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Serban B, Cretu B, Cursaru A, Nitipir C, Orlov-Slavu C, Cirstoiu C. Local recurrence management of extremity soft tissue sarcoma. EFORT Open Rev 2023; 8:606-614. [PMID: 37526250 PMCID: PMC10441250 DOI: 10.1530/eor-23-0095] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/02/2023] Open
Abstract
Patients diagnosed with soft tissue sarcoma (STS) present a number of challenges for physicians, due to the vast array of subtypes and aggressive tumor biology. There is currently no agreed-upon management strategy for these tumors, which has led to the ongoing debate surrounding how frequently surveillance scans should be performed following surgery. However, advances in multidisciplinary care have improved patient outcomes over recent years. The early detection of local recurrence reflects a more aggressive tumor, even in association with the same histopathologic entity. Treating the local recurrence of extremity STS is a difficult clinical challenge. The goal should be to salvage limbs when possible, with treatments such as resection and irradiation, although amputation may be necessary in some cases. Regional therapies such as high-intensity, low-dose or interleukin-1 receptor antagonist treatment are appealing options for either definitive or adjuvant therapy, depending on the location of the disease's recurrence. The higher survival rate following late recurrence may be explained by variations in tumor biology. Since long-term survival is, in fact, inferior in patients with high-grade STS, this necessitates the implementation of an active surveillance approach.
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Affiliation(s)
- Bogdan Serban
- Department of Orthopedics and Traumatology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- University Emergency Hospital Bucharest, Romania
| | - Bogdan Cretu
- Department of Orthopedics and Traumatology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- University Emergency Hospital Bucharest, Romania
| | - Adrian Cursaru
- Department of Orthopedics and Traumatology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- University Emergency Hospital Bucharest, Romania
| | - Cornelia Nitipir
- Department of Oncology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Elias University Emergency Hospital, Bucharest, Romania
| | - Cristina Orlov-Slavu
- Department of Oncology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Elias University Emergency Hospital, Bucharest, Romania
| | - Catalin Cirstoiu
- Department of Orthopedics and Traumatology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- University Emergency Hospital Bucharest, Romania
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Wang D, Harris J, Kraybill WG, Eisenberg B, Kirsch DG, Ettinger DS, Kane JM, Barry PN, Naghavi A, Freeman CR, Chen YL, Hitchcock YJ, Bedi M, Salerno KE, Severin D, Godette KD, Larrier NA, Curran WJ, Torres-Saavedra PA, Lucas DR. Pathologic Complete Response and Clinical Outcomes in Patients With Localized Soft Tissue Sarcoma Treated With Neoadjuvant Chemoradiotherapy or Radiotherapy: The NRG/RTOG 9514 and 0630 Nonrandomized Clinical Trials. JAMA Oncol 2023; 9:646-655. [PMID: 36995690 PMCID: PMC10064284 DOI: 10.1001/jamaoncol.2023.0042] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 11/04/2022] [Indexed: 03/31/2023]
Abstract
Importance Pathologic complete response (pCR) may be associated with prognosis in patients with soft tissue sarcoma (STS). Objective We sought to determine the prognostic significance of pCR on survival outcomes in STS for patients receiving neoadjuvant chemoradiotherapy (CT-RT) (Radiation Therapy Oncology Group [RTOG] 9514) or preoperative image-guided radiotherapy alone (RT, RTOG 0630) and provide a long-term update of RTOG 0630. Design, Setting, and Participants RTOG has completed 2 multi-institutional, nonrandomized phase 2 clinical trials for patients with localized STS. One hundred forty-three eligible patients from RTOG 0630 (n = 79) and RTOG 9514 (n = 64) were included in this ancillary analysis of pCR and 79 patients from RTOG 0630 were evaluated for long-term outcomes. Intervention Patients in trial 9514 received CT interdigitated with RT, whereas those in trial 0630 received preoperative RT alone. Main Outcomes and Measures Overall and disease-free survival (OS and DFS) rates were estimated by the Kaplan-Meier method. Hazard ratios (HRs) and P values were estimated by multivariable Cox model stratified by study, where possible; otherwise, P values were calculated by stratified log-rank test. Analysis took place between December 14, 2016, to April 13, 2017. Results Overall there were 42 (53.2%) men; 68 (86.1%) were white; with a mean (SD) age of 59.6 (14.5) years. For RTOG 0630, at median follow-up of 6.0 years, there was 1 new in-field recurrence and 1 new distant failure since the initial report. From both studies, 123 patients were evaluable for pCR: 14 of 51 (27.5%) in trial 9514 and 14 of 72 (19.4%) in trial 0630 had pCR. Five-year OS was 100% for patients with pCR vs 76.5% (95% CI, 62.3%-90.8%) and 56.4% (95% CI, 43.3%-69.5%) for patients with less than pCR in trials 9514 and 0630, respectively. Overall, pCR was associated with improved OS (P = .01) and DFS (HR, 4.91; 95% CI, 1.51-15.93; P = .008) relative to less than pCR. Five-year local failure rate was 0% in patients with pCR vs 11.7% (95% CI, 3.6%-25.1%) and 9.1% (95% CI, 3.3%-18.5%) for patients with less than pCR in 9514 and 0630, respectively. Histologic types other than leiomyosarcoma, liposarcoma, and myxofibrosarcoma were associated with worse OS (HR, 2.24; 95% CI, 1.12-4.45). Conclusions and Relevance This ancillary analysis of 2 nonrandomized clinical trials found that pCR was associated with improved survival in patients with STS and should be considered as a prognostic factor of clinical outcomes for future studies. Trial Registration ClinicalTrials.gov Identifiers: RTOG 0630 (NCT00589121); RTOG 9514 (NCT00002791).
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Affiliation(s)
- Dian Wang
- Rush University Medical Center, Chicago, Illinois
| | - Jonathan Harris
- NRG Oncology Statistics and Data Management Center, American College of Radiology
| | | | - Burt Eisenberg
- Hoag Memorial Hospital Presbyterian, Newport Beach, California
| | | | - David S. Ettinger
- Johns Hopkins University/Sidney Kimmel Cancer Center, Baltimore, Maryland
| | - John M. Kane
- Roswell Park Cancer Institute, Buffalo, New York
| | | | - Arash Naghavi
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | | | | | | | - Manpreet Bedi
- Froedtert and The Medical College of Wisconsin, Wauwatosa, Wisconsin
| | | | | | | | - Nicole A. Larrier
- Duke University Medical Center, Durham, North Carolina
- Accrual for University of Texas-MD Anderson Cancer Center, Houston, Texas
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Reijers SJM, Gennaro N, Bruining A, van Boven H, Snaebjornsson P, Bekers EM, van Coevorden F, Scholten AN, Schrage Y, van der Graaf WTA, Haas RLM, van Houdt WJ. Correlation of radiological and histopathological response after neoadjuvant radiotherapy in soft tissue sarcoma. Acta Oncol 2023; 62:25-32. [PMID: 36637511 DOI: 10.1080/0284186x.2023.2166427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND The aim of this study was to assess the association between radiological and histopathological response after neoadjuvant radiotherapy (nRT) in soft tissue sarcoma (STS), as well as the prognostic value of the different response evaluation methods on the oncological outcome. METHODS A retrospective cohort of patients with localized STS of the extremity and trunk wall, treated with nRT followed by resection were included. The radiological response was assessed by RECIST 1.1 (RECIST) and MR-adapted Choi (Choi), histopathologic response was evaluated according to the EORTC-STBSG recommendations. Oncological outcome parameters of interest were local recurrence-free survival (LRFS), disease metastases-free survival (DMFS), and overall survival (OS). RESULTS For 107 patients, complete pre- and postoperative pathology and imaging datasets were available. Most tumors were high-grade (77%) and the most common histological subtypes were undifferentiated pleomorphic sarcoma/not otherwise specified (UPS/NOS, 40%), myxoid liposarcoma (MLS, 21%) and myxofibrosarcoma (MFS, 16%). When comparing RECIST to Choi, the response was differently categorized in 58%, with a higher response rate (CR + PR) with Choi. Radiological responders showed a significant lower median percentage of viable cells (RECIST p = .050, Choi p = .015) and necrosis (RECIST p < .001), and a higher median percentage of fibrosis (RECIST p = .005, Choi p = .008), compared to radiological non-responders (SD + PD). RECIST, Choi, fibrosis, and viable cells were not significantly associated with altered oncological outcome, more necrosis was associated with poorer OS (p = .038). CONCLUSION RECIST, Choi and the EORTC-STBSG response score show incongruent results in response evaluation. The radiological response was significantly correlated with a lower percentage of viable cells and necrosis, but a higher percentage of fibrosis. Apart from necrosis, radiological nor other histopathological parameters were associated with oncologic outcomes.
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Affiliation(s)
- Sophie J M Reijers
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Nicolò Gennaro
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Annemarie Bruining
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Hester van Boven
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Petur Snaebjornsson
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Elise M Bekers
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Frits van Coevorden
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Astrid N Scholten
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Yvonne Schrage
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Rick L M Haas
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Winan J van Houdt
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
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Ferreira Neto ODC, Bezerra RB, Silva RPDS, Silva MHR, de Alencar Neto JF, Lopes AJM. Brain metastasis from a thoracic myxofibrosarcoma: A case report and literature review. Surg Neurol Int 2022; 13:537. [DOI: 10.25259/sni_717_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 11/01/2022] [Indexed: 11/19/2022] Open
Abstract
Background:
Myxofibrosarcoma (MFS) is a type of sarcoma that mainly affects elderly people; it represents only 5% of all sarcomas and shows no line of differentiation. Intracranial MFS is a rare condition. At present, limited data exist regarding brain metastasis from MFS. This article reports a case of MFS and reviews the literature regarding MFS metastasis.
Case Description:
We report a case of brain metastasis from chest wall MFS. The patient was diagnosed with an anterior thoracic MFS and underwent surgery and radiotherapy. One year later, he noticed a tumor on his left shoulder, and more than 1 year thereafter, bilateral lung metastasis was observed. Twelve months after lung metastasis, he presented to the emergency department and underwent contrast-enhanced magnetic resonance imaging, which demonstrated a left frontal tumor suggestive of brain metastasis. Since the main hypothesis was a sarcoma metastasis at the location close to the left motor area, and the patient had a good Karnofsky performance scale, the patient underwent neuronavigation-guided surgery. After surgery, the patient developed Grade III hemiparesis and aphasia. Brain tumor histopathology confirmed a malignant neoplasm with osteosarcomatous differentiation and metastasis from MFS.
Conclusion:
We report a rare case of MFS metastasis. To the best of our knowledge, this is the eighth case of intracerebral metastasis from MFS.
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Kobus M, Roohani S, Ehret F, Flörcken A, Striefler JK, Brandes F, Märdian S, Rau D, Wittenberg S, Öllinger R, Kaul D. The role of neoadjuvant radiochemotherapy in the management of localized high-grade soft tissue sarcoma. Radiat Oncol 2022; 17:139. [PMID: 35941656 PMCID: PMC9361547 DOI: 10.1186/s13014-022-02106-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 07/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Standard treatment of soft tissue sarcoma (STS) of the extremities includes limb-sparing surgery combined with pre- or postoperative radiotherapy (RT). The role of perioperative chemotherapy (CTX) remains uncertain. STS patients with high-risk features for local recurrence, distant metastases, and increased mortality may require additional systemic therapy. The objective of this study was to evaluate predictors of outcome regarding local control (LC), overall survival (OS), and freedom from distant metastases (FFDM) in a large single-center cohort of patients suffering from localized high-grade STS (grade 2/3, G2/G3). Special emphasis was put on a subgroup of patients who received combined neoadjuvant radiochemotherapy (RCT). METHODS Overall, 115 adult STS patients were included in this retrospective study. The median follow-up was 34 months. Twenty-three patients (20.0%) were treated with neoadjuvant RCT, 92 (80.0%) received other therapies (adjuvant RT alone (n = 58); neoadjuvant CTX + adjuvant RT (n = 17); adjuvant RCT (n = 10), neoadjuvant RT alone (n = 7)). To assess potential prognostic factors on LC, OS, and FFDM, univariate (UVA) and multivariable (MVA) Cox proportional hazards models were applied. RESULTS UVA showed significantly better LC rates in the neoadjuvant RCT group (p = 0.025), with trends in MVA (p = 0.057). The 3-year LC rate was 89.7% in the neoadjuvant RCT group vs. 75.6% in the "other therapies" group. UVA also showed significantly better OS rates in the neoadjuvant RCT group (p = 0.049), however, this was not confirmed in MVA (p = 0.205), the 3-year OS rate was 85.8% for patients treated with neoadjuvant RCT compared to 73.5% in the "other therapies" group. UVA showed significantly better FFDM rates in (p = 0.018) and a trend towards better FFDM rates in MVA (p = 0.059). The 3-year FFDM rate was 89.7% for patients treated with neoadjuvant RCT compared to 65.9% in the "other therapies" group. In the subgroup of patients with G3 STS, neoadjuvant RCT was a significant positive predictor of LC and FFDM in MVA (p = 0.047, p = 0.027) but not for OS. Overall grade 3 and 4 toxicities were significantly higher (p = 0.019) in the neoadjuvant RCT group and occurred in 73.9% vs. 38.0% in patients receiving other therapies. CONCLUSIONS The results suggest that neoadjuvant RCT might improve LC and FFDM in patients with localized G3 STS while also being associated with increased acute complication rates. Further prospective research is warranted to confirm these findings.
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Affiliation(s)
- Marta Kobus
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Siyer Roohani
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Felix Ehret
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.,Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.,German Cancer Consortium (DKTK), partner site Berlin, and German Cancer Research Center (DKFZ), Charité - Universitätsmedizin Berlin, 69120, Heidelberg, Germany
| | - Anne Flörcken
- German Cancer Consortium (DKTK), partner site Berlin, and German Cancer Research Center (DKFZ), Charité - Universitätsmedizin Berlin, 69120, Heidelberg, Germany.,Department of Hematology, Oncology and Tumor Immunology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Jana Käthe Striefler
- Department of Hematology, Oncology and Tumor Immunology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Franziska Brandes
- Department of Hematology, Oncology and Tumor Immunology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Sven Märdian
- Centre for Musculoskeletal Surgery, Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Daniel Rau
- Centre for Musculoskeletal Surgery, Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Silvan Wittenberg
- Centre for Musculoskeletal Surgery, Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Robert Öllinger
- Department of Surgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - David Kaul
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany. .,German Cancer Consortium (DKTK), partner site Berlin, and German Cancer Research Center (DKFZ), Charité - Universitätsmedizin Berlin, 69120, Heidelberg, Germany.
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6
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Arthur A, Johnston EW, Winfield JM, Blackledge MD, Jones RL, Huang PH, Messiou C. Virtual Biopsy in Soft Tissue Sarcoma. How Close Are We? Front Oncol 2022; 12:892620. [PMID: 35847882 PMCID: PMC9286756 DOI: 10.3389/fonc.2022.892620] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/31/2022] [Indexed: 12/13/2022] Open
Abstract
A shift in radiology to a data-driven specialty has been unlocked by synergistic developments in imaging biomarkers (IB) and computational science. This is advancing the capability to deliver “virtual biopsies” within oncology. The ability to non-invasively probe tumour biology both spatially and temporally would fulfil the potential of imaging to inform management of complex tumours; improving diagnostic accuracy, providing new insights into inter- and intra-tumoral heterogeneity and individualised treatment planning and monitoring. Soft tissue sarcomas (STS) are rare tumours of mesenchymal origin with over 150 histological subtypes and notorious heterogeneity. The combination of inter- and intra-tumoural heterogeneity and the rarity of the disease remain major barriers to effective treatments. We provide an overview of the process of successful IB development, the key imaging and computational advancements in STS including quantitative magnetic resonance imaging, radiomics and artificial intelligence, and the studies to date that have explored the potential biological surrogates to imaging metrics. We discuss the promising future directions of IBs in STS and illustrate how the routine clinical implementation of a virtual biopsy has the potential to revolutionise the management of this group of complex cancers and improve clinical outcomes.
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Affiliation(s)
- Amani Arthur
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, Sutton, United Kingdom
| | - Edward W. Johnston
- Sarcoma Unit, The Royal Marsden National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Jessica M. Winfield
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, Sutton, United Kingdom
- Sarcoma Unit, The Royal Marsden National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Matthew D. Blackledge
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, Sutton, United Kingdom
| | - Robin L. Jones
- Sarcoma Unit, The Royal Marsden National Health Service (NHS) Foundation Trust, London, United Kingdom
- Division of Clinical Studies, The Institute of Cancer Research, London, United Kingdom
| | - Paul H. Huang
- Division of Molecular Pathology, The Institute of Cancer Research, Sutton, United Kingdom
- *Correspondence: Paul H. Huang, ; Christina Messiou,
| | - Christina Messiou
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, Sutton, United Kingdom
- Sarcoma Unit, The Royal Marsden National Health Service (NHS) Foundation Trust, London, United Kingdom
- *Correspondence: Paul H. Huang, ; Christina Messiou,
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7
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von Mehren M, Kane JM, Agulnik M, Bui MM, Carr-Ascher J, Choy E, Connelly M, Dry S, Ganjoo KN, Gonzalez RJ, Holder A, Homsi J, Keedy V, Kelly CM, Kim E, Liebner D, McCarter M, McGarry SV, Mesko NW, Meyer C, Pappo AS, Parkes AM, Petersen IA, Pollack SM, Poppe M, Riedel RF, Schuetze S, Shabason J, Sicklick JK, Spraker MB, Zimel M, Hang LE, Sundar H, Bergman MA. Soft Tissue Sarcoma, Version 2.2022, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2022; 20:815-833. [PMID: 35830886 PMCID: PMC10186762 DOI: 10.6004/jnccn.2022.0035] [Citation(s) in RCA: 86] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Soft tissue sarcomas (STS) are rare malignancies of mesenchymal cell origin that display a heterogenous mix of clinical and pathologic characteristics. STS can develop from fat, muscle, nerves, blood vessels, and other connective tissues. The evaluation and treatment of patients with STS requires a multidisciplinary team with demonstrated expertise in the management of these tumors. The complete NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Soft Tissue Sarcoma provide recommendations for the diagnosis, evaluation, and treatment of extremity/superficial trunk/head and neck STS, as well as retroperitoneal/intra-abdominal STS, desmoid tumors, and rhabdomyosarcoma. This portion of the NCCN Guidelines discusses general principles for the diagnosis and treatment of retroperitoneal/intra-abdominal STS, outlines treatment recommendations, and reviews the evidence to support the guidelines recommendations.
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Affiliation(s)
| | | | | | | | | | - Edwin Choy
- Massachusetts General Hospital Cancer Center
| | - Mary Connelly
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | - Sarah Dry
- UCLA Jonsson Comprehensive Cancer Center
| | | | | | | | - Jade Homsi
- UT Southwestern Simmons Comprehensive Cancer Center
| | | | | | - Edward Kim
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | - David Liebner
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | | | - Nathan W Mesko
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | - Christian Meyer
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | - Alberto S Pappo
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | | | | | - Seth M Pollack
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | | | | | - Jacob Shabason
- Abramson Cancer Center at the University of Pennsylvania
| | | | - Matthew B Spraker
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | - Melissa Zimel
- UCSF Helen Diller Family Comprehensive Cancer Center; and
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8
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Evaluation of two modalities of perioperative treatment in the management of extremity and truncal soft tissue sarcomas: neoadjuvant concurrent chemoradiotherapy and sequential treatment. Strahlenther Onkol 2021; 197:1051-1062. [PMID: 34673991 DOI: 10.1007/s00066-021-01847-5] [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: 04/13/2021] [Accepted: 08/17/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Patients with locally advanced grade 2-3 extremity/truncal soft tissue sarcomas (STS) are at high risk of recurrence. The objective of this study was to assess the efficacy and feasibility of neoadjuvant concurrent chemoradiotherapy (cCRT) in selected grade 2-3 patients with limb or trunk wall STS, and to compare this schedule to a sequential approach combining neoadjuvant chemotherapy and adjuvant radiotherapy. METHODS We retrospectively included patients who underwent neoadjuvant cCRT at two comprehensive cancer centers from 1992-2016. We then compared these results to those of patients treated with preoperative chemotherapy and postoperative radiotherapy from a third comprehensive cancer center with a propensity score matched analysis. RESULTS A total of 53 patients were treated by neoadjuvant cCRT; 58 patients could be matched with 29 patients in each treatment group after propensity score matching. Disease-free survival and overall survival at 5 years were 54.9 and 63.5%, respectively with neoadjuvant cCRT, with no significant difference when compared to the sequential treatment group. R0 resection rate was higher (90.9 vs 44.8%, p < 0.01) in the cCRT group than in the sequential treatment group during a shorter therapeutic sequence (118 vs 210.5 days, p < 0.01), with no impact on the surgical procedure or postoperative complications. CONCLUSION cCRT is feasible with acceptable immediate and late toxicities. It could facilitate surgery by increasing the R0 resection rate and improve patient compliance by shortening the therapeutic sequence.
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9
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Vujanić GM, D'Hooghe E, Graf N, Vokuhl C, Al-Saadi R, Chowdhury T, Pritchard-Jones K, Furtwängler R. Prognostic significance of histopathological response to preoperative chemotherapy in unilateral Wilms' tumor: An analysis of 899 patients treated on the SIOP WT 2001 protocol in the UK-CCLG and GPOH studies. Int J Cancer 2021; 149:1332-1340. [PMID: 34109628 DOI: 10.1002/ijc.33707] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 05/24/2021] [Accepted: 05/28/2021] [Indexed: 11/12/2022]
Abstract
In the SIOP Wilms' tumor (WT) studies, preoperative chemotherapy is used as primary treatment, and tumors are classified thereafter by pathologists. Completely necrotic WTs (CN-WTs) are classified as low-risk tumors. The aim of the study was to evaluate whether a subset of regressive type WTs (RT-WTs) (67%-99% chemotherapy-induced changes [CIC]) showing an exceptionally good response to preoperative chemotherapy had comparably excellent survivals as CN-WTs, and to establish a cut-off point of CIC that could define this subset. The study included 2117 patients with unilateral, nonanaplastic WTs from the UK-CCLG and GPOH-WT studies (2001-2020) treated according to the SIOP-WT-2001 protocol. There were 126 patients with CN-WTs and 773 with RT-WTs, stages I-IV. RT-WTs were subdivided into subtotally necrotic WTs (>95% CIC) (STN-WT96-99) (124 patients) and the remaining of RT-WT (RR-WT67-95) (649 patients). The 5-year event-free survival (EFS) and overall survival (OS) for CN-WTs were 95.3% (±2.1% SE) and 97.3% (±1.5% SE), and for RT-WTs 85.7% (±1.14% SE, P < .01) and 95.2% (±0.01% SE, P = .59), respectively. CN-WT and STN-WT96-99 groups showed significantly better EFS than RR-WT67-95 (P = .003 and P = .02, respectively), which remained significantly superior when adjusted for age, local stage and metastasis at diagnosis, in multivariate analysis, whereas OS were superimposable (97.3 ± 1.5% SE for CN-WT; 97.8 ± 1.5% SE for STN-WT96-99; 94.7 ± 1.0% SE for RR-WT67-95). Patients with STN-WT96-99 share the same excellent EFS and OS as patients with CN-WTs, and although this was achieved by more treatment for patients with STN-WT96-99 than for patients with CN-WT, reduction in postoperative treatment of these patients may be justified.
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Affiliation(s)
- Gordan M Vujanić
- Department of Pathology, Sidra Medicine and Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Ellen D'Hooghe
- Department of Pathology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Norbert Graf
- Department of Hematology and Oncology, University of Saarland, Homburg, Germany
| | | | - Reem Al-Saadi
- Developmental Biology and Cancer Programme, UCL Great Ormond Street of Child Health, University College London, London, UK
| | - Tanzina Chowdhury
- Department of Haematology and Oncology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Kathy Pritchard-Jones
- Developmental Biology and Cancer Programme, UCL Great Ormond Street of Child Health, University College London, London, UK
| | - Rhoikos Furtwängler
- Department of Hematology and Oncology, University of Saarland, Homburg, Germany
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Gennaro N, Reijers S, Bruining A, Messiou C, Haas R, Colombo P, Bodalal Z, Beets-Tan R, van Houdt W, van der Graaf WTA. Imaging response evaluation after neoadjuvant treatment in soft tissue sarcomas: Where do we stand? Crit Rev Oncol Hematol 2021; 160:103309. [PMID: 33757836 DOI: 10.1016/j.critrevonc.2021.103309] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 02/15/2021] [Accepted: 03/03/2021] [Indexed: 12/16/2022] Open
Abstract
Soft tissue sarcomas (STS) represent a broad family of rare tumours for which surgery with radiotherapy represents first-line treatment. Recently, neoadjuvant chemo-radiotherapy has been increasingly used in high-risk patients in an effort to reduce surgical morbidity and improve clinical outcomes. An adequate understanding of the efficacy of neoadjuvant therapies would optimise patient care, allowing a tailored approach. Although response evaluation criteria in solid tumours (RECIST) is the most common imaging method to assess tumour response, Choi criteria and functional and molecular imaging (DWI, DCE-MRI and 18F-FDG-PET) seem to outperform it in the discrimination between responders and non-responders. Moreover, the radiologic-pathology correlation of treatment-related changes remains poorly understood. In this review, we provide an overview of the imaging assessment of tumour response in STS undergoing neoadjuvant treatment, including conventional imaging (CT, MRI, PET) and advanced imaging analysis. Future directions will be presented to shed light on potential advances in pre-surgical imaging assessments that have clinical implications for sarcoma patients.
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Affiliation(s)
- Nicolò Gennaro
- Humanitas Research and Cancer Center, Dept. of Radiology, Rozzano, Italy; Humanitas University, Dept. of Biomedical Sciences, Pieve Emanuele, Italy; The Netherlands Cancer Institute, Dept. of Radiology, Amsterdam, the Netherlands.
| | - Sophie Reijers
- The Netherlands Cancer Institute, Dept. of Surgical Oncology, Amsterdam, the Netherlands
| | - Annemarie Bruining
- The Netherlands Cancer Institute, Dept. of Radiology, Amsterdam, the Netherlands
| | - Christina Messiou
- The Royal Marsden NHS Foundation Trust, Dept. Of Radiology Sarcoma Unit, Sutton, United Kingdom; The Institute of Cancer Research, Sutton, United Kingdom
| | - Rick Haas
- The Netherlands Cancer Institute, Dept. of Radiation Oncology, Amsterdam, the Netherlands; Leiden University Medical Center, Dept. of Radiation Oncology, the Netherlands
| | | | - Zuhir Bodalal
- The Netherlands Cancer Institute, Dept. of Radiology, Amsterdam, the Netherlands; GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
| | - Regina Beets-Tan
- The Netherlands Cancer Institute, Dept. of Radiology, Amsterdam, the Netherlands; GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands; Danish Colorectal Cancer Center South, Vejle University Hospital, Institute of Regional Health Research, University of Southern Denmark, Denmark
| | - Winan van Houdt
- The Netherlands Cancer Institute, Dept. of Surgical Oncology, Amsterdam, the Netherlands
| | - Winette T A van der Graaf
- The Netherlands Cancer Institute, Dept. of Medical Oncology, Amsterdam, the Netherlands; Erasmus MC Cancer Institute, Dept. of Medical Oncology, Erasmus University Medical Center, Rotterdam, the Netherlands
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11
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Tsukamoto S, Mavrogenis AF, Tanaka Y, Errani C. Imaging of Soft Tissue Tumors. Curr Med Imaging 2021; 17:197-216. [PMID: 32660406 DOI: 10.2174/1573405616666200713183400] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/08/2020] [Accepted: 06/20/2020] [Indexed: 02/07/2023]
Abstract
Differentiation of malignant from benign soft tissue tumors is challenging with imaging alone, including that by magnetic resonance imaging and computed tomography. However, the accuracy of this differentiation has increased owing to the development of novel imaging technology. Detailed patient history and physical examination remain essential for differentiation between benign and malignant soft tissue tumors. Moreover, measurement only of tumor size based on Response Evaluation Criteria In Solid Tumors criteria is insufficient for the evaluation of response to chemotherapy or radiotherapy. Change in metabolic activity measured by 18F-fluorodeoxyglucose positron emission tomography or dynamic contrast enhanced-derived quantitative endpoints can more accurately evaluate treatment response compared to change in tumor size. Magnetic resonance imaging can accurately evaluate essential factors in surgical planning such as vascular or bone invasion and "tail sign". Thus, imaging plays a critical role in the diagnosis and treatment of soft tissue tumors.
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Affiliation(s)
- Shinji Tsukamoto
- Department of Orthopaedic Surgery, Nara Medical University, Nara, Japan
| | - Andreas F Mavrogenis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Yasuhito Tanaka
- Department of Orthopaedic Surgery, Nara Medical University, Nara, Japan
| | - Costantino Errani
- Department Orthopaedic Oncology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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12
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Lansu J, van Houdt WJ, van Langevelde K, van den Ende PLA, van der Graaf WTA, Schrage Y, van Boven H, Scholten AN, Haas RL. Local control and postponement of systemic therapy after modest dose radiotherapy in oligometastatic myxoid liposarcomas. Radiother Oncol 2021; 158:33-39. [PMID: 33610624 DOI: 10.1016/j.radonc.2021.02.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 01/27/2021] [Accepted: 02/08/2021] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Oligometastatic disease and/or oligoprogression in myxoid liposarcoma(oMLS) triggers discussions on local treatment options and delay of systemic treatments. We hypothesized that satisfactory local control and postponement of systemic therapy could be achieved with a modest radiotherapy(RT) dose in oMLS. METHODS The DOREMY trial is a multicenter, phase 2 trial evaluating efficacy and toxicity of a modest RT dose in both localized and oMLS; this report presents the data of the oMLS cohort treated with 36 Gy in 12-18 fractions with optional subsequent metastasectomy. The primary endpoint was local progression free survival(LPFS). Secondary endpoints included postponement of systemic therapy, symptom reduction, radiological objective response, and toxicity. RESULTS Nine patients with a total of 25 lesions were included, with a median follow-up of 23 months. The median number of lesions per patient was three and the trunk wall and bone were the most frequently affected sites. In lesions treated with definitive RT(n = 21), LPFS rates at 1, 2, and 3 years were respectively 73%, 61%, and 40%. Radiological objective response and clinical symptom reduction were achieved in 8/15(53%) and 9/10(90%) of the evaluable lesions, respectively. No local recurrences occurred in lesions treated with RT and metastasectomy(n = 4). For the entire study population, the median postponement of systemic therapy was 10 months. Grade ≥ 2 toxicity was observed in 2/9(22%) of patients. CONCLUSIONS This trial suggests that 36 Gy could possibly be effective to achieve local control, postpone systemic therapy and reduce symptoms in oMLS. Given the minimal toxicity this treatment could be reasonably considered in oMLS.
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Affiliation(s)
- Jules Lansu
- Department of Radiotherapy, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Winan J van Houdt
- Department of Surgical Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | | | | | - Yvonne Schrage
- Department of Surgical Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Hester van Boven
- Department of Pathology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Astrid N Scholten
- Department of Radiotherapy, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Rick L Haas
- Department of Radiotherapy, the Netherlands Cancer Institute, Amsterdam, The Netherlands; Department of Radiotherapy, Leiden University Medical Center, The Netherlands.
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13
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Spałek MJ, Koseła-Paterczyk H, Borkowska A, Wągrodzki M, Szumera-Ciećkiewicz A, Czarnecka AM, Castaneda-Wysocka P, Kalinowska I, Poleszczuk J, Dąbrowska-Szewczyk E, Cieszanowski A, Rutkowski P. Combined Preoperative Hypofractionated Radiotherapy With Doxorubicin-Ifosfamide Chemotherapy in Marginally Resectable Soft Tissue Sarcomas: Results of a Phase 2 Clinical Trial. Int J Radiat Oncol Biol Phys 2021; 110:1053-1063. [PMID: 33600887 DOI: 10.1016/j.ijrobp.2021.02.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 01/26/2021] [Accepted: 02/09/2021] [Indexed: 12/18/2022]
Abstract
PURPOSE There is no standard treatment for marginally resectable soft tissue sarcomas (STSs) of the extremities and trunk wall, and current approaches produce unsatisfactory results. We hypothesized that the combination of doxorubicin-ifosfamide (AI) chemotherapy and 5 × 5 Gy hypofractionated radiotherapy can generate a higher ratio of limb-sparing or conservative surgeries with negative microscopic margins (R0) and acceptable treatment toxicity. METHODS AND MATERIALS We conducted a single-arm prospective clinical trial. Treatment combined 1 cycle of AI with subsequent 5 × 5 Gy radiotherapy within 1 week, followed by 2 cycles of AI and surgery. The primary endpoint was to assess the number of patients in whom en bloc R0 resection was achieved. RESULTS Forty-six patients met the eligibility criteria. Three patients had resectable lung metastases at baseline. Forty-two received the planned protocol treatment. In 2 patients, the treatment was prematurely stopped because of the toxicity of chemotherapy. One patient died of septic shock because of severe bone marrow suppression after the second AI cycle; a second death was not related to treatment for STS. Three patients underwent amputation. In 72% of patients in the intention-to-treat analysis, we achieved en bloc R0 resections. Grade 3+ Common Terminology Criteria for Adverse Events 4.03 chemotherapy toxicity requiring dose reduction or treatment interruption occurred in 15 patients. Wound complications occurred in 18 patients, but they were severe in only 6 patients. CONCLUSIONS Preoperative AI combined with 5 × 5 Gy radiotherapy is a promising method for the management of marginally resectable STS. This protocol enables a high ratio of R0 limb-sparing or conservative surgeries. Further evaluation of this strategy is warranted.
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Affiliation(s)
- Mateusz J Spałek
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland.
| | - Hanna Koseła-Paterczyk
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Aneta Borkowska
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Michał Wągrodzki
- Department of Pathology and Laboratory Diagnostics, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Anna Szumera-Ciećkiewicz
- Department of Pathology and Laboratory Diagnostics, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland; Diagnostic Hematology Department, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Anna M Czarnecka
- Department of Pathology and Laboratory Diagnostics, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland; Department of Experimental Pharmacology, Mossakowski Medical Research Centre, Polish Academy of Sciences, Warsaw, Poland
| | - Patricia Castaneda-Wysocka
- Department of Radiology I, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Iwona Kalinowska
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Jan Poleszczuk
- Department of Computational Oncology, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland; Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland
| | - Edyta Dąbrowska-Szewczyk
- Department of Medical Physics, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland; Biomedical Physics Division, Faculty of Physics, University of Warsaw, Warsaw, Poland
| | - Andrzej Cieszanowski
- Department of Radiology I, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Piotr Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
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14
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Neoadjuvant Radiotherapy-Related Wound Morbidity in Soft Tissue Sarcoma: Perspectives for Radioprotective Agents. Cancers (Basel) 2020; 12:cancers12082258. [PMID: 32806601 PMCID: PMC7465163 DOI: 10.3390/cancers12082258] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 07/10/2020] [Accepted: 08/10/2020] [Indexed: 12/18/2022] Open
Abstract
Historically, patients with localized soft tissue sarcomas (STS) of the extremities would undergo limb amputation. It was subsequently determined that the addition of radiation therapy (RT) delivered prior to (neoadjuvant) or after (adjuvant) a limb-sparing surgical resection yielded equivalent survival outcomes to amputation in appropriate patients. Generally, neoadjuvant radiation offers decreased volume and dose of high-intensity radiation to normal tissue and increased chance of achieving negative surgical margins-but also increases wound healing complications when compared to adjuvant radiotherapy. This review elaborates on the current neoadjuvant/adjuvant RT approaches, wound healing complications in STS, and the potential application of novel radioprotective agents to minimize radiation-induced normal tissue toxicity.
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15
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Spałek MJ, Kozak K, Czarnecka AM, Bartnik E, Borkowska A, Rutkowski P. Neoadjuvant Treatment Options in Soft Tissue Sarcomas. Cancers (Basel) 2020; 12:cancers12082061. [PMID: 32722580 PMCID: PMC7464514 DOI: 10.3390/cancers12082061] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/23/2020] [Accepted: 07/24/2020] [Indexed: 12/24/2022] Open
Abstract
Due to the heterogeneity of soft tissue sarcomas (STS), the choice of the proper perioperative treatment regimen is challenging. Neoadjuvant therapy has attracted increasing attention due to several advantages, particularly in patients with locally advanced disease. The number of available neoadjuvant modalities is growing continuously. We may consider radiotherapy, chemotherapy, targeted therapy, radiosensitizers, hyperthermia, and their combinations. This review discusses possible neoadjuvant treatment options in STS with an emphasis on available evidence, indications for each treatment type, and related risks. Finally, we summarize current recommendations of the STS neoadjuvant therapy response assessment.
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Affiliation(s)
- Mateusz Jacek Spałek
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781 Warsaw, Poland; (K.K.); (A.M.C.); (A.B.); (P.R.)
- Correspondence: ; Tel.: +48-22-546-24-55
| | - Katarzyna Kozak
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781 Warsaw, Poland; (K.K.); (A.M.C.); (A.B.); (P.R.)
| | - Anna Małgorzata Czarnecka
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781 Warsaw, Poland; (K.K.); (A.M.C.); (A.B.); (P.R.)
- Department of Experimental Pharmacology, Mossakowski Medical Research Centre, Polish Academy of Sciences, 02-106 Warsaw, Poland
| | - Ewa Bartnik
- Institute of Genetics and Biotechnology, Faculty of Biology, University of Warsaw, 02-106 Warsaw, Poland;
- Institute of Biochemistry and Biophysics, Polish Academy of Sciences, 02-106 Warsaw, Poland
| | - Aneta Borkowska
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781 Warsaw, Poland; (K.K.); (A.M.C.); (A.B.); (P.R.)
| | - Piotr Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781 Warsaw, Poland; (K.K.); (A.M.C.); (A.B.); (P.R.)
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16
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Neoadjuvant Chemoradiation Compared With Neoadjuvant Radiation Alone in the Management of High-Grade Soft Tissue Extremity Sarcomas. Adv Radiat Oncol 2020; 5:231-237. [PMID: 32280823 PMCID: PMC7136634 DOI: 10.1016/j.adro.2019.08.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 07/11/2019] [Accepted: 08/29/2019] [Indexed: 12/02/2022] Open
Abstract
Purpose Patients with large, high-grade soft tissue sarcomas are commonly treated with aggressive limb preservation regimens. This study aimed to assess cancer control outcomes of patients treated with neoadjuvant chemoradiation (CRT) compared with radiation therapy (RT) alone. Methods We reviewed records of patients with high-grade extremity or trunk soft tissue sarcomas ≥5 cm who were treated with neoadjuvant radiation with or without chemotherapy. Patient and disease characteristics were compared using t test and χ2 tests. Standardized mortality ratio weighted method was used to compare overall survival (OS), local control, and disease-free (DFS) survival. Acute radiation and surgical toxicity were reported. Results In the study, 64 patients (34 CRT and 30 RT) treated between 1997 and 2015 were analyzed. In the RT group compared with the CRT group, the patient population was older, with a median age of 65 versus 50 years (P < .001), and more likely to have cardiovascular disease (CVD; 30% vs 0%, P < .001). At a median follow-up of 41 months, after adjusting for propensity score of receiving RT, the 3-year LC was 87.3% versus 86.1%, DFS was 58.5% versus 56.6%, and OS was 75.6% versus 69.0% for the CRT and RT groups, respectively (P > .05). Acute dermatitis occurred in 18% versus 3% and surgical complications occurred in 32% versus 17% of CRT and RT patients, respectively. Conclusions In this study, patients receiving RT alone were more likely to be older and have comorbid cardiovascular disease. When controlling for baseline differences, neoadjuvant CRT and RT provided similar rates of LC, DFS, and OS.
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17
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Chowdhary M, Chowdhary A, Sen N, Zaorsky NG, Patel KR, Wang D. Does the addition of chemotherapy to neoadjuvant radiotherapy impact survival in high-risk extremity/trunk soft-tissue sarcoma? Cancer 2019; 125:3801-3809. [PMID: 31490546 DOI: 10.1002/cncr.32386] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 06/14/2019] [Accepted: 06/15/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND The role of chemotherapy in extremity/trunk soft-tissue sarcoma (ET-STS) is controversial, even for patients at high risk for distant recurrence and death (those with high-grade tumors ≥5 cm in size). This study examines the impact of integrating chemotherapy with neoadjuvant radiotherapy (RT) on overall survival (OS) for patients with high-risk ET-STS. METHODS The National Cancer Data Base was queried for adult patients with high-risk ET-STS who received neoadjuvant RT and limb salvage surgery between 2006 and 2014. Patients were stratified into RT and chemoradiotherapy (CRT) cohorts. OS for the RT and CRT cohorts was analyzed with the Kaplan-Meier method, log-rank tests, and Cox proportional hazards models. Propensity score matching (PSM) analysis was used to account for a potential treatment selection bias between the cohorts. RESULTS A total of 884 patients were identified: 639 (72.3%) in the RT cohort and 245 (27.7%) in the CRT cohort. The unadjusted 5-year Kaplan-Meier OS rate was significantly higher in the CRT cohort: 72.0% versus 56.1% (P < .001). Neoadjuvant chemotherapy was associated with improved OS in univariate and multivariable analyses (hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.41-0.78; P < .001). PSM identified 2 evenly matched cohorts of 212 patients each. The 5-year matched Kaplan-Meier OS rates were 69.8% and 55.4% for the CRT and RT cohorts, respectively (P = .002). The addition of neoadjuvant chemotherapy remained prognostic for OS on PSM (HR, 0.56; 95% CI, 0.39-0.83; P = .003). CONCLUSIONS The addition of chemotherapy to neoadjuvant RT was associated with improved OS for patients with high-risk ET-STS. In the absence of randomized data evaluating CRT versus RT, these findings warrant further investigation.
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Affiliation(s)
- Mudit Chowdhary
- Department of Radiation Oncology, Rush University Medical Center, Chicago, Illinois
| | - Akansha Chowdhary
- Division of Hematology and Medical Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
| | - Neilayan Sen
- Department of Radiation Oncology, Rush University Medical Center, Chicago, Illinois
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, Penn State Cancer Institute, Hersey, Pennsylvania
| | - Kirtesh R Patel
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Dian Wang
- Department of Radiation Oncology, Rush University Medical Center, Chicago, Illinois
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18
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A Meta-Analysis of the Association Between Radiation Therapy and Survival for Surgically Resected Soft-Tissue Sarcoma. Am J Clin Oncol 2019; 41:348-356. [PMID: 26886948 DOI: 10.1097/coc.0000000000000274] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Radiotherapy for soft-tissue sarcoma (STS) has been shown to reduce local recurrence, but without clear improvement in survival. We conducted a meta-analysis to study the association between radiotherapy and survival in patients undergoing surgery for STS. METHODS A systematic review was conducted from PubMed, EMBASE, Web of Science, and Cochrane databases. Our population of interest consisted of adults with primary extremity, chest wall, trunk, or back STS. Our metameters were either an odds or hazard ratio for mortality. A bias score was generated for each study based on margin status and grade. RESULTS Of 1044 studies, 30 met inclusion criteria for final analysis. The pooled odds ratio in patients receiving radiation was 0.94 (95% confidence interval [CI], 0.78-1.14). The pooled estimate of the hazards ratio in patients receiving radiation was 0.87 (95% CI, 0.73-1.03) overall and 0.65 (95% CI, 0.52-0.82) for studies judged to be at low risk of bias. Significant publication bias was not seen. CONCLUSIONS High-quality studies reporting adjusted hazard ratios are associated with improved survival in patients receiving radiotherapy for STS. Studies in which odds ratios are calculated from event data and those that do not report adjusted outcomes do not show the same association, likely due to confounding by indication.
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Neoadjuvant Interdigitated Chemoradiotherapy Using Mesna, Doxorubicin, and Ifosfamide for Large, High-grade, Soft Tissue Sarcomas of the Extremity. Am J Clin Oncol 2019; 42:1-5. [DOI: 10.1097/coc.0000000000000467] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Long-term Outcomes With Ifosfamide-based Hypofractionated Preoperative Chemoradiotherapy for Extremity Soft Tissue Sarcomas. Am J Clin Oncol 2018; 41:1154-1161. [DOI: 10.1097/coc.0000000000000443] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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21
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Baldini EH, Le Cesne A, Trent JC. Neoadjuvant Chemotherapy, Concurrent Chemoradiation, and Adjuvant Chemotherapy for High-Risk Extremity Soft Tissue Sarcoma. Am Soc Clin Oncol Educ Book 2018; 38:910-915. [PMID: 30231383 DOI: 10.1200/edbk_201421] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Standard treatment of large intermediate- and high-grade extremity soft tissue sarcoma (ESTS) typically includes wide excision and radiation therapy. Many patients do well with this approach, but for those with unfavorable features, risk for distant recurrence and, ultimately, mortality can exceed 50%. Unfortunately, universally accepted data elucidating effective treatments to prevent recurrences and improve survival for such high-risk patients are lacking. Accordingly, opinions about the appropriate role of systemic therapy for patients with high-risk localized ESTS vary. This article reviews the current literature pertaining to neoadjuvant chemotherapy, concurrent chemoradiation, and adjuvant chemotherapy for high-risk ESTS. All of these approaches are feasible and reasonable to consider. Ultimately, the decision to incorporate chemotherapy into the treatment regimen is best reached by discussion among an experienced multidisciplinary sarcoma team and should be tailored to the individual patient risk profile.
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Affiliation(s)
- Elizabeth H Baldini
- From the Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA; Department of Adult Medicine, Gustave Roussy, Villejuif, France; Division of Medical Oncology, Sarcoma Program, Sylvester Comprehensive Cancer Center, Miami, FL
| | - Axel Le Cesne
- From the Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA; Department of Adult Medicine, Gustave Roussy, Villejuif, France; Division of Medical Oncology, Sarcoma Program, Sylvester Comprehensive Cancer Center, Miami, FL
| | - Jonathan C Trent
- From the Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA; Department of Adult Medicine, Gustave Roussy, Villejuif, France; Division of Medical Oncology, Sarcoma Program, Sylvester Comprehensive Cancer Center, Miami, FL
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Zschaeck S, Wust P, Melcher I, Nadobny J, Rau D, Striefler J, Pahl S, Flörcken A, Kunitz A, Ghadjar P. Neoadjuvant chemotherapy plus radiation versus chemotherapy plus regional hyperthermia in high-grade soft tissue sarcomas: a retrospective comparison. Int J Hyperthermia 2018; 35:1-9. [PMID: 30300018 DOI: 10.1080/02656736.2018.1498137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
PURPOSE Localized adult high-grade soft tissue sarcomas (STS) usually require multimodality treatment including surgery, radiotherapy, chemotherapy and hyperthermia. If maximal preoperative tumor-shrinkage is envisaged, neoadjuvant chemotherapy + radiation (CRT) is often applied, however at the expense of relatively high toxicities and increased postoperative complication rates. This study aims to compare preoperative CRT with neoadjuvant chemotherapy + regional hyperthermia (HCT) regarding histopathological response, toxicity and outcome. METHODS In this retrospective analysis, 61 consecutive high-grade STS patients treated between 2009 and 2016 were included. All patients were treated within a prospective treatment protocol. 28 patients received neoadjuvant CRT 33 patients HCT. CRT consisted of four cycles doxorubicin/ifosfamide and two cycles ifosfamide concomitant to 50.4 Gray external beam radiotherapy. HCT consisted of 4-6 cycles doxorubicin/ifosfamide with deep regional hyperthermia administered bi-weekly during each cycle. Association of treatment modality with overall survival (OS), local control (LC) and freedom from distant metastases (FFDM) was evaluated by Kaplan-Meier and log-rank analyses. RESULTS The overall patient characteristics were well balanced. Histopathological tumor response did not differ significantly between both groups (p = .67), neither did higher-grade toxicities during neoadjuvant treatment. Wound dehiscence (p = .018) and surgical hospital re-admissions (p < .001) were both significantly more frequent in the CRT group. Two-year OS, LC and FFDM rates of all patients were 93, 85 and 71% with no significant differences between CRT and HCT. CONCLUSION Compared to CRT, HCT seems equally efficient and appears to bear less surgical complications. Interpretation should be cautious due to the low number of patients and the retrospective nature of this study.
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Affiliation(s)
- Sebastian Zschaeck
- a Department of Radiation Oncology , Charité Universitätsmedizin Berlin , Berlin , Germany.,b Berlin Insitute of Health (BIH), Berlin , Germany
| | - Peter Wust
- a Department of Radiation Oncology , Charité Universitätsmedizin Berlin , Berlin , Germany
| | - Ingo Melcher
- c Department of Surgery , Charité Universitätsmedizin Berlin , Berlin , Germany
| | - Jacek Nadobny
- a Department of Radiation Oncology , Charité Universitätsmedizin Berlin , Berlin , Germany
| | - Daniel Rau
- c Department of Surgery , Charité Universitätsmedizin Berlin , Berlin , Germany
| | - Jana Striefler
- d Department of Hematology, Oncology, and Tumorimmunology , Charité Universitätsmedizin Berlin , Berlin , Germany
| | - Stefan Pahl
- e Charité Universitätsmedizin Berlin, Institute of Pathology , Berlin , Germany
| | - Anne Flörcken
- d Department of Hematology, Oncology, and Tumorimmunology , Charité Universitätsmedizin Berlin , Berlin , Germany
| | - Annegret Kunitz
- d Department of Hematology, Oncology, and Tumorimmunology , Charité Universitätsmedizin Berlin , Berlin , Germany
| | - Pirus Ghadjar
- a Department of Radiation Oncology , Charité Universitätsmedizin Berlin , Berlin , Germany
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23
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Schliemann C, Kerkhoff A, Hesse P, Bröckling S, Hardes J, Streitbürger A, Andreou D, Gosheger G, Elges S, Wardelmann E, Hartmann W, Mesters R, Lenz G, Willich N, Kriz J, Eich H, Berdel WE, Kessler T. Adjuvant chemotherapy-Radiotherapy-Chemotherapy sandwich protocol in resectable soft tissue sarcoma: An updated single-center analysis of 104 cases. PLoS One 2018; 13:e0197315. [PMID: 29787570 PMCID: PMC5963910 DOI: 10.1371/journal.pone.0197315] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 03/17/2018] [Indexed: 01/20/2023] Open
Abstract
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.
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Affiliation(s)
| | - Andrea Kerkhoff
- University Hospital Muenster, Department of Medicine A, Muenster, Germany
| | - Paula Hesse
- University Hospital Muenster, Department of Medicine A, Muenster, Germany
| | | | - Jendrik Hardes
- University Hospital Muenster, Department of Orthopedics and Tumororthopedics, Muenster, Germany
| | - Arne Streitbürger
- University Hospital Muenster, Department of Orthopedics and Tumororthopedics, Muenster, Germany
| | - Dimosthenis Andreou
- University Hospital Muenster, Department of Orthopedics and Tumororthopedics, Muenster, Germany
| | - Georg Gosheger
- University Hospital Muenster, Department of Orthopedics and Tumororthopedics, Muenster, Germany
| | - Sandra Elges
- University Hospital Muenster, Gerhard-Domagk-Institute for Pathology, Muenster, Germany
| | - Eva Wardelmann
- University Hospital Muenster, Gerhard-Domagk-Institute for Pathology, Muenster, Germany
| | - Wolfgang Hartmann
- University Hospital Muenster, Gerhard-Domagk-Institute for Pathology, Muenster, Germany
| | - Rolf Mesters
- University Hospital Muenster, Department of Medicine A, Muenster, Germany
| | - Georg Lenz
- University Hospital Muenster, Department of Medicine A, Muenster, Germany
| | - Normann Willich
- University Hospital Muenster, Department of Radiation Oncology, Muenster, Germany
| | - Jan Kriz
- University Hospital Muenster, Department of Radiation Oncology, Muenster, Germany
| | - Hans Eich
- University Hospital Muenster, Department of Radiation Oncology, Muenster, Germany
| | - Wolfgang E. Berdel
- University Hospital Muenster, Department of Medicine A, Muenster, Germany
| | - Torsten Kessler
- University Hospital Muenster, Department of Medicine A, Muenster, Germany
- * E-mail:
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24
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Salah S, Lewin J, Amir E, Abdul Razak A. Tumor necrosis and clinical outcomes following neoadjuvant therapy in soft tissue sarcoma: A systematic review and meta-analysis. Cancer Treat Rev 2018; 69:1-10. [PMID: 29843049 DOI: 10.1016/j.ctrv.2018.05.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 05/10/2018] [Accepted: 05/12/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND The prognostic role of tumor necrosis following neoadjuvant therapy is established in bone sarcomas but remains unclear in soft tissue sarcomas (STS). METHODS We searched MEDLINE, MEDLINE in progress, EMBASE and Cochrane to identify studies that investigated neoadjuvant therapy in STS. Studies were required to report survival data based on extent of necrosis, or provided individual patient data allowing estimation thereof. Hazard ratios (HR) for relapse-free (RFS) and overall survival (OS) and odds ratios (OR) for recurrence at 3 years and for death at 5 years were pooled in a random effect meta-analysis. Associations between patient characteristics and attainment of ≥90% necrosis were explored. RESULTS 21 studies comprising 1663 patients were included. Extremity tumors were most common (n = 1554; 93%). Induction regimens included chemotherapy with radiotherapy (n = 924; 56%), chemotherapy alone (n = 412; 25%), radiotherapy alone (n = 78; 5%), isolated limb perfusion (ILP) (n = 231; 14%), and targeted therapy/radiotherapy (n = 18; 1%). Patients with <90% necrosis had higher hazard of recurrence (hazard ratio [HR] 1.47; 95% CI: 1.06-2.04; p = 0.02) and death (HR 1.86; 95% CI: 1.41-2.46; p < 0.001). Risk of recurrence at 3 years (OR = 3.35; 95% CI: 2.27-4.92; p < 0.001) and of death at 5 years (OR 2.60; 95% CI: 1.59-4.26; p < 0.001) were similarly increased. Compared to other modalities, ILP was associated with higher odds of achieving ≥90% necrosis (OR 12.1; 95% CI: 3.69-39.88; p < 0.001). CONCLUSION Tumour necrosis <90% following neoadjuvant therapy is associated with increased recurrence risk and inferior OS in patients with STS.
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Affiliation(s)
- Samer Salah
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada; Department of Medical Oncology, King Hussein Cancer Centre, Queen Rania Al Abdullah St 202, Amman, Jordan.
| | - Jeremy Lewin
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada.
| | - Eitan Amir
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada.
| | - Albiruni Abdul Razak
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada.
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25
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Kane JM, Magliocco A, Zhang Q, Wang D, Klimowicz A, Harris J, Simko J, DeLaney T, Kraybill W, Kirsch DG. Correlation of High-Risk Soft Tissue Sarcoma Biomarker Expression Patterns with Outcome following Neoadjuvant Chemoradiation. Sarcoma 2018; 2018:8310950. [PMID: 29681762 PMCID: PMC5851029 DOI: 10.1155/2018/8310950] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Revised: 12/18/2017] [Accepted: 01/04/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Sarcoma mortality remains high despite adjuvant chemotherapy. Biomarker predictors of treatment response and outcome could improve treatment selection. METHODS Tissue microarrays (TMAs) were created using pre- and posttreatment tumor from two prospective trials (MGH pilot and RTOG 9514) of neoadjuvant/adjuvant MAID chemotherapy and preoperative radiation. Biomarkers were measured using automated computerized imaging (AQUA or ACIS). Expression was correlated with disease-free survival (DFS), distant disease-free survival (DDFS), and overall survival (OS). RESULTS Specimens from 60 patients included 23 pretreatment (PRE), 40 posttreatment (POST), and 12 matched pairs (MPs). In the MP set, CAIX, GLUT1, and PARP1 expression significantly decreased following neoadjuvant therapy, but p53 nuclear/cytoplasmic (N/C) ratio increased. In the PRE set, no biomarker expression was associated with DFS, DDFS, or OS. In the POST set, increased p53 N/C ratio was associated with a significantly decreased DFS and DDFS (HR 4.13, p=0.017; HR 4.16, p=0.016), while increased ERCC1 and XPF expression were associated with an improved DFS and DDFS. No POST biomarkers were associated with OS. CONCLUSIONS PRE biomarker expression did not predict survival outcomes. Expression pattern changes after neoadjuvant chemoradiation supports the concepts of tumor reoxygenation, altered HIF-1α signaling, and a p53 nuclear accumulation DNA damage response. CLINICAL TRIAL REGISTRATION NRG Oncology RTOG 9514 is registered with ClinicalTrials.gov. The ClinicalTrials.gov Identifier is NCT00002791.
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Affiliation(s)
| | | | - Qiang Zhang
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA, USA
| | - Dian Wang
- Rush University Medical Center, Chicago, IL, USA
| | | | - Jonathan Harris
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA, USA
| | - Jeff Simko
- University of California, San Francisco, CA, USA
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26
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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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27
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Messiou C, Morosi C. Imaging in retroperitoneal soft tissue sarcoma. J Surg Oncol 2017; 117:25-32. [PMID: 29193092 PMCID: PMC5836919 DOI: 10.1002/jso.24891] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 10/07/2017] [Indexed: 12/29/2022]
Abstract
Patients with retroperitoneal sarcoma can present to a variety of clinicians with non‐specific symptoms and retroperitoneal sarcomas can be incidental findings. Failure to recognize retroperitoneal sarcomas on imaging can lead to inappropriate management in non‐specialist centers. Therefore it is critical that the possibility of retroperitoneal sarcoma should be considered with prompt referral to a soft tissue sarcoma unit. This review guides clinicians through a diagnostic pathway, introduces concepts in response assessment and new imaging developments.
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Affiliation(s)
- Christina Messiou
- Department of Radiology, The Royal Marsden Hospital London and The Institute of Cancer Research, London, UK
| | - Carlo Morosi
- Department of Radiology, Fondazione IRCCS Istituto Nazionale Tumori Milan, Milan, Italy
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28
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Eckert F, Braun LH, Traub F, Kopp HG, Sipos B, Lamprecht U, Müller AC, Paulsen F, Zips D. Radiotherapy and hyperthermia with curative intent in recurrent high risk soft tissue sarcomas. Int J Hyperthermia 2017; 34:980-987. [PMID: 28826283 DOI: 10.1080/02656736.2017.1369174] [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] [Indexed: 12/16/2022] Open
Abstract
PURPOSE Radiotherapy before or after resection is one of the pillars of treatment for localised high risk soft tissue sarcomas. Treatment intensification has been described with concurrent chemotherapy and hyperthermia. The aim of this study is to assess local control after multimodal treatment, focussing on the treatment of local recurrences after surgery only. PATIENTS AND METHODS Of 42 patients treated in a prospective protocol with radiotherapy and hyperthermia, nine were treated for isolated local recurrences without metastatic spread. Most patients were treated with trimodal therapy including chemotherapy with ifosfamide and underwent resection whenever possible. Median follow-up was 1.4 years. RESULTS The treatment was well tolerated. Estimated disease free survival, distant metastases free survival and local control for the whole cohort after 1.5 years were 66, 73 and 88%, respectively. Neoadjuvant vs. adjuvant treatment influenced local control with a trend to statistical significance. Resection status did not influence local control. The cohort of patients treated for local recurrence after surgery alone had a significantly impaired local control compared to multimodal treatment at primary diagnosis (100 vs. 52%, p < 0.001). CONCLUSIONS With multimodal therapy including radiotherapy and hyperthermia local tumour control is achievable even in locally recurrent tumours. The clear-cut difference of the treatment of local recurrence in contrast to primary diagnosis might either reflect difficulties in diagnosis and treatment of local recurrences or biological aggressiveness of recurrent tumours. However, we recommend to consider multimodal treatment at primary diagnosis of high risk soft tissue sarcomas.
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Affiliation(s)
- Franziska Eckert
- a Department of Radiation Oncology , Eberhard-Karls-University Tuebingen , Tuebingen , Germany.,b Center for Soft Tissue Sarcoma, GIST and bone tumors , Eberhard-Karls-University Tuebingen , Tuebingen , Germany
| | - Lore Helene Braun
- a Department of Radiation Oncology , Eberhard-Karls-University Tuebingen , Tuebingen , Germany
| | - Frank Traub
- b Center for Soft Tissue Sarcoma, GIST and bone tumors , Eberhard-Karls-University Tuebingen , Tuebingen , Germany.,c Department of Orthopaedic Surgery , Eberhard-Karls-University Tuebingen , Tuebingen , Germany
| | - Hans-Georg Kopp
- b Center for Soft Tissue Sarcoma, GIST and bone tumors , Eberhard-Karls-University Tuebingen , Tuebingen , Germany.,d Department of Medical Oncology , Eberhard-Karls-University Tuebingen , Tuebingen , Germany
| | - Bence Sipos
- b Center for Soft Tissue Sarcoma, GIST and bone tumors , Eberhard-Karls-University Tuebingen , Tuebingen , Germany.,e Institute for Pathology , Eberhard-Karls-University Tuebingen , Tuebingen , Germany
| | - Ulf Lamprecht
- a Department of Radiation Oncology , Eberhard-Karls-University Tuebingen , Tuebingen , Germany
| | - Arndt-Christian Müller
- a Department of Radiation Oncology , Eberhard-Karls-University Tuebingen , Tuebingen , Germany
| | - Frank Paulsen
- a Department of Radiation Oncology , Eberhard-Karls-University Tuebingen , Tuebingen , Germany.,b Center for Soft Tissue Sarcoma, GIST and bone tumors , Eberhard-Karls-University Tuebingen , Tuebingen , Germany
| | - Daniel Zips
- a Department of Radiation Oncology , Eberhard-Karls-University Tuebingen , Tuebingen , Germany
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29
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The Impact of Perioperative Chemotherapy Timing in Conjunction With Postoperative External-Beam Radiation Therapy on Extremity Soft-Tissue Sarcomas Outcome. Am J Clin Oncol 2017; 39:528-34. [PMID: 24879472 DOI: 10.1097/coc.0000000000000087] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE The perioperative management of primary extremity soft-tissue sarcomas (ESTS) is multidisciplinary including radiation therapy and chemotherapy (CT). The interplay between these modalities and the relative importance of each remain unclear. Our study aims to determine the relative impact of CT and radiotherapy on the outcome of ESTS patients treated with limb-sparing surgery. MATERIALS AND METHODS A retrospective review of ESTS registry yielded 97 patients who received neoadjuvant chemotherapy (NCT) and/or adjuvant CT with or without external-beam radiation therapy (EBRT) from January 1, 1999 through December 31, 2009. The cohort comprised 56 males and 41 females whose age at surgery ranged from 17 to 83 years (median, 56 y). Tumor characteristics included the following: 73 lower ESTS; 70 grade 3 lesions; 63 American Joint Committee on Cancer stage III tumors; and 27 lesions with positive microscopic margins. The following outcome parameters were evaluated for the patients' subgroups: overall survival (OS), locoregional control (LRC), and disease-free survival (DFS). RESULTS EBRT was delivered postoperatively to 81 patients and 49 received CT. Median EBRT dose was 63 Gy (range, 50 to 72 Gy). At median follow-up of 54.6 months, the 5-year OS, LRC, DFS was 68.9%, 87.1%, 66.5%, respectively. On multivariate analysis, positive surgical margins negatively impacted LRC, DFS, and OS (hazard ratio [HR]=10.43, P=0.004), (HR=2.37, P=0.03), (HR=2.26, P=0.038), respectively. EBRT use improved LRC (HR=0.24, P=0.018) and DFS (HR=0.36, P=0.021). The impact of EBRT on DFS was retained (HR=0.28, P=0.006) in the high-grade ESTS subgroup who received CT. The 5-year local failure rate was 6.5%, 28.6%, and 22.2% (P=0.019) for patient receiving NCT, adjuvant chemotherapy, and no CT, respectively. CONCLUSION Our data support the use of NCT followed by limb-sparing surgery and adjuvant EBRT in ESTS for local failure reduction with a trend toward improved DFS.
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30
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Regional hyperthermia for high-risk soft tissue sarcoma treatment: present status and next questions. Curr Opin Oncol 2017; 28:447-52. [PMID: 27455134 DOI: 10.1097/cco.0000000000000316] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Recent developments of neo-adjuvant chemotherapy treatment strategies for high-risk soft tissue sarcoma (STS) with special emphasis on regional hyperthermia (RHT) are reviewed. RECENT FINDINGS Attempts to improve outcomes using up-front strategies in addition to surgery have essentially focused on neo-adjuvant and adjuvant chemotherapy or preoperative radiochemotherapy. Unfortunately, the results are either confounded by retrospective analyses of nonrandomized studies with small sample size or are negative showing no substantial clinical benefit in the few randomized trials. RHT targets the region of tumor burden by heat. The pleotropic effects on malignant cells and tumor stroma to counteract tumor growth and progression have been recently summarized as hallmarks of hyperthermia. An updated analysis of a completed EORTC-ESHO Intergroup randomized phase 3 trial for the most common types of high-risk STS demonstrates a significantly improved long-term overall survival for patients receiving RHT in combination with neo-adjuvant chemotherapy added to standard surgery and postoperative radiation. SUMMARY By comparison with other strategies, RHT combined with preoperative and postoperative chemotherapy improves overall survival and adds an important but underused standard for high-risk STS.
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31
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Pasquali S, Gronchi A. Neoadjuvant chemotherapy in soft tissue sarcomas: latest evidence and clinical implications. Ther Adv Med Oncol 2017; 9:415-429. [PMID: 28607580 PMCID: PMC5455882 DOI: 10.1177/1758834017705588] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 03/27/2017] [Indexed: 12/20/2022] Open
Abstract
Soft tissue sarcomas are a rare and multifaceted group of solid tumours. Neoadjuvant chemotherapy is increasingly used to limit loss of function after wide surgical excision with the ultimate aim of improving patient survival. Recently, advances in the identification of effective treatment strategies and improvements in patient risk stratification have been reached. A randomized trial demonstrated that neoadjuvant epirubicin and ifosfamide improves survival of patients affected by five high-risk soft tissue sarcoma histologies of trunk and extremities, including undifferentiated pleomorphic sarcoma, myxoid liposarcoma, synovial sarcoma, malignant peripheral nerve sheath tumours, and leiomyosarcoma. Selection of patients for these treatments is expected to be improved by the eighth edition of the American Joint Committee on Cancer (AJCC) TNM staging system, as it tailors T-stage categories on primary tumour site and considers a prognostic nomogram for retroperitoneal sarcoma, which also includes soft tissue sarcoma histology and other patient and tumour features not directly included in the TNM staging. Within this framework, this article will present neoadjuvant treatment strategies for high-risk soft tissue sarcoma, emphasizing the most recent advances and discussing the need for further research to improve the effectiveness of neoadjuvant treatments.
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Affiliation(s)
- Sandro Pasquali
- Sarcoma Service, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Alessandro Gronchi
- Sarcoma Service, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Via G Venezian 1, 20013 Milano, Italy
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32
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Dobke M, Mackert GA. Upper extremity sarcoma: impact of current practice guidelines and controversies on reconstructive approaches. SICOT J 2017; 3:15. [PMID: 28220751 PMCID: PMC5319376 DOI: 10.1051/sicotj/2017003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 01/01/2017] [Indexed: 11/15/2022] Open
Abstract
The goals of sarcoma management include both a cure and the functional preservation of involved tissues and adjacent critical structures with common opinions favoring immediate reconstruction. The question arises whether these goals are contradictory. This paper discusses the question based on the experience of 28 patients with different types of extremity sarcoma, with 24 surgically treated by the University of California San Diego (UCSD) orthopedic and plastic surgery team (2011–2016) and the collection of evidence from published practice guidelines, reviews, case studies, and clinical trials. Included are the impact of limb-sparing and functional reconstructive concepts, efforts regarding the adequacy of surgical margins, and the rationale of immediate versus delayed reconstructive approaches, and the disease-free status of sarcoma management.
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Affiliation(s)
- Marek Dobke
- Division of Plastic Surgery, Department of Surgery, University of California San Diego, San Diego, CA 92103-8890, USA
| | - Gina A Mackert
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center, 67071 Ludwigshafen, Germany , the affiliated Department of ptastic surgery of the University of Heidelberg, Germany
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33
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(Neo)adjuvant treatment in localised soft tissue sarcoma: The unsolved affair. Eur J Cancer 2016; 70:1-11. [PMID: 27866094 DOI: 10.1016/j.ejca.2016.09.030] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 09/21/2016] [Accepted: 09/26/2016] [Indexed: 01/21/2023]
Abstract
Soft tissue sarcomas (STS) are rare and heterogeneous tumours. A correct definition of STS is imperative from the very beginning of disease management, to guide the diagnostic and imaging work-up, and help to establish the prognosis on which the therapeutic strategy will be based. Over the last few years, many efforts have been made to identify characteristics that could predict disease behaviour and to enrich the therapeutic armamentarium against the advanced disease, that is still characterised by poor prognosis. Surgery remains the milestone of treatment for localised STS, whereas many uncertainties regarding the role of adjuvant and neoadjuvant treatment persist. Some controlled evidence is available, but often conflicting and insufficient to make chemotherapy (CT) a standard practice and, currently, a common and shared strategy does not exist. The biggest question concerns the prospective identification of the subgroup of patients who would benefit the most from (neo)adjuvant therapies. In light of the growing understanding of different biologies and sensitivities of the various sarcoma subtypes, the value of histology in the selection of peri-operative treatments is one of the most intriguing topics under discussion. In this perspective, a new generation of neoadjuvant trials have been planned and are currently ongoing. The aim of this review was to rekindle interest in the long-standing topic of (neo)adjuvant CT in localised STS, providing an update on its role in sarcomas' management and highlighting future directions and consequential factors needed to further improve outcomes in this disease.
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Tiwari A, Shah S, Sharma AK, Mehta S, Batra U, Sharma SK, Dewan AK. Prognostic Factors in Indian Patients Operated for Soft Tissue Sarcomas-a Retrospective Cross-sectional Analysis. Indian J Surg Oncol 2016; 8:128-135. [PMID: 28546706 DOI: 10.1007/s13193-016-0569-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 10/18/2016] [Indexed: 01/25/2023] Open
Abstract
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.
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Affiliation(s)
- Akshay Tiwari
- Department of Surgical Oncology, Rajiv Gandhi Cancer Institute, Sector 5, Rohini, Delhi 110085 India
| | - Swati Shah
- Department of Surgical Oncology, Rajiv Gandhi Cancer Institute, Sector 5, Rohini, Delhi 110085 India
| | - Ashwani Kumar Sharma
- Department of Surgical Oncology, Rajiv Gandhi Cancer Institute, Sector 5, Rohini, Delhi 110085 India
| | - Sandeep Mehta
- Department of Reconstructive Surgery, BLK Cancer Center, Delhi, India
| | - Ullas Batra
- Department of Medical Oncology, Rajiv Gandhi Cancer Institute, Rohini, Delhi India
| | - S K Sharma
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute, Rohini, Delhi India
| | - A K Dewan
- Department of Surgical Oncology, Rajiv Gandhi Cancer Institute, Sector 5, Rohini, Delhi 110085 India
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Nathenson MJ, Sausville E. Looking for answers: the current status of neoadjuvant treatment in localized soft tissue sarcomas. Cancer Chemother Pharmacol 2016; 78:895-919. [PMID: 27206640 PMCID: PMC7577379 DOI: 10.1007/s00280-016-3055-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Accepted: 05/04/2016] [Indexed: 12/19/2022]
Abstract
PURPOSE Sarcomas are a rare and heterogeneous variant of cancer. The standard of care treatment involves surgical resection with radiation in high-risk patients. Despite appropriate treatment approximately 50 % of patients will suffer and die from recurrent disease. The purpose of this article is to review the current evidence concerning the use of neoadjuvant chemotherapy with or without radiation in soft tissue sarcomas. METHODS An in-depth literature search was conducted using Ovid Medline and PubMed. RESULTS The most active chemotherapeutic agents in sarcoma are anthracyclines and ifosfamide. Adjuvant chemotherapy trials show only minimal benefit. Neoadjuvant chemotherapy offers the potential advantage of reducing the extent of surgery, increasing the limb salvage rate, early exposure of micrometastatic disease to chemotherapy, and assessment of tumor response to chemotherapy. Some retrospective and phase II trials suggest a benefit to neoadjuvant chemotherapy. Unfortunately, no clearly positive phase III prospectively randomized trials exist for neoadjuvant therapy in soft tissue sarcomas. CONCLUSIONS The current neoadjuvant chemotherapy trials that do exist are heterogeneous resulting in conflicting results. However, neoadjuvant chemotherapy with or without radiation can be considered in patients with high-risk disease in an attempt to improve long-term outcomes.
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Affiliation(s)
- Michael J Nathenson
- Department of Sarcoma Medical Oncology, MD Anderson Cancer Center, 1515 Holcombe Blvd Unit 450, Houston, TX, 77030, USA.
| | - Edward Sausville
- Department of Medicine, University of Maryland Medical Center, 22 South Greene Street Suite 9d10, Baltimore, MD, 21201, USA
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Hoefkens F, Dehandschutter C, Somville J, Meijnders P, Van Gestel D. Soft tissue sarcoma of the extremities: pending questions on surgery and radiotherapy. Radiat Oncol 2016; 11:136. [PMID: 27733179 PMCID: PMC5062836 DOI: 10.1186/s13014-016-0668-9] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 07/13/2016] [Indexed: 12/18/2022] Open
Abstract
Soft tissue sarcomas are uncommon tumours of mesenchymal origin, most commonly arising in the extremities. Treatment includes surgical resection in combination with radiotherapy. Resection margins are of paramount importance in surgical treatment of soft tissue sarcomas but unambiguous guidelines for ideal margins of resection are still missing as is an uniform guideline on the use of radiotherapy. The present paper reviews the literature on soft tissue sarcomas of the extremities regarding the required resection margins, the impact of new radiotherapy techniques and the timing of radiotherapy, more particularly if it should be administered before or after surgical resection. This review was started by searching guidelines in different databases (National Guideline Clearinghouse, EBMPracticeNet, TRIP database, NCCN guidelines,…). After refinement of the query, more specific articles were found using MEDLINE, PubMed, Web of Science and Google Scholar. Used keywords include “soft tissue sarcoma”; “extremities OR limbs”; “radiotherapy”, “surgery”, “margins”, “local recurrence” and “overall survival”. Finally, the articles were selected based on the accessibility of the full text, use of the English language and relevance based on title and abstract. Literature demonstrates positive resection margins to be an important adverse prognostic factor for local recurrence of soft tissue sarcomas of the extremities. Still, no consensus is reached on the definition of what a good margin might be. The evolution of new radiation techniques, especially Intensity Modulated Radiotherapy, resulted in a s healthy surrounding tissues. However, the timing of radiotherapy treatment remains controversial as both preoperative and postoperative radiotherapy are characterised by several advantages and disadvantages.
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Affiliation(s)
- Fien Hoefkens
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | | | - Johan Somville
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,Department of Orthopaedic Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Paul Meijnders
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,Department of Radiotherapy, University Radiotherapy Antwerp UZA/ZNA, Antwerp, Belgium
| | - Dirk Van Gestel
- Department of Radiotherapy, University Radiotherapy Antwerp UZA/ZNA, Antwerp, Belgium. .,Department of Radiotherapy, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium.
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Larrier NA, Czito BG, Kirsch DG. Radiation Therapy for Soft Tissue Sarcoma: Indications and Controversies for Neoadjuvant Therapy, Adjuvant Therapy, Intraoperative Radiation Therapy, and Brachytherapy. Surg Oncol Clin N Am 2016; 25:841-60. [PMID: 27591502 DOI: 10.1016/j.soc.2016.05.012] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Soft tissue sarcomas are rare mesenchymal cancers that pose a treatment challenge. Although small superficial soft tissue sarcomas can be managed by surgery alone, adjuvant radiotherapy in addition to limb-sparing surgery substantially increases local control of extremity sarcomas. Compared with postoperative radiotherapy, preoperative radiotherapy doubles the risk of a wound complication, but decreases the risk for late effects, which are generally irreversible. For retroperitoneal sarcomas, intraoperative radiotherapy can be used to safely escalate the radiation dose to the tumor bed. Patients with newly diagnosed sarcoma should be evaluated before surgery by a multidisciplinary team that includes a radiation oncologist.
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Affiliation(s)
- Nicole A Larrier
- Department of Radiation Oncology, Duke University Medical Center, 450 Research Drive, Durham, NC 27708, USA
| | - Brian G Czito
- Department of Radiation Oncology, Duke University Medical Center, 450 Research Drive, Durham, NC 27708, USA
| | - David G Kirsch
- Department of Radiation Oncology, Duke University Medical Center, 450 Research Drive, Durham, NC 27708, USA; Department of Pharmacology & Cancer Biology, Duke University Medical Center, 450 Research Drive, Durham, NC 27708, USA.
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Ahmad R, Jacobson A, Hornicek F, Haynes AB, Choy E, Cote G, Nielsen GP, Chen YL, DeLaney TF, Mullen JT. The Width of the Surgical Margin Does Not Influence Outcomes in Extremity and Truncal Soft Tissue Sarcoma Treated With Radiotherapy. Oncologist 2016; 21:1269-1276. [PMID: 27440063 DOI: 10.1634/theoncologist.2015-0534] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Accepted: 05/13/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND OBJECTIVES It is unclear whether the quantitative width of the surgical margin influences outcomes in patients with extremity and truncal soft tissue sarcoma (STS) treated with radiotherapy (RT). METHODS We performed a retrospective review of 382 patients with localized extremity or truncal STS who underwent limb-sparing surgery and RT from 1983 to 2010, and we analyzed the significance of resection margin status and quantitative margin width on outcomes. RESULTS Surgical margins were positive in 68 (18%) patients and negative in 314 (82%) patients. For those patients with a reported quantitative margin width (n = 235), the width of the negative margin was ≤1 mm (n = 128), >1 mm and ≤5 mm (n = 79), and >5 mm (n = 28). At a median follow-up of 82 months, the local recurrence rates were 5.4% and 11.8% for margin-negative and margin-positive patients, respectively. There were no differences in the rates of local or distant recurrence nor of any survival outcome based on the quantitative width of the surgical margin, provided that it was negative. CONCLUSIONS In patients undergoing RT and limb-sparing surgery for STS, achieving a negative margin is essential for optimizing both local control and survival. However, the absolute quantitative width of the negative margin does not significantly influence outcome, and so attempts at wide margins of resection appear to be unnecessary. Importantly, the conclusions drawn from this study must not be applied to those patients undergoing surgery alone as the local treatment of their STS, in which case wider margins of resection may be necessary. IMPLICATIONS FOR PRACTICE In patients undergoing radiation therapy and limb-sparing surgery for soft tissue sarcoma, the quantitative width of the negative margin does not influence outcome, and so attempts at wide margins of resection appear to be unnecessary, especially when such attempts compromise the functional outcome. Importantly, the conclusions drawn from this study must not be applied to those patients undergoing surgery alone as the local treatment of their soft tissue sarcoma, in which case wider margins of resection may be necessary.
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Affiliation(s)
- Rima Ahmad
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Alex Jacobson
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Francis Hornicek
- Department of Orthopedics, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Alex B Haynes
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Edwin Choy
- Department of Medical Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Gregory Cote
- Department of Medical Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - G Petur Nielsen
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Yen-Lin Chen
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Thomas F DeLaney
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - John T Mullen
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
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Evaluation of response after pre-operative radiotherapy in soft tissue sarcomas; the European Organisation for Research and Treatment of Cancer – Soft Tissue and Bone Sarcoma Group (EORTC – STBSG) and Imaging Group recommendations for radiological examination and reporting with an emphasis on magnetic resonance imaging. Eur J Cancer 2016; 56:37-44. [DOI: 10.1016/j.ejca.2015.12.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 12/08/2015] [Indexed: 11/20/2022]
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Stubbe F, Agaimy A, Ott O, Lettmaier S, Vassos N, Croner R, Hohenberger W, Fietkau R, Semrau S. Effective local control of advanced soft tissue sarcoma with neoadjuvant chemoradiotherapy and surgery: A single institutional experience. Cancer Radiother 2016; 20:6-13. [DOI: 10.1016/j.canrad.2015.05.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 04/22/2015] [Accepted: 05/29/2015] [Indexed: 01/25/2023]
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Wardelmann E, Haas R, Bovée J, Terrier P, Lazar A, Messiou C, LePechoux C, Hartmann W, Collin F, Fisher C, Mechtersheimer G, DeiTos A, Stacchiotti S, Jones R, Gronchi A, Bonvalot S. Evaluation of response after neoadjuvant treatment in soft tissue sarcomas; the European Organization for Research and Treatment of Cancer–Soft Tissue and Bone Sarcoma Group (EORTC–STBSG) recommendations for pathological examination and reporting. Eur J Cancer 2016; 53:84-95. [DOI: 10.1016/j.ejca.2015.09.021] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 09/14/2015] [Accepted: 09/16/2015] [Indexed: 12/25/2022]
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Palassini E, Ferrari S, Verderio P, De Paoli A, Martin Broto J, Quagliuolo V, Comandone A, Sangalli C, Palmerini E, Lopez-Pousa A, De Sanctis R, Bottelli S, Libertini M, Picci P, Casali PG, Gronchi A. Feasibility of Preoperative Chemotherapy With or Without Radiation Therapy in Localized Soft Tissue Sarcomas of Limbs and Superficial Trunk in the Italian Sarcoma Group/Grupo Español de Investigación en Sarcomas Randomized Clinical Trial: Three Versus Five Cycles of Full-Dose Epirubicin Plus Ifosfamide. J Clin Oncol 2015; 33:3628-34. [PMID: 26351345 DOI: 10.1200/jco.2015.62.9394] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
PURPOSE We report on feasibility of preoperative chemotherapy with or without radiation therapy (RT) in the context of a phase III randomized clinical trial involving localized, high-risk, soft tissue sarcomas. PATIENTS AND METHODS Of 321 eligible patients, 161 were randomly assigned to three preoperative cycles of epirubicin 120 mg/m(2) plus ifosfamide 9 g/m(2), and 160 were randomly assigned to three preoperative plus two postoperative cycles. Among them, 303 patients were included in this analysis; 169 were male and 134 were female, with a median age of 48 years (range, 15 to 79 years). One hundred fifty-two patients received concurrent RT preoperatively at a total dose of 44 to 50 Gy. Preoperative chemotherapy-related hematologic toxicity and early postoperative complications were reported. The influence of RT, age, and sex on hematologic grade 3 or 4 toxicities and wound complications was analyzed. Chemotherapeutic dose intensity (DI) was analyzed. RESULTS Among the patients, 61.4%, 22.4%, and 23.8% experienced, grade 4 leucopenia, grade 3 or 4 anemia, and grade 3 or 4 thrombocytopenia, respectively. Respective rates were 66.4%, 24.3%, and 31.6% when RT was added preoperatively, and 56.3%, 20.5%, and 15.9% when preoperative chemotherapy was administered alone. Patient age affected grade 3 or 4 thrombocytopenia. Grade 4 leucopenia and grade 3 or 4 anemia presented 2.5 times more frequently in female patients than in male patients. Wound complications were observed in 13.5% of patients: 17% with preoperative RT and 10% without. Chemotherapeutic DI was greater than 90%, even in patients receiving preoperative RT and in patients age 65 years or older. CONCLUSION This preoperative chemotherapy is feasible and can also be proposed for selected elderly patients. Grade 3 or 4 hematologic toxicity was common, but DI was excellent. Concurrent preoperative RT is safe, although an increased rate of grade 4 thrombocytopenia and limited increase in wound complications may be observed.
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Affiliation(s)
- Elena Palassini
- Elena Palassini, Paolo Verderio, Claudia Sangalli, Stefano Bottelli, Michela Libertini, Paolo G. Casali, and Alessandro Gronchi, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori; Vittorio Quagliuolo and Rita De Sanctis, Istituto Clinico Humanitas, Milan; Stefano Ferrari, Emanuela Palmerini, and Piero Picci, Istituto Ortopedico Rizzoli, Bologna; Antonino De Paoli, Centro di Riferimento Oncologico, Aviano; Alessandro Comandone, Presidio Sanitario Gradenigo, Torino, Italy; Javier Martin Broto, Hospital Universitario Virgen del Rocío, Sevilla; and Antonio Lopez-Pousa, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Stefano Ferrari
- Elena Palassini, Paolo Verderio, Claudia Sangalli, Stefano Bottelli, Michela Libertini, Paolo G. Casali, and Alessandro Gronchi, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori; Vittorio Quagliuolo and Rita De Sanctis, Istituto Clinico Humanitas, Milan; Stefano Ferrari, Emanuela Palmerini, and Piero Picci, Istituto Ortopedico Rizzoli, Bologna; Antonino De Paoli, Centro di Riferimento Oncologico, Aviano; Alessandro Comandone, Presidio Sanitario Gradenigo, Torino, Italy; Javier Martin Broto, Hospital Universitario Virgen del Rocío, Sevilla; and Antonio Lopez-Pousa, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Paolo Verderio
- Elena Palassini, Paolo Verderio, Claudia Sangalli, Stefano Bottelli, Michela Libertini, Paolo G. Casali, and Alessandro Gronchi, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori; Vittorio Quagliuolo and Rita De Sanctis, Istituto Clinico Humanitas, Milan; Stefano Ferrari, Emanuela Palmerini, and Piero Picci, Istituto Ortopedico Rizzoli, Bologna; Antonino De Paoli, Centro di Riferimento Oncologico, Aviano; Alessandro Comandone, Presidio Sanitario Gradenigo, Torino, Italy; Javier Martin Broto, Hospital Universitario Virgen del Rocío, Sevilla; and Antonio Lopez-Pousa, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Antonino De Paoli
- Elena Palassini, Paolo Verderio, Claudia Sangalli, Stefano Bottelli, Michela Libertini, Paolo G. Casali, and Alessandro Gronchi, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori; Vittorio Quagliuolo and Rita De Sanctis, Istituto Clinico Humanitas, Milan; Stefano Ferrari, Emanuela Palmerini, and Piero Picci, Istituto Ortopedico Rizzoli, Bologna; Antonino De Paoli, Centro di Riferimento Oncologico, Aviano; Alessandro Comandone, Presidio Sanitario Gradenigo, Torino, Italy; Javier Martin Broto, Hospital Universitario Virgen del Rocío, Sevilla; and Antonio Lopez-Pousa, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Javier Martin Broto
- Elena Palassini, Paolo Verderio, Claudia Sangalli, Stefano Bottelli, Michela Libertini, Paolo G. Casali, and Alessandro Gronchi, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori; Vittorio Quagliuolo and Rita De Sanctis, Istituto Clinico Humanitas, Milan; Stefano Ferrari, Emanuela Palmerini, and Piero Picci, Istituto Ortopedico Rizzoli, Bologna; Antonino De Paoli, Centro di Riferimento Oncologico, Aviano; Alessandro Comandone, Presidio Sanitario Gradenigo, Torino, Italy; Javier Martin Broto, Hospital Universitario Virgen del Rocío, Sevilla; and Antonio Lopez-Pousa, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Vittorio Quagliuolo
- Elena Palassini, Paolo Verderio, Claudia Sangalli, Stefano Bottelli, Michela Libertini, Paolo G. Casali, and Alessandro Gronchi, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori; Vittorio Quagliuolo and Rita De Sanctis, Istituto Clinico Humanitas, Milan; Stefano Ferrari, Emanuela Palmerini, and Piero Picci, Istituto Ortopedico Rizzoli, Bologna; Antonino De Paoli, Centro di Riferimento Oncologico, Aviano; Alessandro Comandone, Presidio Sanitario Gradenigo, Torino, Italy; Javier Martin Broto, Hospital Universitario Virgen del Rocío, Sevilla; and Antonio Lopez-Pousa, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Alessandro Comandone
- Elena Palassini, Paolo Verderio, Claudia Sangalli, Stefano Bottelli, Michela Libertini, Paolo G. Casali, and Alessandro Gronchi, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori; Vittorio Quagliuolo and Rita De Sanctis, Istituto Clinico Humanitas, Milan; Stefano Ferrari, Emanuela Palmerini, and Piero Picci, Istituto Ortopedico Rizzoli, Bologna; Antonino De Paoli, Centro di Riferimento Oncologico, Aviano; Alessandro Comandone, Presidio Sanitario Gradenigo, Torino, Italy; Javier Martin Broto, Hospital Universitario Virgen del Rocío, Sevilla; and Antonio Lopez-Pousa, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Claudia Sangalli
- Elena Palassini, Paolo Verderio, Claudia Sangalli, Stefano Bottelli, Michela Libertini, Paolo G. Casali, and Alessandro Gronchi, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori; Vittorio Quagliuolo and Rita De Sanctis, Istituto Clinico Humanitas, Milan; Stefano Ferrari, Emanuela Palmerini, and Piero Picci, Istituto Ortopedico Rizzoli, Bologna; Antonino De Paoli, Centro di Riferimento Oncologico, Aviano; Alessandro Comandone, Presidio Sanitario Gradenigo, Torino, Italy; Javier Martin Broto, Hospital Universitario Virgen del Rocío, Sevilla; and Antonio Lopez-Pousa, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Emanuela Palmerini
- Elena Palassini, Paolo Verderio, Claudia Sangalli, Stefano Bottelli, Michela Libertini, Paolo G. Casali, and Alessandro Gronchi, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori; Vittorio Quagliuolo and Rita De Sanctis, Istituto Clinico Humanitas, Milan; Stefano Ferrari, Emanuela Palmerini, and Piero Picci, Istituto Ortopedico Rizzoli, Bologna; Antonino De Paoli, Centro di Riferimento Oncologico, Aviano; Alessandro Comandone, Presidio Sanitario Gradenigo, Torino, Italy; Javier Martin Broto, Hospital Universitario Virgen del Rocío, Sevilla; and Antonio Lopez-Pousa, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Antonio Lopez-Pousa
- Elena Palassini, Paolo Verderio, Claudia Sangalli, Stefano Bottelli, Michela Libertini, Paolo G. Casali, and Alessandro Gronchi, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori; Vittorio Quagliuolo and Rita De Sanctis, Istituto Clinico Humanitas, Milan; Stefano Ferrari, Emanuela Palmerini, and Piero Picci, Istituto Ortopedico Rizzoli, Bologna; Antonino De Paoli, Centro di Riferimento Oncologico, Aviano; Alessandro Comandone, Presidio Sanitario Gradenigo, Torino, Italy; Javier Martin Broto, Hospital Universitario Virgen del Rocío, Sevilla; and Antonio Lopez-Pousa, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Rita De Sanctis
- Elena Palassini, Paolo Verderio, Claudia Sangalli, Stefano Bottelli, Michela Libertini, Paolo G. Casali, and Alessandro Gronchi, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori; Vittorio Quagliuolo and Rita De Sanctis, Istituto Clinico Humanitas, Milan; Stefano Ferrari, Emanuela Palmerini, and Piero Picci, Istituto Ortopedico Rizzoli, Bologna; Antonino De Paoli, Centro di Riferimento Oncologico, Aviano; Alessandro Comandone, Presidio Sanitario Gradenigo, Torino, Italy; Javier Martin Broto, Hospital Universitario Virgen del Rocío, Sevilla; and Antonio Lopez-Pousa, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Stefano Bottelli
- Elena Palassini, Paolo Verderio, Claudia Sangalli, Stefano Bottelli, Michela Libertini, Paolo G. Casali, and Alessandro Gronchi, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori; Vittorio Quagliuolo and Rita De Sanctis, Istituto Clinico Humanitas, Milan; Stefano Ferrari, Emanuela Palmerini, and Piero Picci, Istituto Ortopedico Rizzoli, Bologna; Antonino De Paoli, Centro di Riferimento Oncologico, Aviano; Alessandro Comandone, Presidio Sanitario Gradenigo, Torino, Italy; Javier Martin Broto, Hospital Universitario Virgen del Rocío, Sevilla; and Antonio Lopez-Pousa, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Michela Libertini
- Elena Palassini, Paolo Verderio, Claudia Sangalli, Stefano Bottelli, Michela Libertini, Paolo G. Casali, and Alessandro Gronchi, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori; Vittorio Quagliuolo and Rita De Sanctis, Istituto Clinico Humanitas, Milan; Stefano Ferrari, Emanuela Palmerini, and Piero Picci, Istituto Ortopedico Rizzoli, Bologna; Antonino De Paoli, Centro di Riferimento Oncologico, Aviano; Alessandro Comandone, Presidio Sanitario Gradenigo, Torino, Italy; Javier Martin Broto, Hospital Universitario Virgen del Rocío, Sevilla; and Antonio Lopez-Pousa, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Piero Picci
- Elena Palassini, Paolo Verderio, Claudia Sangalli, Stefano Bottelli, Michela Libertini, Paolo G. Casali, and Alessandro Gronchi, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori; Vittorio Quagliuolo and Rita De Sanctis, Istituto Clinico Humanitas, Milan; Stefano Ferrari, Emanuela Palmerini, and Piero Picci, Istituto Ortopedico Rizzoli, Bologna; Antonino De Paoli, Centro di Riferimento Oncologico, Aviano; Alessandro Comandone, Presidio Sanitario Gradenigo, Torino, Italy; Javier Martin Broto, Hospital Universitario Virgen del Rocío, Sevilla; and Antonio Lopez-Pousa, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Paolo G Casali
- Elena Palassini, Paolo Verderio, Claudia Sangalli, Stefano Bottelli, Michela Libertini, Paolo G. Casali, and Alessandro Gronchi, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori; Vittorio Quagliuolo and Rita De Sanctis, Istituto Clinico Humanitas, Milan; Stefano Ferrari, Emanuela Palmerini, and Piero Picci, Istituto Ortopedico Rizzoli, Bologna; Antonino De Paoli, Centro di Riferimento Oncologico, Aviano; Alessandro Comandone, Presidio Sanitario Gradenigo, Torino, Italy; Javier Martin Broto, Hospital Universitario Virgen del Rocío, Sevilla; and Antonio Lopez-Pousa, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Alessandro Gronchi
- Elena Palassini, Paolo Verderio, Claudia Sangalli, Stefano Bottelli, Michela Libertini, Paolo G. Casali, and Alessandro Gronchi, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori; Vittorio Quagliuolo and Rita De Sanctis, Istituto Clinico Humanitas, Milan; Stefano Ferrari, Emanuela Palmerini, and Piero Picci, Istituto Ortopedico Rizzoli, Bologna; Antonino De Paoli, Centro di Riferimento Oncologico, Aviano; Alessandro Comandone, Presidio Sanitario Gradenigo, Torino, Italy; Javier Martin Broto, Hospital Universitario Virgen del Rocío, Sevilla; and Antonio Lopez-Pousa, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.
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Harris SJ, Benson C, Jones RL. Current and advancing systemic treatment options for soft tissue sarcomas. Expert Opin Pharmacother 2015; 16:2023-37. [PMID: 26255951 DOI: 10.1517/14656566.2015.1074176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Soft tissue sarcomas are a collection of rare malignancies, the treatment of which has evolved over time. Although cytotoxic chemotherapy remains the cornerstone of management of metastatic disease, many new treatments have been developed or show great promise in the treatment of soft tissue sarcoma. Research into the different underlying pathogenesis of individual subtypes has driven progress in treatment. This has allowed development of treatments targeted to specific subtypes of sarcoma. AREAS COVERED We provide a review of the current field of systemic therapy in soft tissue sarcoma. This is followed by an in-depth analysis of recent developments in treatment, as well as new treatments that are aimed at specific subtypes of sarcoma, and the biological rationale behind these therapies. We also look in detail at the promising new agents currently in development. EXPERT OPINION Much progression has been made in treatment of soft tissue sarcomas with multiple exciting new treatments in development. However outcomes in general remain poor. Further research into the underlying pathogenesis of soft tissue sarcomas may help deliver more effective systemic therapies. Increased collaboration between basic science, translational and clinical investigators is required at national and international levels to maximise progress.
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Affiliation(s)
- Samuel J Harris
- The Royal Marsden NHS Foundation Trust , Sarcoma Unit , Fulham Road, London, SW3 6JJ , UK
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Ernst A, Anders H, Kapfhammer H, Orth M, Hennel R, Seidl K, Winssinger N, Belka C, Unkel S, Lauber K. HSP90 inhibition as a means of radiosensitizing resistant, aggressive soft tissue sarcomas. Cancer Lett 2015; 365:211-22. [PMID: 26044951 DOI: 10.1016/j.canlet.2015.05.024] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 05/20/2015] [Accepted: 05/29/2015] [Indexed: 01/27/2023]
Abstract
Radiotherapy is an essential part of multi-modal treatment for soft tissue sarcomas. Treatment failure is commonly attributed to radioresistance, but comprehensive analyses of radiosensitivity are not available, and suitable biomarkers or candidates for targeted radiosensitization are scarce. Here, we systematically analyzed the intrinsic radioresistance of a panel of soft tissue sarcoma cell lines, and extracted scores of radioresistance by principal component analysis (PCA). To identify molecular markers of radioresistance, transcriptomic profiling of DNA damage response regulators was performed. The expression levels of HSP90 and its clients ATR, ATM, and NBS1 revealed strong, positive correlations with the PCA-derived radioresistance scores. Their functional involvement was addressed by HSP90 inhibition, which preferentially sensitized radioresistant sarcoma cells and was accompanied by delayed γ-H2AX foci clearance and HSP90 client protein degradation. The induction of apoptosis and necrosis was not significantly enhanced, but increased levels of basal and irradiation-induced senescence upon HSP90 inhibition were detected. Finally, evaluation of our findings in the TCGA soft tissue sarcoma cohort revealed elevated expression levels of HSP90, ATR, ATM, and NBS1 in a relevant subset of cases with particularly poor prognosis, which might preferentially benefit from HSP90 inhibition in combination with radiotherapy in the future.
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Affiliation(s)
- Anne Ernst
- Clinic for Radiotherapy and Radiation Oncology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Heike Anders
- Clinic for Radiotherapy and Radiation Oncology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Heidi Kapfhammer
- Clinic for Radiotherapy and Radiation Oncology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Michael Orth
- Clinic for Radiotherapy and Radiation Oncology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Roman Hennel
- Clinic for Radiotherapy and Radiation Oncology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Karin Seidl
- Clinic for Radiotherapy and Radiation Oncology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Nicolas Winssinger
- Department of Organic Chemistry, NCCR Chemical Biology, University of Geneva, Geneva, Switzerland
| | - Claus Belka
- Clinic for Radiotherapy and Radiation Oncology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Steffen Unkel
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Kirsten Lauber
- Clinic for Radiotherapy and Radiation Oncology, Ludwig-Maximilians-University Munich, Munich, Germany.
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Mullen JT, Hornicek FJ, Harmon DC, Raskin KA, Chen YL, Szymonifka J, Yeap BY, Choy E, DeLaney TF, Nielsen GP. Prognostic significance of treatment-induced pathologic necrosis in extremity and truncal soft tissue sarcoma after neoadjuvant chemoradiotherapy. Cancer 2014; 120:3676-82. [PMID: 25081640 DOI: 10.1002/cncr.28945] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Revised: 05/26/2014] [Accepted: 06/30/2014] [Indexed: 11/10/2022]
Abstract
BACKGROUND Histologic response to chemotherapy has been shown to be an independent prognostic factor in patients with osteosarcoma and Ewing sarcoma. However, in patients with soft tissue sarcoma (STS), the prognostic impact of histologic response to chemotherapy is less clear. In the current study, the authors sought to determine the prognostic significance of treatment-induced pathologic necrosis in patients receiving neoadjuvant chemoradiotherapy for STS. METHODS Between 1989 and 2011, a total of 113 patients with grade 2 or 3 (graded according to the National Cancer Institute grading system using 3 tiers) extremity or truncal STS were identified who received neoadjuvant interdigitated chemoradiotherapy according to protocol followed by surgery. The extent of tumor necrosis in the resected specimens was quantified and correlated with outcome. RESULTS The median tumor necrosis rate was 90%, and 103 patients (91%) received all 3 cycles of planned neoadjuvant chemotherapy. The likelihood of achieving ≥95% necrosis was not related to the number of preoperative cycles of chemotherapy received but was found to be related to tumor histology (62% for malignant fibrous histiocytoma vs 0% for synovial sarcoma [P<.001]; 56% for myxoid liposarcoma vs 0% for synovial sarcoma [P = .002]). At a median follow-up of 6 years, there were no statistically significant differences noted in the 5-year local control, disease-specific survival, and overall survival rates for patients with ≥95% necrosis (50 patients; 44%) and <95% necrosis (63 patients; 56%), even when stratifying by histology. CONCLUSIONS In a homogeneous population of patients with high-grade extremity and truncal STS who were treated with neoadjuvant chemoradiotherapy, the extent of pathologic tumor necrosis did not correlate with outcome.
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Affiliation(s)
- John T Mullen
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
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Linch M, Miah AB, Thway K, Judson IR, Benson C. Systemic treatment of soft-tissue sarcoma-gold standard and novel therapies. Nat Rev Clin Oncol 2014; 11:187-202. [PMID: 24642677 DOI: 10.1038/nrclinonc.2014.26] [Citation(s) in RCA: 159] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Soft-tissue sarcoma (STS) is a rare and heterogeneous group of tumours that comprise approximately 1% of all adult cancers, and encompass over 50 different subtypes. These tumours exhibit a wide range of differing behaviours and underlying molecular pathologies, and can arise anywhere in the body. Surgical resection is critical to the management of locoregional disease. In the locally advanced or metastatic disease settings, systemic therapy has an important role in the multidisciplinary management of sarcoma. Cytotoxic therapy that usually consists of doxorubicin and ifosfamide has been the mainstay of treatment for many years. However recent advances in molecular pathogenesis, the development of novel targeted therapies, changes in clinical trial design and increased international collaboration have led to the development of histology-driven therapy. Furthermore, genomic profiling has highlighted that some STS are driven by translocation, mutation or amplification and others have more complex and chaotic karyotypes. In this Review, we aim to describe the current gold standard treatment for specific STS subtypes as well as outline future promising therapies in the pipeline.
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Affiliation(s)
- Mark Linch
- Sarcoma Unit, Department of Medical Oncology, Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK
| | - Aisha B Miah
- Department of Clinical Oncology, Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK
| | - Khin Thway
- Department of Histopathology, Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK
| | - Ian R Judson
- Sarcoma Unit, Department of Medical Oncology, Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK
| | - Charlotte Benson
- Sarcoma Unit, Department of Medical Oncology, Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK
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Tumour volume changes following pre-operative radiotherapy in borderline resectable limb and trunk soft tissue sarcoma. Eur J Surg Oncol 2014; 40:394-401. [PMID: 24534361 DOI: 10.1016/j.ejso.2014.01.011] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 12/31/2013] [Accepted: 01/17/2014] [Indexed: 11/24/2022] Open
Abstract
AIMS To evaluate tumour volume changes after preoperative radiotherapy (PRT) for borderline operable soft tissue sarcomas (STS). MATERIALS AND METHODS A retrospective review was performed of 68 patients who received PRT between December 2004 and July 2011. Endpoints were radiological response, surgical margins, local control and survival. RESULTS Median tumour size was 12.5 cm. Tumour location was extremity (87%), trunk (12%), and neck (1%). Commonest histological subtypes were myxoid liposarcoma (32%) and myxofibrosarcoma (16%). The majority of patients (88%) received 50 Gy in 25 fractions. Post-radiotherapy imaging was available in 55 cases. By RECIST there was stable disease in 89%, partial response in 7% and progressive disease in 4%. Tumour volumes reduced in 80%. Median change in maximal tumour dimension was -13.6%; median change in volume was greater, at -33.3%. Tumour volumes increased in 11 cases (20%). However, surgical margins were clear in all 11 cases, with no local recurrences in this group. For the entire group, surgical margins were clear in 93%, and microscopically positive in 7%. Eight patients (12%) had local relapse at 2-24.8 months after surgery. Two year local relapse free survival was 87.5%; 2 year overall survival was 74.7%. CONCLUSION The majority of tumours showed reduction in volume. A small number of tumours increased in volume, but there was no definite relationship between volume increase and poor surgical outcomes or lower local control rates. Local control was equivalent to published series' of PRT. PRT is a reasonable approach in patients with borderline resectable tumours.
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