high-grade tumours and thus help in clinical decision making.

MATERIAL AND METHODS

We studied 36 patients with myxoid liposarcomas treated at our centre between 2010 and 2018. We analysed clinical variables (age, sex, and tumour site) and MRI features (size, depth, borders, fatty component, myxoid component, non-fatty/non-myxoid component, apparent diffusion coefficient (ADC), and type of enhancement after the administration of intravenous contrast material). We correlated the MRI features with the histologic grade and the percentage of round cells.

RESULTS

In our series, patients with myxoid liposarcomas were mainly young adults (median age, 43 years). There were no differences between sexes; 97.2% were located in the lower limbs, 86.1% were deep, and 77.8% had well-defined borders. Of the 23 myxoid liposarcomas that contained no fat, 16 (69.6%) were high grade (p = 0.01). All the tumors with a myxoid component of less than 25% were high grade (p = 0.01); 83.3% of those with a non-fatty/non-myxoid component greater than 50% were high grade (p = 0.03) and 61.5% had more than 5% round cells (p = 0.01). Diffusion sequences were obtained in 14 of the 36 patients; ADC values were high (median, 2 × 10-3 mm2/s), although there were no significant associations between low-grade and high-grade tumours. Contrast-enhanced images were available for 30 (83.3%) patients; 83.3% of the tumours with heterogeneous enhancement were high grade (p = 0.01).

CONCLUSIONS

MRI can be useful for differentiating between high- and low-grade myxoid liposarcomas and can help in clinical decision making.

Intraosseous synovial sarcoma of the mandible: A case report and review of the literature

Synovial sarcoma (SS) is a malignant soft tissue tumor that usually arises in the para-articular regions of the extremities. Only nine cases of SS in the mandible have been reported to date. The present study described a case of SS arising from the left mandible. A 54-year-old woman was referred to Kyushu University Hospital (Fukuoka, Japan) with a complaint of numbness in the left mental nerve area. Computed tomography revealed replacement of the left mandibular bone marrow with soft tissue and destruction of the mandibular canal. Magnetic resonance imaging revealed an isointense mass on T1-weighted images and hyperintensity on T2-weighted images. The tumor showed homogeneous enhancement. A biopsy was performed, and monophasic SS was diagnosed based on immunohistochemical staining features and genetic analysis. Hemimandible dissection and supraomophyoid neck resection were performed with fibular osteocutaneous flap reconstruction, followed by adjuvant chemotherapy. There was no evidence of recurrence or distant metastases. The present study also reviewed the clinical, imaging, histological, and immunohistochemical features of the SS in the mandible.

Clinical Outcomes of Soft Tissue Sarcoma around the Elbow Joint: A Retrospective Single Institution Study

Background

We report a retrospective case series analysis of clinical outcomes of patients with soft tissue sarcoma around the elbow.

Methods

Twenty-two patients underwent surgical tumor excision between January 1999 and May 2017, with a mean follow-up of 85.2 months.

Results

Six tumors were localized in the upper arm, nine in the elbow, and seven in the forearm. Sixteen tumors were deep-seated, and six were superficially located. Fifteen patients underwent wide excision, including one amputation, and 18 achieved (81.8%) negative margins histologically. Two local recurrences and four distant metastases developed. The mean Musculoskeletal Tumor Society score was 92.0% (range, 33.3-100). The 5-year local recurrence-free survival rate, metastasis-free survival rate, and overall survival rate were 90.0%, 77.0%, and 79.7%, respectively.

Conclusions

Local control and limb function can have favorable outcomes when the tumor excised has a histologically negative margin without sacrificing the major structure.

Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of soft tissue tumors 2020 - Secondary publication

BACKGROUND

These clinical practice guidelines are intended to provide recommendations based on the best evidence obtained to date on key issues in clinical practice to improve the prognosis, diagnostic and therapeutic processes for patients with soft tissue tumors.

METHODS

The Guidelines Development Committee and Systematic Review Committee were composed of a multidisciplinary team of specialists who play an important role in soft tissue tumor care. Clinical questions (CQs) were determined by choosing key decision-making points based on Algorithms for the diagnosis and treatment of soft tissue tumors. The guidelines were developed according to the "Medical Information Network Distribution Service (Minds) Handbook for Clinical Practice Guideline Development 2014" and "Minds Manual for Clinical Practice Guideline Development 2017." Recommendation strength was rated on two levels and the strength of evidence was rated on four levels. The recommendations were decided based on agreement by 70% or more voters.

RESULTS

Twenty-two CQs were chosen by the Guidelines Development Committee. The Systematic Review Committee reviewed the evidence concerning each CQ, a clinical value judgment was added by experts, and the text of each recommendation was determined.

CONCLUSION

We established 22 CQs and recommendations for key decision-making points in the diagnosis and treatment of soft tissue tumors according to the Minds Clinical Practice Guideline development methods. We hope that these guidelines will assist the decision-making of all medical staff engaged in the treatment and diagnosis of soft tissue tumors, and eventually lead to improved soft tissue tumor care in the country.

Optimal surgical treatment for paratesticular leiomyosarcoma: retrospective analysis of 217 reported cases

BACKGROUND

Paratesticular leiomyosarcoma (LMS) is a rare tumor. Conventionally, tumor resection by high inguinal orchiectomy is performed as the preferred treatment approach for paratesticular sarcoma. On the other hand, testis-sparing surgery has recently attracted attention as a less-invasive treatment option for paratesticular sarcoma. However, the prognostic predictors and optimal treatment strategy for paratesticular LMS remain unclear because of its rarity. In this study, we systematically reviewed previously reported cases of paratesticular LMS to evaluate the prognostic factors and establish the optimal treatment strategy.

METHODS

A systematic search of Medline, Web of Science, Embase, and Google was performed to find articles describing localized paratesticular LMS published between 1971 and 2020 in English. The final cohort included 217 patients in 167 articles. The starting point of this study was the time of definitive surgical treatment, and the end point was the time of local recurrence (LR), distant metastasis (DM), and disease-specific mortality.

RESULTS

Patients with cutaneous LMS had a slightly better LR-free survival, DM-free survival, and disease-specific survival than those with subcutaneous LMS (p = 0.745, p = 0.033, and p = 0.126, respectively). Patients with higher grade tumors had a significantly higher risk of DM and disease-specific mortality (Grade 3 vs Grade 1 p < 0.001, and Grade 3 vs Grade 1 p < 0.001, respectively). In addition, those with a microscopic positive margin had a significantly higher risk of LR and DM than those with a negative margin (p < 0.001, and p = 0.018, respectively). Patients who underwent simple tumorectomy had a slightly higher risk of LR than those who underwent high inguinal orchiectomy (p = 0.067). Subgroup analysis of cutaneous LMS demonstrated that the difference in LR between simple tumorectomy and high inguinal orchiectomy was limited (p = 0.212). On the other hand, subgroup analysis of subcutaneous LMS revealed a significant difference in LR (p = 0.039).

CONCLUSIONS

Our study demonstrated that subcutaneous LMS and high-grade tumors are prognostic factors for paratesticular LMS. For subcutaneous LMS, tumorectomy with high inguinal orchiectomy should be the optimal treatment strategy to achieve a negative surgical margin.

Clinical value of baseline 18F-FDG PET/CT in soft tissue sarcomas

Background

The use of ¹⁸F-FDG Positron emission tomography/Computed tomography (PET/CT) in the initial staging of many cancers is clearly established. Most soft tissue sarcoma (STS) has a high affinity for ¹⁸F-FDG, which is why ¹⁸F-FDG PET/CT has been proposed as a non-invasive method, useful in diagnosis and follow-up. The standardized uptake value values (SUV), the volume-based metabolic parameters MTV (metabolic tumor volume), and TLG (total lesion glycolysis) determine tumor viability and provide its total volume and the total activity of metabolically active tumor cells. The histological grade is the most important predictor of metastases and mortality associated with STS, and a significant relationship between the metabolic parameters of ¹⁸F-FDG PET/CT and the histological grade has been described.

Methods

A retrospective study was conducted on STS patients, who had histological grade according to the FNCLCC (Fédération Nationale des Centres de Lutte Contre Le Cancer) criteria, as well as a baseline PET/CT. SUV (SUV_max, SUV_mean, and SUV_peak), MTV, and TLG were quantified. A T-student test was performed to establish the relationship between the metabolic biomarkers and the histological grade. Their usefulness as predictors of the histological grade was verified using receiver operator characteristic (ROC) curves. A survival function study was performed using the Kaplan–Meier method. To assess the prognostic utility of the metabolic biomarkers we use the Log-Rank method.

Results

The SUV values were useful to discriminate high-grade STS. We found a significant relationship between the histological grade and the SUV values. SUV_max, SUV_peak, MTV, and TLG were predictors of overall survival (OS). There were no significant differences in the OS for the SUV_mean, or in the disease-free survival (DFS) for SUV_max, SUV_mean, SUV_peak, MTV, and TLG.

Conclusions

The SUV_max, SUV_mean, and SUV_peak values correlate with the HG and are useful to discriminate high-grade from low-grade STS. Patients with high SUV_max, SUV_peak, MTV, and TLG have a significantly lower OS.

Clinical features of bone and soft tissue tumors of the foot and ankle: Results from a retrospective single-center case-series

BACKGROUND

The malignant potential of the musculoskeletal tumors of the foot and ankle has often been underestimated because of their rarity. The current study reviewed the clinical features of the tumors of the foot and ankle, and evaluated the tumor size via imaging-based analysis to distinguish between benign and malignant lesions.

METHODS

A retrospective review was performed using the clinical records of all patients with histologically confirmed musculoskeletal tumors of the foot and ankle, treated between 1998 and 2020 at our institution. We examined the distribution of tumors, rate of unplanned excision for primary surgery, and subsequent outcomes. In addition, the tumor size was examined via magnetic resonance imaging, and the cut-off value was determined via receiver operating characteristic (ROC) curve.

RESULTS

A total of 103 bone and soft tissue tumors of the foot and ankle were included, of which 78 were soft tissue tumors and 25 were bone tumors. Of the 14 cases of malignant bone and soft tissue tumors, 6 (42.9%) received unplanned excision in the primary surgery, followed by amputation in 3 cases. Tumor size of malignant soft tissue tumors was significantly larger than that of benign soft tissue tumors (47.6 mm vs. 31.0 mm, respectively, P < .001). However, the difference between benign and malignant bone tumors was not statistically significant with the numbers available. ROC curve determined that the optimum diagnostic cutoff value for soft tissue tumor size was 40 mm, with a high area under the ROC curve 0.816 (95% CI: 0.711-0.921, sensitivity 91.7%, specificity 70.5%) CONCLUSIONS: We highlighted that bone and soft tissue tumors of the foot and ankle were often misdiagnosed and initially inadequately treated. We suggest that a cutoff value of 40 mm may be a useful index for prediction of malignancy in soft tissue tumors of the foot and ankle.

LEVEL OF EVIDENCE

Ⅲ.

Impact of comorbidities on oncological outcomes of Japanese patients with high grade soft tissue sarcomas

BACKGROUND

Considering the invasiveness of standard multidisciplinary approaches used for the treatment of soft tissue sarcoma, including surgery with wide margins, intensive chemotherapy, and radiotherapy, evaluation of comorbidities in high-grade soft tissue sarcoma patients is essential. Several previous studies have reported the impact of comorbidities on the survival of soft tissue sarcoma patients. Patient health status differs between nationalities or ethnic groups and only limited data has been reported with respect to the impact of comorbidities on Japanese soft tissue sarcoma patients.

METHODS

The incidence of each comorbidity, relationship between comorbidities and underlying clinicopathological factors, relationship between treatment status and comorbidities, and impact of comorbidities on disease-specific death in 136 patients with high-grade soft tissue sarcoma at the authors' institution were analyzed. For the evaluation of comorbidities, the updated Charlson comorbidity index was applied.

RESULTS

Of the patients, 25% presented with more than one comorbidity. Elderly patients showed a significantly higher incidence of comorbidities (p < 0.0001). Patients with congestive heart failure (p = 0.004), dementia (p < 0.0001), hemiplegia/paraplegia (p < 0.0001), and renal disease (p < 0.0001) showed worse prognosis. Tumor grade (p = 0.01) and updated Charlson comorbidity index (p < 0.0001) were independent risk factors for disease-specific death.

CONCLUSIONS

Comorbidity status was a significant risk factor for disease-specific death in Japanese patients with high-grade soft tissue sarcoma. Innovations in comorbidity management may be a means for the improvement of oncological outcomes in soft tissue sarcoma. Given the difficulties in conducting standard randomized control studies in this field, data accumulation from real-world cases appears to be the most practical approach in establishing and applying strategies for the treatment of patients with comorbidities or elderly patients.

Stewart-Treves syndrome and other cutaneous malignancies in the context of chronic lymphedema: a systematic review

INTRODUCTION

Angiosarcoma developing in chronically lymphedematous tissue, or Stewart-Treves syndrome (STS), is a rare and lethal complication of lymphedema. This systematic review summarizes characteristics and outcomes of STS and other cutaneous malignancies arising in chronic lymphedema.

METHODS

MEDLINE and EMBASE databases were searched on February 19th, 2021, to identify 200 articles included in the analysis.

RESULTS

Of 369 included patients, 89.7% (n = 331/369) had STS and 10.3% (n = 38/369) had other associated malignancies. Mean age of onset was 61.2 years, and 85.9% (n = 317/369) of cases were female. Common risk factors were previous cancer history (69.8%, n = 258/369) and radiation history (53.7%, n = 198/369). Lymphedema was most commonly attributed to surgical causes (68.3%, n = 252/369). STS begins on average 14.9 years after lymphedema with mortality of 53.9% (n = 178/331) and remission rate of 16.1% (n = 53/331). Other malignancies begin on average 23.7 years after lymphedema, with mortality of 10.5% (n = 4/38) and remission rate of 31.6% (n = 12/38). STS and other malignancies had 5-year survivals of 22.4% and 65.2%, respectively (P = 0.00145). For all patients, patients initially treated with excision had the best survival (median: 48 months, 5-year survival: 43.3%) and radiotherapy had the worst survival (median: 10 months, 5-year survival: 6.5%) (P = 0.0141).

CONCLUSION

Malignancy can appear in lymphedematous tissue many years after lymphedema onset. STS has poorer prognosis compared to other malignancies. Further research should be conducted to better understand the causes, risk factors, and management of this phenomenon.

Is immunotherapy in the future of therapeutic management of sarcomas?

Sarcomas are rare, ubiquitous and heterogeneous tumors usually treated with surgery, chemotherapy, target therapy, and radiotherapy. However, 25-50% of patients experience local relapses and/or distant metastases after chemotherapy with an overall survival about 12-18 months. Recently, immuno-therapy has revolutionized the cancer treatments with initial indications for non-small cell lung cancer (NSCLC) and melanoma (immune-checkpoint inhibitors).Here, we provide a narrative review on the topic as well as a critical description of the currently available trials on immunotherapy treatments in patients with sarcoma. Given the promising results obtained with anti-PD-1 monoclonal antibodies (pembrolizumab and nivolumab) and CAR-T cells, we strongly believe that these new immunotherapeutic approaches, along with an innovative characterization of tumor genetics, will provide an exciting opportunity to ameliorate the therapeutic management of sarcomas.

Myxoid liposarcoma: MRI features with histological correlation

BACKGROUND AND AIMS

Myxoid liposarcoma is classified in the group of sarcomas with adipose differentiation, which is the second most common group of sarcomas. However, myxoid liposarcoma is not a homogeneous entity, because the behavior and clinical course of these tumors can vary widely. This study aimed to describe the magnetic resonance imaging (MRI) features of myxoid liposarcomas and to determine whether the MRI features are associated with the histologic grade and can differentiate between low-grade and high-grade tumors and thus help in clinical decision making.

MATERIAL AND METHODS

We studied 36 patients with myxoid liposarcomas treated at our center between 2010 and 2018. We analyzed clinical variables (age, sex, and tumor site) and MRI features (size, depth, borders, fatty component, myxoid component, non-fatty / non-myxoid component, apparent diffusion coefficient (ADC), and type of enhancement after the administration of intravenous contrast material). We correlated the MRI features with the histologic grade and the percentage of round cells.

RESULTS

In our series, patients with myxoid liposarcomas were mainly young adults (median age, 43 years). There were no differences between sexes; 97.2% were located in the lower limbs, 86.1% were deep, and 77.8% had well-defined borders. Of the 23 myxoid liposarcomas that contained no fat, 16 (69.6%) were high grade (p=0.01). All the tumors with a myxoid component of less than 25% were high grade (p=0.01); 83.3% of those with a non-fatty / non-myxoid component greater than 50% were high grade (p=0.03) and 61.5% had more than 5% round cells (p=0.01). Diffusion sequences were obtained in 14 of the 36 patients; ADC values were high (median, 2 x 10-3 mm2/s), although there were no significant associations between low-grade and high-grade tumors. Contrast-enhanced images were available for 30 (83.3%) patients; 83.3% of the tumors with heterogeneous enhancement were high grade (p=0.01).

CONCLUSIONS

MRI can be useful for differentiating between high- and low-grade myxoid liposarcomas and can help in clinical decision making.

Efficacy of combination-chemotherapy with pirarubicin, ifosfamide, and etoposide for soft tissue sarcoma: a single-institution retrospective analysis

Background

The standard chemotherapy regimens for soft tissue sarcoma are doxorubicin-based. This retrospective study aimed to assess the efficacy and safety of pirarubicin, ifosfamide, and etoposide combination therapy for patients with this disease.

Methods

Between 2008 and 2017, 25 patients with soft tissue sarcoma were treated with pirarubicin (30 mg/m², 2 days), ifosfamide (2 g/m², 5 days), and etoposide (100 mg/m², 3 days) every 3 weeks. The primary endpoint was overall response, and the secondary endpoint was adverse events of this regimen.

Results

Responses to this regimen according to RECIST criteria were partial response (n = 9, 36%), stable disease (n = 9, 36%) and progressive disease (n = 7, 28%). During the treatment phase, frequent grade 3 or worse adverse events were hematological toxicities including white blood cell decreases (96%), febrile neutropenia (68%), anemia (68%), and platelet count decreases (48%). No long-term adverse events were reported during the study period.

Conclusion

This regimen was comparable to previously published doxorubicin-based combination chemotherapy in terms of response rate. Although there were no long-lasting adverse events, based on our results, severe hematological toxicity should be considered.

Intraoperative ultrasonography-guided surgery for malignant soft tissue tumor

BACKGROUND AND OBJECTIVES

A clear surgical margin is crucial for preventing the recurrence of soft tissue sarcomas (STSs). Recognizing the tumor border is difficult when the STS is impalpable or ill-defined. Ultrasonography (US) is a widely used diagnostic device that can visualize certain tumors intraoperatively. However, its usefulness for intraoperatively assessing STSs is unclear and was investigated here.

METHODS

Our study comprised 19 patients with STSs that were impalpable, ill-defined, or beneath the fascia. All patients underwent intraoperative US (IOUS), with follow-up times ranging from 5 to 103 months (mean, 49 months).

RESULTS

The mean age of the study participants was 56 years (range, 25-83 months). The most common histological diagnosis was undifferentiated pleomorphic sarcoma (UPS) (nine patients). The mean tumor size was 51 mm (range, 7-126 mm). According to the residual tumor classification, 18 tumors were microscopically negative (R0), including seven close to the fascia, and one was microscopically positive (R1). Local recurrence occurred in two cases (both classified as R0). The recurrence-free survival rate was 88.9% in 5 years.

CONCLUSIONS

IOUS-guided surgery is useful for visualizing STSs. Using this technique, STSs can be precisely localized, evaluated, and excised.

Outcomes of Sarcoma Resections Requiring Vascular Surgical Assistance: A Single-Center Experience

Objective: To describe the types of intervention and determine patency and survival after arterial and venous reconstruction after surgical excision of sarcomas. Methods: Between November 2001 and July 2015, 42 patients with sarcomas and vascular involvement underwent surgical oncologic resection followed by arterial or venous reconstruction or preservation of the native vascular bundle. Univariate, multivariate, and Kaplan-Meier survival analyses were performed on abstracted data, which included demographics, risk factors, oncologic and vascular treatment modalities, postoperative complications, graft patency, and survival outcomes. Results: A total of 42 sarcomas required vascular assistance for oncologic removal. The majority of sarcomas were malignant fibrous histiocytoma (23.8%), and the most common anatomic location was the retroperitoneum (48%). A total of 12 revascularizations procedures were performed, including 5 arterial, 3 venous, and 2 concomitant arterial and venous. In 32 cases, a vascular surgeon was needed for vessel ligation, repair, or mobilization. The overall 2- and 5-year survival was 77.7% and 26.2%, respectively, with no significant survival difference between patients who underwent revascularization compared to those without revascularization. There was a 100% patency rate in all cases at last follow-up, regardless of the type of vascular reconstruction (median 18 months, range 1-29 months). On multivariate analysis, chronic obstructive pulmonary disease (COPD; P = .002) and positive surgical margins (P = .003) were associated with decreased survival. Most cases were performed in the last 5 years of the study (n = 27, 64.3%). Conclusions: Vascular reconstruction is feasible after surgical oncologic resection of sarcomas with good mid-term patency and limb preservation. Factors independently associated with mortality included COPD and positive surgical margins.

Optimal treatment strategy for paratesticular liposarcoma: retrospective analysis of 265 reported cases

BACKGROUND

Liposarcoma is one of the most common subtypes of soft tissue sarcoma. Although the standard treatment for localized liposarcoma is surgical resection with negative margins, a treatment specific to paratesticular liposarcoma has yet to be quantitatively evaluated.

METHODS

A systematic search of Medline, Web of Science, Embase, and Google was performed to find articles describing localized paratesticular liposarcoma published between 1979 and 2018 in English. The final cohort included 265 patients in 183 articles. The starting point was the time of surgical treatment, and the endpoint was the time of recurrence, including local recurrence, or distant metastasis.

RESULTS

The median patient age was 62 years and the median tumor size was 9.5 cm. In total, 178 patients underwent high inguinal orchiectomy and 40 underwent simple tumorectomy. Based on the Kaplan-Meier curves, recurrence-free survival rates were significantly higher for those who underwent high inguinal orchiectomy than for those who underwent tumorectomy. Moreover, those with microscopic positive margins had a higher risk of recurrence than those with negative margins, but adjuvant radiation therapy after resection had no statistically significant effect on recurrence-free survival, even in subgroup analysis of patients with positive margins. Regarding the pathological subtypes, dedifferentiated, pleomorphic, and round-cell liposarcoma had a higher risk of recurrence than well-differentiated or myxoid liposarcoma. In the multivariate analysis, high inguinal orchiectomy greatly affected recurrence-free survival. The tumor size and histological subtype were independent risk factors for recurrence.

CONCLUSION

Complete resection with high inguinal orchiectomy is the optimal treatment for paratesticular liposarcoma.

Soft tissue sarcomas in the elbow region and influence of their anatomical features in their treatment. Experience in the Unit of Musculoskeletal Tumours

BACKGROUND AND AIM

Soft tissue sarcomas are exceptionally located in the elbow region. The aim of this work was to study the soft tissue sarcomas of the elbow region, their epidemiological and histopathological characteristics, anatomical features, the treatment performed, and the results obtained, in a unit of musculoskeletal tumours.

METHODS

Retrospective review of ten patients with a mean follow-up of 65.0 ± 11.9 (range 21-132) months with soft tissue sarcomas located in the elbow region operated in our centre between 2008 and 2016.

RESULTS

Mean age was 60.8 ± 6.7 years. Undifferentiated pleomorphic sarcoma was the most frequent histological diagnosis. Limb preservation surgery was performed in 90% of patients. Three patients were previously operated without following surgical oncology guidelines in another hospital, and this was statistically related to the need for more than one surgery to control the disease. R1 margin was obtained in 5 patients and R0 in another 5. Adjuvant radiotherapy was used in 7 cases. In 4 patients, subsequent surgery was performed for local or systemic control of the disease. Local recurrence occurred in 3 cases and in 5 there was distant disease.

CONCLUSION

The elbow region presents difficulty in achieving wide margins due to the proximity of neurovascular structures, adjuvant and / or neoadjuvant therapies could play an important role in performing limb preservation surgery. It would be advisable to refer these tumours to specialized units with multidisciplinary teams.

Racial Differences in Extremity Soft Tissue Sarcoma Treatment in a Universally Insured Population

BACKGROUND

In prior reports from population-based databases, black patients with extremity soft tissue sarcoma (ESTS) have lower reported rates of limb-sparing surgery and adjuvant treatment. The objective of this study was to compare the multimodality treatment of ESTS between black and white patients within a universally insured and equal-access health care system.

METHODS

Claims data from TRICARE, the US Department of Defense insurance plan that provides health care coverage for 9 million active-duty personnel, retirees, and dependents, were queried for patients younger than 65 y with ESTS who underwent limb-sparing surgery or amputation between 2006 and 2014 and identified as black or white race. Multivariable logistic regression analysis was used to evaluate the impact of race on the utilization of surgery, chemotherapy, and radiation.

RESULTS

Of the 719 patients included for analysis, 605 patients (84%) were white and 114 (16%) were black. Compared with whites, blacks had the same likelihood of receiving limb-sparing surgery (odds ratio [OR], 0.861; 95% confidence interval [95% CI], 0.284-2.611; P = 0.79), neoadjuvant radiation (OR, 1.177; 95% CI, 0.204-1.319; P = 0.34), and neoadjuvant (OR, 0.852; 95% CI, 0.554-1.311; P = 0.47) and adjuvant (OR, 1.211; 95% CI, 0.911-1.611; P = 0.19) chemotherapy; blacks more likely to receive adjuvant radiation (OR, 1.917; 95% CI, 1.162-3.162; P = 0.011).

CONCLUSIONS

In a universally insured population, racial differences in the rates of limb-sparing surgery for ESTS are significantly mitigated compared with prior reports. Biologic or disease factors that could not be accounted for in this study may contribute to the increased use of adjuvant radiation among black patients.

Update in pelvic and retroperitoneal sarcoma management: The role of compartment surgery

Surgery for retroperitoneal sarcomas should be "en bloc" compartmental, which involves resection of unaffected organs. Its upfront use is key, providing a high percentage of resections with negative margins, resulting in a better local control and increased survival in many patients. Preservation of organs should be done in an individualized manner, especially in the pelvic location, and adapted to the histological aggressiveness of the tumor. Preoperative biopsy is able to establish the diagnosis of sarcoma subtype and consequently an adequate perioperative strategy. These patients should be managed by expert surgeons at referral centers with multidisciplinary units and oncology committees. The use of chemotherapy and radiotherapy is not yet well defined, so it is only recommended at referral centers with clinical trials. Currently, this is the only option to offer the best morbidity and mortality rates, as well as possible improvements in the survival of these patients.

The PTEN Tumor Suppressor Gene in Soft Tissue Sarcoma

Soft tissue sarcoma (STS) is a rare malignancy of mesenchymal origin classified into more than 50 different subtypes with distinct clinical and pathologic features. Despite the poor prognosis in the majority of patients, only modest improvements in treatment strategies have been achieved, largely due to the rarity and heterogeneity of these tumors. Therefore, the discovery of new prognostic and predictive biomarkers, together with new therapeutic targets, is of enormous interest. Phosphatase and tensin homolog (PTEN) is a well-known tumor suppressor that commonly loses its function via mutation, deletion, transcriptional silencing, or protein instability, and is frequently downregulated in distinct sarcoma subtypes. The loss of PTEN function has consequent alterations in important pathways implicated in cell proliferation, survival, migration, and genomic stability. PTEN can also interact with other tumor suppressors and oncogenic signaling pathways that have important implications for the pathogenesis in certain STSs. The aim of the present review is to summarize the biological significance of PTEN in STS and its potential role in the development of new therapeutic strategies.

One-bloc percutaneous large biopsy of soft-tissue tumours: feasibility study and possible indications

AIM

To report the early results of the Intact lesion excision system (LES) regarding feasibility, tolerance and efficiency in obtaining soft-tissue tumour samples under ultrasound guidance.

MATERIALS AND METHODS

The feasibility and tolerance of Intact LES procedures under ultrasound guidance were studied prospectively in 15 patients. The procedure was performed on an outpatient basis under local anaesthesia by a single interventional radiologist with 6 years of experience and lasted around 30 min.

RESULTS

The feasibility of the Intact LES for soft-tissue masses was good except when lesions were hard and calcified. Tolerance was good, with median pain experienced during the procedure evaluated at 4.5/10 (SD 2.2) and median post-procedural pain at day 1 evaluated at 1.8/10 (SD 2.5). No major complications were observed; however, for vascularised lesions, one case of acute wound bleeding and two post-procedural haematomas led to delayed pain.

CONCLUSION

Percutaneous biopsy of suspected soft-tissue sarcoma using the LES device under ultrasound guidance is well tolerated and feasible. After a first non-contributing core biopsy, and especially, in the case of lipomatous lesions, it is a valuable option to consider, as is surgical incision biopsy.

Evidence mapping based on systematic reviews of therapeutic interventions for soft tissue sarcomas

PURPOSE

Soft tissue sarcomas are a heterogeneous group of rare tumours of mesenchymal origin. Evidence mapping is one of the most didactic and friendly approaches to organise and summarise the range of research activity in broad topic fields. The objective of this evidence mapping is to identify, describe and organise the current available evidence about therapeutic interventions on soft tissues sarcomas.

METHODS

We followed the methodology of global evidence mapping. We performed a search of the PubMed, EMBASE, The Cochrane Library and Epistemonikos to identify systematic reviews (SRs) with or without meta-analyses published between 1990 and March 2016. Two independent literature reviewers assessed eligibility and extracted data. Methodological quality of the included systematic reviews was assessed using AMSTAR. We organised the results according to identified PICO questions and used tables and a bubble plot to display the results.

RESULTS

The map is based on 24 SRs that met eligibility criteria and included 66 individual studies. Three-quarters were either observational or uncontrolled clinical trials. The quality of the included SRs was in general moderate or high. We identified 64 PICO questions from them. The corresponding results mostly favoured the intervention arm.

CONCLUSIONS

This evidence mapping was built on the basis of SRs, which mostly included non-experimental studies and were qualified by the AMSTAR tool as of moderate quality. The evidence mapping created from PICO questions is a useful approach to describe complex and huge clinical topics through graphical media and orientate further research to fulfil the existing gaps. However, it is important to delimitate the steps of the evidence mapping in a pre-established protocol.

In Reply

Authors of the recently published article from the Spanish Group for Research in Sarcoma respond to comments on the results of their study.

A meta-analysis of randomized controlled trials that compare standard doxorubicin with other first-line chemotherapies for advanced/metastatic soft tissue sarcomas

Objective

The standard treatment for patients with advanced/metastatic soft tissue sarcomas (ASTS) is systemic chemotherapy with doxorubicin. A previous meta-analysis of 8 randomized controlled trials (RCTs) demonstrated the superiority of single-agent doxorubicin over doxorubicin-based combination chemotherapy for ASTS. However, meta-analyses of all RCTs that compare doxorubicin to other single-agent or combination regimens as first-line treatments for ASTS are lacking. We conducted a systematic review and meta-analysis to evaluate the efficacy and toxicity of current primary treatments for ASTS.

Methods

Eligible studies were RCTs of first-line chemotherapies for ASTS comparing doxorubicin alone to other single agents or to combination therapies (experimental arm). Data from studies reporting hazard ratios (HR) and 95% confidence intervals (CI) for overall survival (OS) and progression-free survival (PFS) were pooled. Other time-to-event endpoints were extracted from the studies based on Kaplan-Meier estimates, and pooled odds ratios (OR) and 95% CI were calculated.

Results

Twenty-seven eligible RCTs comprising 6156 patients were identified. Overall, the 1-year OS (OR 0.88, 95% CI 0.79–0.99, P = 0.03) was significantly improved in the experimental arm over the doxorubicin-only arm; however, there was no significant difference in 2-year OS (OR 0.87, 95% CI 0.73–1.03, P = 0.11) or OS (HR 0.97, 95% CI 0.91–1.03, P = 0.28) between the two groups. PFS and other time-to-event endpoints were not significantly different between the two treatment arms. While incidences of overall severe adverse events were not significantly different (OR 1.20, 95% CI 0.88–1.65, P = 0.26), severe nausea/vomiting was significantly more frequent in the experimental arm (OR 1.90, 95% CI 1.27–2.83, P = 0.002).

Conclusion

The efficacies of doxorubicin-only and experimental arm regimens were similar, although toxicities were more frequent in the experimental arms. Hence, doxorubicin monotherapy remains suitable as a standard first-line regimen for ASTS.

Adjuvant chemotherapy-Radiotherapy-Chemotherapy sandwich protocol in resectable soft tissue sarcoma: An updated single-center analysis of 104 cases

Adjuvant therapy of local soft tissue sarcomas (STS) after wide surgical excision still is a topic under controversial scientific debate. In this single center report we have offered an adjuvant “sandwich” therapy protocol consisting of 4 cycles of doxorubicin (75 mg/m² i.v. over 1 h on day 1) followed by ifosfamide (5 g/m² i.v. over 24 h starting on day 1) and local radiotherapy scheduled between chemotherapy cycles 2 and 3 to 104 consecutive patients after wide surgical excision (R0) of histologically proven high-grade STS. After a mean follow-up of 39 months (range 5–194 months) relapse free survival (RFS) at 2 and 5 years was 68.1% (95% CI, 58.5–77.7%) and 61.2% (95% CI, 50.4–71.6%). When analyzing the 82 STS cases of the extremities only 2- and 5-year RFS was 74.0% (95% CI, 64.0–84.0%) and 65.3% (95% CI, 53.7–76.9%). By intent-to-treat analysis, the overall survival (OS) at 2 years was 87.3% (95% CI, 80.5–94.1%) and 75.6% (95% CI, 65.2–86.0%) at 5 years, while OS for STS of the extremities only cohort was 90.5% (95% CI, 83.7–97.3%) and 79.0% (95% CI, 68.4–89.6%), respectively. Tolerability of the treatment was good. This analysis demonstrates the feasibility of adjuvant chemoradiotherapy and reflects the results of the long lasting intensive multidisciplinary team approach at our “high-volume” sarcoma center. The long-term survival in our patients is among the highest reported and the low local and distant recurrence rate in high-risk STS is at least comparable to the published data.

Prediction of clinical outcome and survival in soft-tissue sarcoma using a ten-lncRNA signature

The prognostic value of long non-coding RNAs (lncRNAs) in patients with soft-tissue sarcoma has rarely been unraveled. The aim of the study was to find a lncRNA signature to predict the clinical outcome and survival in soft-tissue sarcoma based on the high-throughput RNA-seq data from The Cancer Genome Atlas (TCGA) database. The lncRNAs which closely correlated with overall survival in 258 soft-tissue sarcoma patients were identified with Cox proportional regression model. Ten lncRNAs, including RP11-560J1.2, AP001432.14, RP4-665J23.1, LINC00680, AC006129.2, RP11-230G5.2, BACH1-IT2, RP11-274B21.9, RP11-504A18.1 and RP11-713P17.3, were selected to calculate a risk score. The risk score could effectively predict patients’ outcome, such as the status of mitotic count of tumor cells, person neoplasm cancer and residual tumor. More inspiringly, the risk score generated from the 10-lncRNA signature was an independent prognostic indicator for soft-tissue sarcoma patients. Overall, this 10-lncRNA signature gains the potential as an effective prognostic tool for soft-tissue sarcoma as part of the integrated clinical RNA-seq program.