Multimodality therapy for advanced or metastatic sarcoma

Can Posttransarterial Chemoembolization Volumetric Oil Deposition on Computed Tomography Predict Treatment Response on Magnetic Resonance Imaging in Leiomyosarcoma Metastases to the Liver?

OBJECTIVE

To predict early tumor response to transarterial chemoembolization (TACE) based on volumetric oil deposition on posttreatment computed tomography (CT) in patients with leiomyosarcoma liver metastases.

METHODS

This retrospective lesion-by-lesion based study included 32 lesions. The volumetric percent enhancing tumor on pre-TACE and 1-month post-TACE venous phase magnetic resonance imaging (MRI), and the percent oil deposition on CT 1 day after TACE were calculated. The predicted post-TACE enhanced percentage was computed by subtracting percent oil deposition from baseline percent enhanced.

RESULTS

Mean percentage of viable tumor on pre-TACE MRI was 90.6% ± 9.3%. Mean oil deposition was calculated as 51.4% ± 26.2%. Mean percentage of measured residual tumor enhancement 1 month after TACE was 58.3% ± 27%, which correlates with predicted enhancement percentage of 43.9% ± 25.1% (r = 0.72, P < 0.001). A threshold of 35.5% for enhancement reduction was determined to predict tumor response with an accuracy of 78.1%.

CONCLUSION

Volumetric oil deposition on CT can predict residual enhancement on post-TACE MRI.

Stereotactic Body Radiotherapy in Oligomestatic/Oligoprogressive Sarcoma: Safety and Effectiveness Beyond Intrinsic Radiosensitivity

BACKGROUND

Metastatic soft tissue sarcoma (STS) patients may benefit from local ablative treatments due to modest efficacy of systemic chemotherapy. However, use of stereotactic body radiotherapy (SBRT) is controversial because of presumed radioresistance of STS.

METHODS

Patients treated with SBRT for oligometastatic and oligoprogressive metastatic STS were retrospectively reviewed to assess results in terms of local control (LC), disease-free survival (DFS), and overall survival (OS). Incidence and grade of adverse events were reported. Statistical analysis was performed to identify variables correlated with outcome and toxicity.

RESULTS

Forty patients were treated with SBRT to a median biologic effective dose (BED) of 105 (66-305) Gy5 to 77 metastases. Two-year LC, DFS, and OS were 67%, 23%, and 40%. Improved LC was shown in patients receiving a BED >150 Gy5 (hazard ratio [HR], 3.9; 95% confidence interval [CI], 1.6-9.7; P = 0.028). A delay >24 months between primary tumor diagnosis and onset of metastases was associated with improved DFS (HR, 0.46; 95% CI, 0.22-0.96; P = 0.01) and OS (HR, 0.48; 95% CI, 0.23-0.99; P = 0.03). No toxicity grade ≥3 was observed.

CONCLUSIONS

Stereotactic body radiotherapy is effective in metastatic STS with a benign toxicity profile. A BED >150 Gy5 is required to maximize tumor control rates. Metastatic relapse >24 months after diagnosis is correlated to improved survival.

Multidisciplinary Management of Retroperitoneal Sarcoma: Diagnosis, Prognostic Factors and Treatment

Simple Summary

The management of retroperitoneal sarcomas can be challenging due to the variety of their presentation, histopathological types, and behaviours. This literature review provides a comprehensive and practical overview of the management of retroperitoneal sarcomas, focusing on diagnostic challenges, prognostic factors, multidisciplinary aspects of treatment and new research perspectives.

Abstract

Retroperitoneal sarcomas (RPS) are rare cancers whose management can be challenging due to various presentation patterns, multiple organ involvement, and a high local and distant recurrence rate. Histopathology and prognostic factors analysis are essential to predict the behaviour of the disease and plan the best therapeutic strategy. To date, surgery is still the main therapeutic option that guarantees a chance of cure from the primary disease. While chemotherapy and radiotherapy seem to be good options for controlling metastatic and recurrent irresectable disease, their role in the treatment of primary RPS remains unclear. This literature review aims to provide a comprehensive overview of the multidisciplinary aspects of RPS management in high-volume centres, summarising the diagnostic path, the prognostic factors, and the most suitable therapeutic options.

SEOM Clinical Guideline of management of soft-tissue sarcoma (2020)

Soft-tissue sarcomas constitute an uncommon and heterogeneous group of tumors of mesenchymal origin. Diagnosis, treatment, and management should be performed by an expert multidisciplinary team. MRI/CT of the primary tumor and biopsy is mandatory before any treatment. Wide surgical resection with tumor-free tissue margin is the mainstay for localized disease. Radiotherapy is indicated in large, deep, high-grade tumors, or after marginal resection not suitable for re-excision. Perioperative chemotherapy should be discussed for high-risk sarcomas of the extremities and trunk-wall. In the case of oligometastatic disease, patients should be considered for local therapies. First-line treatment with anthracyclines (or in combination with ifosfamide) is the treatment of choice. Other drugs have shown activity in second-line therapy and in specific histological subtypes but options are limited and thus, a clinical trial should always be discussed.

Management of metastatic retroperitoneal sarcoma: a consensus approach from the Trans-Atlantic Retroperitoneal Sarcoma Working Group (TARPSWG)

Introduction

Retroperitoneal sarcoma (RPS) is a rare disease accounting for 0.1%-0.2% of all malignancies. Management of RPS is complex and requires multidisciplinary, tailored treatment strategies at all stages, but especially in the context of metastatic or multifocal recurrent disease. Due to the rarity and heterogeneity of this family of diseases, the literature to guide management is limited.

Methods

The Trans-Atlantic Retroperitoneal Sarcoma Working Group (TARPSWG) is an international collaboration of sarcoma experts from all disciplines convened in an effort to overcome these limitations. The TARPSWG has compiled the available evidence surrounding metastatic and multifocally recurrent RPS along with expert opinion in an iterative process to generate a consensus document regarding the complex management of this disease. The objective of this document is to guide sarcoma specialists from all disciplines in the diagnosis and treatment of multifocal recurrent or metastatic RPS.

Results

All aspects of patient assessment, diagnostic processes, local and systemic treatments, and palliation are reviewed in this document, and consensus recommendations provided accordingly. Recommendations were guided by available evidence, in conjunction with expert opinion where evidence was lacking.

Conclusions

This consensus document combines the available literature regarding the management of multifocally recurrent or metastastic RPS with the practical expertise of high-volume sarcoma centers from multiple countries. It is designed as a tool for decision making in the complex multidisciplinary management of this condition and is expected to standardize management across centers, thereby ensuring that patients receive the highest quality care.

Multidisciplinary Management of Oligometastatic Soft Tissue Sarcoma

Soft tissue sarcomas (STS) encompass a group of rare but heterogeneous diseases. Nevertheless, many patients, particularly those with oligometastatic disease can benefit from thoughtful multimodality evaluation and treatment regardless of the STS subtype. Here, we review surgical, interventional radiology, radiation, and chemotherapy approaches to maximize disease palliation and improve survival, including occasionally long-term disease-free survival. Surgical resection can include lung or other visceral, soft tissue and bone metastases with a goal of rendering the patient disease free. Staged resections can be appropriate, and serial resection of oligometastatic recurrent disease can be appropriate. Retrospective series suggest survival benefit from this approach, although selection bias may contribute. Interventional radiology techniques such as percutaneous thermal ablation (PTA) and arterial embolization can present nonoperative local approaches in patients who are not medically fit for surgery, surgery is too morbid, or patients who decline surgery. Similarly, radiation therapy can be delivered safely to areas that are inaccessible surgically or would result in excessive morbidity. Currently no randomized trials exist comparing interventional radiologic approaches or radiation therapy to surgery but retrospective reviews show relatively similar magnitude of benefit in terms of disease palliation and survival, although it is felt unlikely that these procedures will render a patient to long-term disease-free status. Chemotherapy has evolved recently with the addition of several new treatment options, briefly reviewed here. Importantly, if a patient sustains a good response to chemotherapy resulting in true oligometastatic disease, consideration of multimodality local therapy approaches can be considered in the appropriate patient.

Unsupervised versus Supervised Identification of Prognostic Factors in Patients with Localized Retroperitoneal Sarcoma: A Data Clustering and Mahalanobis Distance Approach

The aim of this report is to unveil specific prognostic factors for retroperitoneal sarcoma (RPS) patients by univariate and multivariate statistical techniques. A phase I-II study on localized RPS treated with high-dose ifosfamide and radiotherapy followed by surgery (ISG-STS 0303 protocol) demonstrated that chemo/radiotherapy was safe and increased the 3-year relapse-free survival (RFS) with respect to historical controls. Of 70 patients, twenty-six developed local, 10 distant, and 5 combined relapse. Median disease-free interval (DFI) was 29.47 months. According to a discriminant function analysis, DFI, histology, relapse pattern, and the first treatment approach at relapse had a statistically significant prognostic impact. Based on scientific literature and clinical expertise, clinicopathological data were analyzed using both a supervised and an unsupervised classification method to predict the prognosis, with similar sample sizes (66 and 65, resp., in casewise approach and 70 in mean-substitution one). This is the first attempt to predict patients' prognosis by means of multivariate statistics, and in this light, it looks noticable that (i) some clinical data have a well-defined prognostic value, (ii) the unsupervised model produced comparable results with respect to the supervised one, and (iii) the appropriate combination of both models appears fruitful and easily extensible to different clinical contexts.