1
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Skubitz KM, Marette S, Murugan P, Yueh B, Clohisy DR. Multifocal Desmoid-Type Fibromatosis: Case Series and Potential Relationship to Neuronal Spread. Cureus 2024; 16:e53771. [PMID: 38465095 PMCID: PMC10921122 DOI: 10.7759/cureus.53771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2024] [Indexed: 03/12/2024] Open
Abstract
Multifocal desmoid-type fibromatosis (DTF) is very rare and usually regional. We report three cases that initially appeared to be multifocal, but subsequent detailed imaging revealed unsuspected tracking along nerves in two cases. This neural spread is reminiscent of neuromuscular choristoma (NMC), a rare developmental lesion in which mature skeletal muscle cells, or rarely smooth muscle cells, infiltrate and enlarge peripheral nerves. NMC is frequently associated with DTF. These two cases suggest that DTF spread along nerves and appeared as distinct multifocal lesions while actually being contiguous. The third case was felt to represent true multifocal tumor development, possibly due to tumor seeding at the time of chest surgery. The relationship of DTF to NMC is discussed.
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Affiliation(s)
| | | | - Paari Murugan
- Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, USA
| | - Bevan Yueh
- Otolaryngology, University of Minnesota, Minneapolis, USA
| | - Denis R Clohisy
- Orthopaedic Surgery, University of Minnesota, Minneapolis, USA
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2
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Borghi A, Gronchi A. Desmoid tumours (extra-abdominal), a surgeon's nightmare. Bone Joint J 2023; 105-B:729-734. [PMID: 37391208 DOI: 10.1302/0301-620x.105b7.bjj-2023-0117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
Desmoid tumours are a rare fibroblastic proliferation of monoclonal origin, arising in deep soft-tissues. Histologically, they are characterized by locally aggressive behaviour and an inability to metastasize, and clinically by a heterogeneous and unpredictable course. Desmoid tumours can occur in any anatomical site, but commonly arise in the limbs. Despite their benign nature, they can be extremely disabling and sometimes life-threatening, causing severe pain and functional limitations. Their surgical management is complex and challenging, due to uncertainties surrounding the biological and clinical behaviour, rarity, and limited available literature. Resection has been the first-line approach for patients with a desmoid tumour but, during the last few decades, a shift towards a more conservative approach has occurred, with an initial 'wait and see' policy. Many medical and regional forms of treatment are also available for the management of this condition, and others have recently emerged with promising results. However, many areas of controversy remain, and further studies and global collaboration are needed to obtain prospective and randomized data, in order to develop an appropriate shared stepwise approach.
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Affiliation(s)
- Alessandra Borghi
- Department of Surgery, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
| | - Alessandro Gronchi
- Department of Surgery, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
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3
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Reijers SJM, Davies E, Grünhagen DJ, Fiore M, Honore C, Rastrelli M, Vassos N, Podleska LE, Niethard M, Jakob J, Perhavec A, Duarte C, González F, Deroose JP, Stas M, Boecxstaens V, Schrage Y, Snow H, Algarra SM, Said HM, Ortega DYG, Martin K, Mattsson J, Djafarrian R, Di Lorenzo G, Colombo C, Gronchi A, Matter M, Verhoef C, Bagge RO, Hohenberger P, Hayes AJ, van Houdt WJ. Variation in response rates to isolated limb perfusion in different soft-tissue tumour subtypes: an international multi-centre study. Eur J Cancer 2023; 190:112949. [PMID: 37453241 DOI: 10.1016/j.ejca.2023.112949] [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: 03/29/2023] [Revised: 05/11/2023] [Accepted: 06/13/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE The aim of this study was to investigate the response rates of different extremity soft-tissue sarcoma subtypes (eSTS) after isolated limb perfusion (ILP), based on an international multi-centre study. MATERIALS AND METHODS The retrospective cohort comprised eSTS patients from 17 specialised ILP centres that underwent melphalan-based ILP, with or without recombinant human tumour necrosis factor (rhTNFα) (TM-ILP and M-ILP, respectively). Response was measured on imaging (magnetic resonance imaging) and/or clinical response, for which M-ILPs were excluded. RESULTS A total of 1109 eSTS patients were included. The three most common histological subtypes were undifferentiated pleomorphic sarcoma (17%, n = 184), synovial sarcoma (16%, n = 175) and myxofibrosarcoma (8%, n = 87). rhTNFα was used in 93% (TM-ILP) and resulted in a significantly better overall response rate (ORR, p = 0.031) and complete responses (CR, p < 0.001) in comparison to M-ILP, without significant differences among histological subgroups. The ORR of TM-ILP was 68%, including 17% CR. Also, 80% showed progressive disease. Significantly higher response rates were shown for Kaposi sarcoma (KS) with 42% CR and 96% ORR (both p < 0.001), and significantly higher CR rates for angiosarcoma (AS, 45%, p < 0.001) and clear cell sarcoma (CCS, 31%, p = 0.049). ILP was followed by resection ≤ 6 months in 80% of the patients. The overall limb salvage rate was 88%, without significant differences among histological subgroups, but was significantly higher for ILP responders compared to non-responders (93% versus 76%, p < 0.001). CONCLUSION ILP resulted in high response and LRS among all eSTS subtypes, however, with significant differences between subtypes with most promising results for KS, AS and CCS.
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Affiliation(s)
- Sophie J M Reijers
- Department of Surgical Oncology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands.
| | - Emma Davies
- Department of Surgical Oncology, Royal Marsden Hospital, 203 Fulham Rd., SW3 6JJ London, UK.
| | - Dirk J Grünhagen
- Department of Surgical Oncology, Erasmus Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.
| | - Marco Fiore
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Giacomo Venezian, 1, 20133 Milan, Italy.
| | - Charles Honore
- Department of Surgical Oncology, Gustave Roussy Cancer Campus, 114 Rue Edouard Vaillant, 94805 Villejuif, France.
| | - Marco Rastrelli
- Department of Surgery Oncology and Gastroenterology, University of Padova, Via VIII Febbraio, 2, 35122 Padua, Italy; Department of Surgical Oncology, Istituto Oncologico Veneto (IOV), Via Gattamelata, 64, 35128 Padua, Italy.
| | - Nikolaos Vassos
- Division of Surgical Oncology, Mannheim University Medical Center, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
| | - Lars E Podleska
- Department of Orthopaedic Oncology and Soft Tissue Sarcoma, Essen University Hospital, Hufelandstraße 55, 45147 Essen, Germany.
| | - Maya Niethard
- Department of Surgical Oncology, Helios Klinikum Berlin-Buch, Schwanebecker Ch 50, 13125 Berlin, Germany; Department of Orthopedic Surgery, University Medicine Greifswald, Fleischmannstraße 6, 17489 Greifswald, Germany.
| | - Jens Jakob
- Department of Orthopaedic Oncology and Soft Tissue Sarcoma, Essen University Hospital, Hufelandstraße 55, 45147 Essen, Germany.
| | - Andraz Perhavec
- Department of Surgical Oncology, Institute of Oncology Ljubljana, Zaloška cesta 2, 1000 Ljubljana, Slovenia.
| | - Carlos Duarte
- Department of Surgical Oncology, Instituto Nacional de Cancerología, Cl. 1 #9-85, Bogota, Colombia.
| | - Felipe González
- Department of Surgical Oncology, Instituto Nacional de Cancerología, Cl. 1 #9-85, Bogota, Colombia.
| | - Jan P Deroose
- Department of Surgical Oncology, Martini Ziekenhuis, Van Swietenplein 1, 9728 NT Groningen, the Netherlands.
| | - Marguerite Stas
- Department of Surgical Oncology, Universitair Ziekenhuis Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Veerle Boecxstaens
- Department of Surgical Oncology, Universitair Ziekenhuis Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Yvonne Schrage
- Department of Surgical Oncology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands.
| | - Hayden Snow
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC 3000. Australia.
| | - Salvador Martín Algarra
- Department of Medical Oncology, Clínica Universidad de Navarra, Av. de Pío XII, 36, 31008 Pamplona, Spain.
| | - Hector Martinez Said
- Department of Surgical Oncology, National Cancer Institute Mexico, Av. San Fernando 22, Belisario Domínguez Secc 16, Tlalpan, 14080 Mexico City, Mexico.
| | - Dorian Yarih Garcia Ortega
- Department of Surgical Oncology, National Cancer Institute Mexico, Av. San Fernando 22, Belisario Domínguez Secc 16, Tlalpan, 14080 Mexico City, Mexico.
| | - Karla Martin
- Department of Surgical Oncology, National Cancer Institute Mexico, Av. San Fernando 22, Belisario Domínguez Secc 16, Tlalpan, 14080 Mexico City, Mexico.
| | - Jan Mattsson
- Department of Surgery, Sahlgrenska University Hospital, Blå stråket 5, 413 45 Gothenburg, Sweden; Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Medicinaregatan 3, 413 90 Gothenburg, Sweden.
| | - Reza Djafarrian
- Department of Visceral Surgery, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland.
| | - Giorgia Di Lorenzo
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Giacomo Venezian, 1, 20133 Milan, Italy.
| | - Chiara Colombo
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Giacomo Venezian, 1, 20133 Milan, Italy.
| | - Alessandro Gronchi
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Giacomo Venezian, 1, 20133 Milan, Italy.
| | - Maurice Matter
- Department of Visceral Surgery, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland.
| | - Cornelis Verhoef
- Department of Surgical Oncology, Erasmus Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.
| | - Roger Olofsson Bagge
- Department of Surgery, Sahlgrenska University Hospital, Blå stråket 5, 413 45 Gothenburg, Sweden; Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Medicinaregatan 3, 413 90 Gothenburg, Sweden.
| | - Peter Hohenberger
- Division of Surgical Oncology, Mannheim University Medical Center, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
| | - Andrew J Hayes
- Department of Surgical Oncology, Royal Marsden Hospital, 203 Fulham Rd., SW3 6JJ London, UK.
| | - Winan J van Houdt
- Department of Surgical Oncology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands.
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4
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Savvidou OD, Koutsouradis P, Bolia IK, Kaspiris A, Chloros GD, Papagelopoulos PJ. Soft tissue tumours of the elbow: current concepts. EFORT Open Rev 2020; 4:668-677. [PMID: 32010455 PMCID: PMC6986393 DOI: 10.1302/2058-5241.4.190002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Soft tissue tumours of the elbow are mostly benign. Malignant tumours in this area, although uncommon, often present unique clinical and histopathological characteristics that are helpful for diagnosis.Management of soft tissue tumours around the elbow may be challenging because of their rarity and the proximity to neurovascular structures. Careful staging, histological diagnosis and treatment are essential to optimize clinical outcome. A missed or delayed diagnosis or an improperly executed biopsy may have devastating consequences for the patient.This article reviews the most common benign and malignant soft tissue tumours of the elbow and discusses the clinicopathological findings, imaging features and current therapeutic concepts. Cite this article: EFORT Open Rev 2019;4:668-677. DOI: 10.1302/2058-5241.4.190002.
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Affiliation(s)
- Olga D Savvidou
- First Department of Orthopaedic Surgery, National and Kapodistrian University of Athens, 'ATTIKON' Hospital, Athens, Greece
| | | | - Ioanna K Bolia
- First Department of Orthopaedic Surgery, National and Kapodistrian University of Athens, 'ATTIKON' Hospital, Athens, Greece
| | - Angelos Kaspiris
- Laboratory of Molecular Pharmacology/Sector for Bone Research, School of Health Sciences, University of Patras, Patras 26504, Greece
| | - George D Chloros
- First Department of Orthopaedic Surgery, National and Kapodistrian University of Athens, 'ATTIKON' Hospital, Athens, Greece
| | - Panayiotis J Papagelopoulos
- First Department of Orthopaedic Surgery, National and Kapodistrian University of Athens, 'ATTIKON' Hospital, Athens, Greece
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5
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van Houdt WJ, Husson O, Patel A, Jones RL, Smith MJF, Miah AB, Messiou C, Moskovic E, Al-Muderis O, Benson C, Zaidi S, Dunlop A, Strauss DC, Hayes AJ, van der Graaf WTA. Outcome of Primary Desmoid Tumors at All Anatomic Locations Initially Managed with Active Surveillance. Ann Surg Oncol 2019; 26:4699-4706. [DOI: 10.1245/s10434-019-07826-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Indexed: 12/21/2022]
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6
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Timbergen MJM, Smits R, Grünhagen DJ, Verhoef C, Sleijfer S, Wiemer EAC. Activated Signaling Pathways and Targeted Therapies in Desmoid-Type Fibromatosis: A Literature Review. Front Oncol 2019; 9:397. [PMID: 31165043 PMCID: PMC6534064 DOI: 10.3389/fonc.2019.00397] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 04/26/2019] [Indexed: 12/17/2022] Open
Abstract
Desmoid-type fibromatosis (DTF) is a rare, soft tissue tumor of mesenchymal origin which is characterized by local infiltrative growth behavior. Besides “wait and see,” surgery and radiotherapy, several systemic treatments are available for symptomatic patients. Recently, targeted therapies are being explored in DTF. Unfortunately, effective treatment is still hampered by the limited knowledge of the molecular mechanisms that prompt DTF tumorigenesis. Many studies focus on Wnt/β-catenin signaling, since the vast majority of DTF tumors harbor a mutation in the CTNNB1 gene or the APC gene. The established role of the Wnt/β-catenin pathway in DTF forms an attractive therapeutic target, however, drugs targeting this pathway are still in an experimental stage and not yet available in the clinic. Only few studies address other signaling pathways which can drive uncontrolled growth in DTF such as: JAK/STAT, Notch, PI3 kinase/AKT, mTOR, Hedgehog, and the estrogen growth regulatory pathways. Evidence for involvement of these pathways in DTF tumorigenesis is limited and predominantly based on the expression levels of key pathway genes, or on observed clinical responses after targeted treatment. No clear driver role for these pathways in DTF has been identified, and a rationale for clinical studies is often lacking. In this review, we highlight common signaling pathways active in DTF and provide an up-to-date overview of their therapeutic potential.
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Affiliation(s)
- Milea J M Timbergen
- Department of Surgical Oncology, Erasmus MC-University Medical Center, Rotterdam, Netherlands.,Department of Medical Oncology, Erasmus MC-University Medical Center, Rotterdam, Netherlands
| | - Ron Smits
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center, Rotterdam, Netherlands
| | - Dirk J Grünhagen
- Department of Surgical Oncology, Erasmus MC-University Medical Center, Rotterdam, Netherlands
| | - Cornelis Verhoef
- Department of Surgical Oncology, Erasmus MC-University Medical Center, Rotterdam, Netherlands
| | - Stefan Sleijfer
- Department of Medical Oncology, Erasmus MC-University Medical Center, Rotterdam, Netherlands
| | - Erik A C Wiemer
- Department of Medical Oncology, Erasmus MC-University Medical Center, Rotterdam, Netherlands
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7
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Olofsson Bagge R, Carlson P, Razzazian R, Hansson C, Hjärpe A, Mattsson J, Katsarelias D. Minimally invasive isolated limb perfusion – technical details and initial outcome of a new treatment method for limb malignancies. Int J Hyperthermia 2018; 35:667-673. [DOI: 10.1080/02656736.2018.1522000] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Roger Olofsson Bagge
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Per Carlson
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Roya Razzazian
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Christoffer Hansson
- Department of Thoracic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Hjärpe
- Department of Thoracic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jan Mattsson
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Dimitrios Katsarelias
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
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8
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Belgrano V, Ben-Shabat I, Bergh P, Olofsson Bagge R. Isolated limb perfusion as a treatment option for rare types of tumours. Int J Hyperthermia 2016; 32:595-9. [PMID: 27269515 DOI: 10.1080/02656736.2016.1188999] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Isolated limb perfusion (ILP) is an established and effective treatment for advanced melanoma and soft tissue sarcomas of the extremities with a high overall response rate. The aim of this study was to describe our experience of ILP for more rare types of tumours. METHODS Patients with Merkel cell carcinoma (MCC) (n = 4), squamous cell carcinoma (SCC) (n = 2), B-cell lymphoma (n = 1), desmoid tumours (n = 3), pigmented villonodular synovitis (PVNS) (n = 1) and giant cell tumour (n = 1) were treated with ILP and analysed retrospectively. RESULTS The four patients with in-transit MCC had three complete responses (CR) and one partial response (PR); the two patients with SCC had one CR and one stable disease (SD); the patients with desmoid tumours had two PR and one SD. A CR was also observed for the patient with a giant cell tumour, but the patient with PVNS had a SD. The patient with cutaneous metastases of B-cell lymphoma showed a CR, however with rapid systemic progression. Local toxicity according to Wieberdink was grade II in 10 patients (83%) and grade III in two patients (17%). CONCLUSIONS These results show that ILP can be used as a treatment option also for more rare disease entities when other treatments have failed.
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Affiliation(s)
- Valerio Belgrano
- a Department of Surgery , Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg , Gothenburg , Sweden ;,b Department of Surgical Sciences and Integrated Diagnostics (DISC) , University of Genoa, IRCCS AOU San Martino-IST University-Hospital , Genoa , Italy
| | - Ilan Ben-Shabat
- a Department of Surgery , Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg , Gothenburg , Sweden
| | - Peter Bergh
- c Department of Orthopaedics , Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg , Gothenburg , Sweden
| | - Roger Olofsson Bagge
- a Department of Surgery , Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg , Gothenburg , Sweden
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9
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Smith H, Hayes A. The role of regional chemotherapy in the management of extremity soft tissue malignancies. Eur J Surg Oncol 2016; 42:7-17. [DOI: 10.1016/j.ejso.2015.08.165] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 08/06/2015] [Accepted: 08/15/2015] [Indexed: 10/23/2022] Open
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10
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Doyen J, Duranton-Tanneur V, Hostein I, Karanian-Philippe M, Chevreau C, Breibach F, Coutts M, Dadone B, Saint-Paul MC, Gugenheim J, Duffaud F, Pedeutour F. Spatio-temporal genetic heterogeneity of CTNNB1 mutations in sporadic desmoid type fibromatosis lesions. Virchows Arch 2015; 468:369-74. [PMID: 26666421 DOI: 10.1007/s00428-015-1883-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Revised: 10/13/2015] [Accepted: 11/17/2015] [Indexed: 01/10/2023]
Abstract
Desmoid type fibromatosis (DT) is a rare lesion of unclear pathogenesis that most often presents a mutation of the (β-catenin) gene. The natural history and clinical evolution are highly variable between patients and to date there is no consensus on optimal therapy. We report two cases of a patient with multiple DT lesions. Molecular investigations performed in both patients on multiple tumors at different anatomical sites revealed non-identical CTNNB1 mutations. The first patient was a 39-year-old man with a history of recurrent DT. In two of the DT lesions, three different mutations were found in codons 41 and 45, respectively. The lesions showed marked inflammatory features, characterized by IgG4 positive lymphoplasmacytic infiltrates and a foreign body reaction, which increased in intensity over time. The patient was eventually treated with a COX-2 inhibitor and the remaining mass was stabilized. In the two DT lesions of the second patient, CTNNB1 mutations S45P and T41A were found. The presence of different mutations in multiple focally recurrent sporadic DT lesions indicates that they do not have a clonal relationship. Our data suggest that a CTNNB1 mutation is a necessary event probably by providing a selective growth advantage. An IgG4 host antigen response is discussed as a potential predisposing factor for one of the patients.
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Affiliation(s)
- Jérôme Doyen
- Laboratory of Solid Tumours Genetics, Nice University Hospital, 28 Avenue de Valombrose, 06107, Nice, France. .,Institute for Research on Cancer and Aging of Nice (IRCAN), Nice, France. .,Department of Radiation Oncology, Antoine-Lacassagne Center, Nice, France.
| | - Valérie Duranton-Tanneur
- Laboratory of Solid Tumours Genetics, Nice University Hospital, 28 Avenue de Valombrose, 06107, Nice, France.,Institute for Research on Cancer and Aging of Nice (IRCAN), Nice, France
| | | | - Marie Karanian-Philippe
- Department of Biopathology, Institut Bergonié, Bordeaux, France.,INSERM U916, Bordeaux, France.,University of Bordeaux, Bordeaux, France
| | - Christine Chevreau
- Department of Medical Oncology, Institut Universitaire du Cancer Toulouse-Oncopôle, Toulouse, France
| | - Florence Breibach
- Department of Pathology, Institut Universitaire du Cancer Toulouse-Oncopôle, Toulouse, France
| | - Michael Coutts
- Central Laboratory of Pathology, Nice University Hospital, Nice, France.,Wells NHS Trust Maidstone Hospital Hermitage Lane, Maidstone, UK
| | - Bérengère Dadone
- Laboratory of Solid Tumours Genetics, Nice University Hospital, 28 Avenue de Valombrose, 06107, Nice, France.,Institute for Research on Cancer and Aging of Nice (IRCAN), Nice, France.,Central Laboratory of Pathology, Nice University Hospital, Nice, France
| | | | - Jean Gugenheim
- Department of Digestive Surgery and Center for Hepatic Transplantation, Nice University Hospital, Nice, France
| | - Florence Duffaud
- Medical Oncology Unit, CHU La Timone, Aix-Marseille University, Marseille, France
| | - Florence Pedeutour
- Laboratory of Solid Tumours Genetics, Nice University Hospital, 28 Avenue de Valombrose, 06107, Nice, France.,Institute for Research on Cancer and Aging of Nice (IRCAN), Nice, France
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11
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Colombo C, Baratti D, Kusamura S, Deraco M, Gronchi A. The role of hyperthermic intraperitoneal chemotherapy (HIPEC) and isolated perfusion (ILP) interventions in sarcoma. J Surg Oncol 2014; 111:570-9. [PMID: 25351775 DOI: 10.1002/jso.23808] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 08/13/2014] [Indexed: 01/28/2023]
Abstract
Locally advanced sarcomas in the extremity and in the retroperitoneum/abdominal cavity (peritoneal sarcomatosis, PS) can be managed administering chemotherapy locally using isolated limb perfusion (ILP) and hyperthermic intraperitoneal chemotherapy (HIPEC), respectively. In this review, the authors discuss the pros and cons of the use of these locoregional therapies in locally advanced soft tissue sarcoma, with a view to establishing their role in the multidisciplinary approach to these difficult diseases.
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Affiliation(s)
- Chiara Colombo
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
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12
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van Broekhoven DLM, Deroose JP, Bonvalot S, Gronchi A, Grünhagen DJ, Eggermont AMM, Verhoef C. Isolated limb perfusion using tumour necrosis factor α and melphalan in patients with advanced aggressive fibromatosis. Br J Surg 2014; 101:1674-80. [DOI: 10.1002/bjs.9659] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 08/07/2014] [Accepted: 08/21/2014] [Indexed: 11/07/2022]
Abstract
Abstract
Background
Aggressive fibromatoses (desmoid tumours) may be locally aggressive, but do not metastasize. Although a conservative approach is advocated for most patients, pain and functional impairment are indications for active treatment. Tumour necrosis factor (TNF) α and melphalan-based isolated limb perfusion (TM-ILP) is a limb-saving treatment modality for soft tissue tumours. This study reports the results of TM-ILP treatment in patients with aggressive fibromatosis.
Methods
Institutional databases of three European centres were searched. All patients who received TM-ILP treatment for aggressive fibromatosis between 1990 and 2012 were included. Before therapy, the patients were discussed at multidisciplinary tumour board meetings.
Results
Twenty-five patients received 28 TM-ILP treatments. The median age of patients was 28 (i.q.r. 19–34) years and median hospital stay was 8 (7–12) days. Median follow-up was 84 (34–114) months. A complete response was achieved after two TM-ILP treatments, and a partial response after 17 treatments in 16 patients. Stable disease was reported after eight treatments in seven patients, including a patient with stable disease after the first treatment and progression after the second TM-ILP. Toxicity was modest after most treatments; Wieberdink grade IV (extensive epidermolysis, and threatening or manifest compartment syndrome) was seen after two TM-ILP treatments. Systemic leakage was reported after one treatment, but did not lead to systemic toxicity. Functional outcome was good; 16 patients had no physical limitations, and six patients had some limitations but did not need medical aids. Amputation was prevented in all but three patients.
Conclusion
TNF-α-based ILP is effective in patients with aggressive fibromatosis.
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Affiliation(s)
- D L M van Broekhoven
- Department of Surgical Oncology, Erasmus Medical Centre Cancer Institute, Rotterdam, The Netherlands
| | - J P Deroose
- Department of Surgical Oncology, Erasmus Medical Centre Cancer Institute, Rotterdam, The Netherlands
| | - S Bonvalot
- Department of Surgical Oncology, Institut de Cancérologie Gustave Roussy, Paris, France
| | - A Gronchi
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - D J Grünhagen
- Department of Surgical Oncology, Erasmus Medical Centre Cancer Institute, Rotterdam, The Netherlands
| | - A M M Eggermont
- Department of Surgical Oncology, Erasmus Medical Centre Cancer Institute, Rotterdam, The Netherlands
- Gustave Roussy Cancer Campus Grand Paris, Villejuif, Paris, France
| | - C Verhoef
- Department of Surgical Oncology, Erasmus Medical Centre Cancer Institute, Rotterdam, The Netherlands
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13
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Seinen JM, Hoekstra HJ. Isolated limb perfusion of soft tissue sarcomas: A comprehensive review of literature. Cancer Treat Rev 2013; 39:569-77. [DOI: 10.1016/j.ctrv.2012.10.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2012] [Revised: 10/22/2012] [Accepted: 10/28/2012] [Indexed: 12/28/2022]
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14
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Redmond KC, Kuppusamy M, Nicholson AG, Searle A, Thomas M, Goldstraw P. Limb salvage surgery in the excision of a massive fibromatosis. Ann Thorac Surg 2011; 92:e53-5. [PMID: 21871256 DOI: 10.1016/j.athoracsur.2011.03.113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Revised: 03/08/2011] [Accepted: 03/17/2011] [Indexed: 11/24/2022]
Abstract
Fibromatosis is a rare fibroproliferative disorder with a tendency for local infiltrative and destructive growth. Local recurrence is frequent, despite apparent complete resection after radical excision. We present a case of a 22-year-old woman with massive recurrent thoracic fibromatosis extending into the neck and impairing the function of her right upper limb. This required a multidisciplinary approach to surgery to salvage the limb. The case highlights the fact that while every attempt should be made to achieve negative histologic margins, local recurrence is not uncommon. Therefore, if fibromatosis occurs adjacent to or involves vital structures, these should not be sacrificed to achieve negative margins. Function and structure preserving procedures are important as the primary goal, if not even more important.
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Affiliation(s)
- Karen C Redmond
- Department of Thoracic Surgery, Royal Brompton Hospital, London, United Kingdom
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15
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Sanki A, Kroon HM, Kam PCA, Thompson JF. Isolated limb perfusion and isolated limb infusion for malignant lesions of the extremities. Curr Probl Surg 2011; 48:371-430. [PMID: 21549235 DOI: 10.1067/j.cpsurg.2011.02.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Amira Sanki
- Senior Registrar in Plastic and Reconstructive Surgery, Sydney, Australia
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16
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Drouet A, Le Moigne F, Have L, Blondet R, Jacquin O, Chauvin F. Common peroneal nerve palsy following TNF-based isolated limb perfusion for irresectable extremity desmoid tumor. Orthop Traumatol Surg Res 2009; 95:639-44. [PMID: 19944662 DOI: 10.1016/j.otsr.2009.09.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2008] [Revised: 05/18/2009] [Accepted: 09/01/2009] [Indexed: 02/02/2023]
Abstract
Hyperthermic isolated limb perfusion (ILP) (2 mg, TNF-alpha and 100mg, melphalan) was performed for an irresectable right thigh desmoid tumor with calf extension in a 49-year-old man. The patient had a history of four resections since the age of 19 years. Local ILP toxicity appeared with extensive edema and common peroneal neurologic impairment including paresis that remained severe 10 months later. One of the most troublesome side effects of perfusion is peripheral nerve damage, which has been reported at a rate of between 1 and 48% of perfused patients. ILP is an effective treatment in recurrence situations or where resection threatens loss of function; it, however, requires administration in specialized centers, progress in standardization and close monitoring to avoid locoregional toxicity, the mechanisms of which merit further investigation. Emergency compartmental pressure measurement may indicate fasciotomy, can be of great interest.
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Affiliation(s)
- A Drouet
- Neurology Department, Desgenettes Military Teaching Hospital, 108, boulevard Pinel, 69275 Lyon cedex 3, France.
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17
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Revolutionizing the treatment of locally advanced extremity soft tissue sarcomas: a review on TNFα-based isolated limb perfusion. Eur Surg 2009. [DOI: 10.1007/s10353-009-0479-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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18
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de Bree E, Keus R, Melissas J, Tsiftsis D, van Coevorden F. Desmoid tumors: need for an individualized approach. Expert Rev Anticancer Ther 2009; 9:525-35. [PMID: 19374605 DOI: 10.1586/era.09.9] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Desmoid tumor, also known as aggressive fibromatosis or desmoid-type fibromatosis, is a rare monoclonal, fibroblastic proliferation arising in musculoaponeurotic structures. Although histologically benign, desmoids are often locally invasive and associated with a high local recurrence rate after resection. Since it is a heterogeneous disease, in particular regarding clinical presentation, anatomic location and biological behavior, treatment should be individualized to reduce local tumor control failure with concurrently acceptable morbidity and preservation of quality of life. Many issues regarding optimal treatment of desmoids remain controversial. However, wide surgical excision remains the treatment of choice, except when surgery is mutilating and is associated with considerable function loss or major morbidity. Involvement of surgical margins is probably associated with an increased risk of local recurrence. Postoperative radiotherapy results in a significant reduction of the local recurrence rate, but only in the case of involved surgical margins. Radiotherapy for gross disease is considerably effective, but is associated with a relatively high rate of complications, which are usually mild or moderate and radiation dose dependent. Radiotherapy should only be applied where anatomic constraints preclude complete resection and radiotherapy is not too toxic. Risk factors for local tumor control failure include young age, large size, presentation as recurrent disease, limb/girdle or intra-abdominal location, involved surgical margins, omission of radiotherapy, radiation dose less than 50 Gy and insufficient radiation field size. Increased comprehension of the pathogenesis and biological behavior of desmoids resulted in the emerging applicability of systemic therapies and a wait-and-see policy. Systemic treatment may be indicated in patients that have anatomic barriers to effective surgery or radiotherapy. Considering the significant morbidity of surgery and/or radiotherapy for certain locations, especially mutilation and loss of function, and the tumor's natural history, which is often characterized by prolonged periods of stability or even regression, a period of watchful waiting may compose the most appropriate management in selected asymptomatic patients. Attempts to complete eradication of the disease may be worse than the disease itself.
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Affiliation(s)
- Eelco de Bree
- Department of Surgical Oncology, Medical School of Crete University Hospital, PO Box 1352, 71110 Herakleion, Greece.
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19
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Isolated limb perfusion with TNF-alpha and melphalan in locally advanced soft tissue sarcomas of the extremities. Recent Results Cancer Res 2009; 179:257-70. [PMID: 19230545 DOI: 10.1007/978-3-540-77960-5_16] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Limb-sparing surgery has become all the more important in soft tissue sarcoma (STS) of the extremities since we learned that amputation does not improve survival of these patients. In bulky tumours, however, preoperative strategies to reduce tumour size are then required. Isolated limb perfusion (ILP) with tumour necrosis factor (TNF) has been developed as a biochemotherapeutic therapy to act both on the tumour-associated vasculature and on the tumour itself. It has shown to be a very potent treatment modality, as in early reports response rates were around 80%. Limb salvage could then be achieved in a quite similar percentage. Many confirmatory studies have been performed since, with consistent results even in patients with multiple tumours, after extensive radiotherapy or with metastatic disease, all at the cost of very limited toxicity. This chapter gives an overview of the ILP studies performed in patients with soft tissue limb sarcoma, discusses the mechanism of TNF-mediated vasculotoxic effects on tumour vasculature, and places TNF-based ILP in the multimodality treatment of these patients with extensive STS of the extremities.
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20
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21
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Stoeckle E, Coindre JM, Longy M, Binh MBN, Kantor G, Kind M, de Lara CT, Avril A, Bonichon F, Bui BN. A critical analysis of treatment strategies in desmoid tumours: a review of a series of 106 cases. Eur J Surg Oncol 2008; 35:129-34. [PMID: 18760561 DOI: 10.1016/j.ejso.2008.06.1495] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2008] [Revised: 06/19/2008] [Accepted: 06/17/2008] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The management of desmoid tumours, previously based on strategies employed for sarcomas, should be reassessed, given the morbidity of interventions used in their treatment. METHODS Long-term follow-up (median 123 months) of a series of 106 treated patients with 69 primary and 37 recurrent desmoids, in order to study natural history and outcome. RESULTS Desmoids typically evolved actively over a median period of 3 years, and stabilised thereafter. Recurrences or progression most commonly occurred between 14 and 17 months. Risk factors for recurrence were presentation (primary vs. recurrent), gender, tumour location and resection margins. However, survival was independent from these factors, with equivalent survival whether resection had been performed or not. Tumour control and functional outcome depended on location and presentation. Functional impairment was proportional to number of operations and whether patients had received radiotherapy. Recurrences were observed in 12/23 patients after radiotherapy. CONCLUSION Desmoids are relatively indolent tumours needing different approaches than sarcomas. Direct surgery is advisable only in primary lower trunk wall/girdle locations. Wait-and-see and medical treatment is preferable in other types of presentations.
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Affiliation(s)
- E Stoeckle
- Department of Surgery, Institut Bergonié, Regional Cancer Centre, Bordeaux Cedex, France.
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22
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Bonvalot S, Eldweny H, Haddad V, Rimareix F, Missenard G, Oberlin O, Vanel D, Terrier P, Blay JY, Le Cesne A, Le Péchoux C. Extra-abdominal primary fibromatosis: Aggressive management could be avoided in a subgroup of patients. Eur J Surg Oncol 2008; 34:462-8. [PMID: 17709227 DOI: 10.1016/j.ejso.2007.06.006] [Citation(s) in RCA: 199] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2007] [Accepted: 06/20/2007] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE To evaluate the impact of surgery as first-line treatment on event-free survival (EFS) of primary aggressive fibromatosis. PATIENTS AND METHODS Treatments were categorized into: surgery with or without radiotherapy and nonsurgical strategies with systemic treatment alone or wait and see policy. Eighty-nine patients had initial resection of their primary tumour followed by postoperative radiotherapy in 13 cases. Twenty-three did not undergo surgery but received systemic treatment or watch and wait policy. RESULTS Median follow-up was 76 months. Overall 3 years EFS was 49%. In the univariate analysis, patients with microscopically complete surgery had a similar outcome to patients in the no-surgery group (3 years EFS of 65% and 68%, respectively). Gender, age, tumour size, treatment period and strategy (surgery versus no-surgery) were not statistically significant. Quality of resection according to margins and the tumour site were the only prognostic factors. There was a significant correlation between tumour site and quality of surgery (p=0.0002). CONCLUSIONS A subset of patients with extra-abdominal fibromatosis could be managed with a nonaggressive policy, as growth arrest concerned 2/3 of nonoperated patients. When surgery is finally necessary, it should be performed with the aim of achieving negative margins.
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Affiliation(s)
- S Bonvalot
- Department of Surgery, Institut Gustave Roussy, 39 rue Camille Desmoulins, 94805 Villejuif, France.
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23
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Verhoef C, de Wilt JHW, Grünhagen DJ, van Geel AN, ten Hagen TLM, Eggermont AMM. Isolated limb perfusion with melphalan and TNF-alpha in the treatment of extremity sarcoma. Curr Treat Options Oncol 2007; 8:417-27. [PMID: 18066703 PMCID: PMC2781100 DOI: 10.1007/s11864-007-0044-y] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2007] [Accepted: 11/15/2007] [Indexed: 11/29/2022]
Abstract
Isolated limb perfusion (ILP) with chemotherapy alone has uniformly failed in the treatment of irresectable extremity soft tissue sarcomas. The addition of tumor necrosis factor-alpha (TNF-α) to this treatment approach contributed to a major step forward in the treatment of locally advanced extremity soft tissue sarcoma (STS). High response rates and limb salvage rates have been reported in multicenter trials, which combined ILP with TNF-α plus melphalan, which resulted in the approval of TNF-α for this indication in Europe in 1998. Subsequently a series of confirmatory single institution reports on the efficacy of the procedure have now been published. TNF-α has an early and a late effect; it enhances tumor-selective drug uptake during the perfusion and plays an essential role in the subsequent selective destruction of the tumor vasculature. These effects result in a high response rate in high-grade soft tissue sarcomas. This induction therapy thus allows for resection of tumor remnants some 3 months after ILP and thus avoidance of limb amputation. TNF-α-based ILP is a well-established treatment to avoid amputations. It represents an important example of tumor vasculatory-modulating combination therapy and should be offered in large volume tertiary referral centers.
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Affiliation(s)
- Cornelis Verhoef
- Department of Surgical Oncology, ErasmusMC-Daniel den Hoed Cancer Center, 310 Groene Hilledijk, 3075 EA, Rotterdam, The Netherlands.
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24
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Jeys LM, Grimer RJ, Carter SR, Tillman RM, Abudu A. Post Operative Infection and Increased Survival in Osteosarcoma Patients: Are They Associated? Ann Surg Oncol 2007; 14:2887-95. [PMID: 17653803 DOI: 10.1245/s10434-007-9483-8] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2006] [Accepted: 05/11/2007] [Indexed: 02/04/2023]
Abstract
BACKGROUND Despite neo-adjuvant chemotherapy osteosarcomas having significant mortality, recent studies have shown survival advantages following infections for some tumour types. This study investigates the effect of post-operative infection in patients treated for osteosarcoma using endoprosthetic replacement and neo-adjuvant chemotherapy. MATERIAL AND METHODS A consecutive series of 547 patients underwent surgery between 1981 and 2001 for osteosarcoma. Patients were excluded from the study if over 60 years old at diagnosis (n = 14) as they would not routinely receive chemotherapy. Studies showed that 70% of deep infections occur within one year from reconstruction. Therefore landmark analysis was performed; all patients infected after 12 months of reconstruction were excluded (15 patients, 2.7%) and those who died within 12 months from diagnosis due to metastases were excluded (105 patients, 19.2%), leaving 412 patients. Any survival advantage of early infection was analysed by Kaplan-Meier survival analysis from this landmark point. RESULTS Overall population survival was 65% at 10 years after landmarking. There were 41 patients (10%) who developed an infection within one year of implantation. These patients had significantly better survival (p = 0.017). The 10-year survival for patients with osteosarcoma with infection was 84.5% compared to 62.3% in the non-infected group after landmarking. There was no significant difference in the percentage post-chemotherapy specimen necrosis between the two groups (p = 0.36). Infection was an independent prognostic factor on cox regression analysis. CONCLUSIONS There was evidence for increased survival after deep post-operative infection in osteosarcoma patients, in keeping with other research. The authors feel this warrants further investigation.
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Affiliation(s)
- L M Jeys
- Royal Orthopaedic Hospital Oncology Service, Bristol Road South, Northfield, Birmingham, B31 2AP, United Kingdom.
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25
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Grünhagen DJ, de Wilt JHW, ten Hagen TLM, Eggermont AMM. Technology insight: Utility of TNF-alpha-based isolated limb perfusion to avoid amputation of irresectable tumors of the extremities. ACTA ACUST UNITED AC 2006; 3:94-103. [PMID: 16462850 DOI: 10.1038/ncponc0426] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2005] [Accepted: 12/14/2005] [Indexed: 01/12/2023]
Abstract
Isolated limb perfusion (ILP) with melphalan is effective in the treatment of small multiple melanoma intransit metastases and is utilized widely for this indication. The treatment is much less effective against bulky melanoma metastases and has uniformly failed in the treatment of irresectable extremity soft tissue sarcomas. The addition of tumor-necrosis factor-alpha (TNF-alpha) to this treatment approach has changed the situation dramatically. High response rates and limb-salvage rates have been reported in multicenter trials that combined ILP with TNF-alpha plus melphalan; these trials resulted in the approval of TNF-alpha for bulky melanoma metastases and soft tissue sarcomas in Europe in 1998. Subsequently, many doctors working in European centers have been trained, and a series of confirmatory reports from single institutions have now been published regarding the efficacy of the procedure. TNF-alpha has an early and a late effect; it enhances tumor-selective drug uptake during the perfusion, and plays an essential role in the subsequent selective destruction of the tumor vasculature. These effects result in a high response rate in bulky tumors, soft tissue sarcomas, bulky melanomas, and various other tumor types. This induction therapy therefore allows tumor remnants to be resected some 3 months after ILP thus avoiding limb amputation. TNF-alpha-based ILP is a well-established treatment that aims to avoid amputations regardless of the tumor size and type. It represents an important example of combination therapy that modulates the tumor vasculature and should be offered in high-volume tertiary referral centers.
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Affiliation(s)
- Dirk J Grünhagen
- Department of Surgical Oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, The Netherlands
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