Surgery with curative intent is associated with prolonged survival in patients with cutaneous angiosarcoma of the scalp and face -a retrospective study of 38 untreated cases in the Japanese population

Clinical outcomes of scalp or face angiosarcoma treatment with intensity-modulated radiotherapy: a multicenter study

Combined modality therapy, including radiotherapy (RT), is a common treatment for scalp or face angiosarcoma. Although intensity-modulated radiotherapy (IMRT) can deliver homogeneous doses to the scalp or face, clinical data are limited. This multicenter study aimed to evaluate scalp or face angiosarcoma treated with definitive or post-operative IMRT. We retrospectively analyzed data from patients who received IMRT for scalp or face angiosarcoma at three institutions between January 2015 and March 2020. Local control (LC) rate, overall survival (OS), progression-free survival (PFS), recurrence patterns and toxicity were evaluated. Fifteen patients underwent IMRT during the study period. Definitive RT was performed on 10 patients and post-operative RT was performed on 5 patients. The 1-year LC rate was 85.7% (95% confidence interval [CI], 53.9-96.2%). The 1-year OS and PFS rates were 66.7% (95% CI, 37.5-84.6%) and 53.3% (95% CI, 26.3%-74.4%), respectively. Univariate analysis revealed that a clinical target volume over 500 cm3 was associated with poor LC. Distant metastasis was the most common recurrence pattern. All patients experienced Grade 2 or 3 radiation dermatitis, and five patients experienced grade ≥ 3 skin ulceration. One patient who underwent maintenance therapy with pazopanib developed Grade 5 skin ulceration. Fisher's exact test showed that post-operative RT was significantly associated with an increased risk of skin ulceration of grade ≥ 3. These results demonstrate that IMRT is a feasible and effective treatment for scalp or face angiosarcoma, although skin ulceration of grade ≥ 3 is a common adverse event in patients who receive post-operative RT.

John M. Cutaneous head and neck angiosarcoma: The 30-year UCLA experience

Background

Cutaneous angiosarcoma is an aggressive tumor commonly found in the head and neck region. There is no consensus regarding the definitive treatment for angiosarcoma.

Methods

This was a retrospective chart review that evaluated 64 patients from 1983 to 2019. Demographic and clinical variables were examined for impact on recurrence using the time to recurrence and the overall survival in Kaplan-Meier curves.

Results

Average age at diagnosis was 71 (32-95) years, with a 2.8 male: female ratio. Surgery was utilized in 62% of patients, with mean defect size of 11.4 ± 8.1 cm. Recurrence was found in 70% of patients, and mean time to recurrence was 15.3 ± 12.3 months. Decreased recurrence was associated with use of intraoperative frozen section analysis (p = .036) and negative margins (p = .086). Two-year overall survival was 80%, and recurrence free survival was 30%.

Conclusions

Negative margins are associated with decreased recurrence, and intraoperative frozen section analysis may be considered to obtain preliminary surgical margins.Level of Evidence: 4.

Recurrence of scalp angiosarcoma after multiple surgeries: A case report and literature review

Scalp angiosarcoma (SA) is rare, accounting for <1% of soft tissue sarcomas, with a high degree of malignancy, a high recurrence rate and a poor prognosis. The best treatment strategy is uncertain. Therefore, it is essential to continuously refine treatment strategies and improve the prognosis of patients. Curative-intent surgery increases overall survival in patients with primary cutaneous angiosarcoma of the scalp and face, and radiation therapy combined with chemotherapy is now recommended for the curative treatment of patients who both can or cannot undergo surgery. The present case report is of an 87-year-old man hospitalised for the fifth time with SA. He had experienced four recurrences and previously underwent curative-intent surgery four times. However, the patient did not undergo radiotherapy or chemotherapy after any of the surgeries. A detailed report of the management of this case is presented along with a review of the relevant literature. It is hypothesised that patients with SA should receive a combination of radiotherapy and chemotherapy after surgery whenever possible, which may improve patient prognosis.

Utility of Multimodal Treatment Protocols in the Management of Scalp Cutaneous Angiosarcoma

Cutaneous angiosarcomas are rare, aggressive tumors with high recurrence and poor prognosis. We share our experiences with the challenging surgical management of these lesions, focusing on both ablative and reconstructive outcomes.

Methods

Retrospective cross-sectional chart review was conducted of patients diagnosed with scalp cutaneous angiosarcoma between 2005 and 2021. Resectability, defect reconstruction, and survival outcomes were analyzed.

Results

Thirty patients were included, 27 (90%) men and three (10%) women, with a mean age at diagnosis of 71.77 ± 7.3 years, and mean follow-up of 429.43 ± 305.6 days. Only 12 patients completed their regular follow-up, while the remaining patients died. There was a median survival of 443.50 days (range, 42-1283) and median time to recurrence of 21 days (range, 30-1690). Multimodal therapy compared with surgery alone had a significantly better overall median survival (468 days versus 71 days; P = 0.021). Defect coverage was obtained in 24 cases (75%) through an anterolateral thigh flap, two patients (6%) with a local transposition flap, and one patient (3%) with a transverse rectus abdominis myocutaneous flap. The remaining three patients received a skin graft. All of the flaps survived, with one requiring a vein graft for venous congestion.

Conclusions

Timely multimodal therapy with a histologically safe margin, combined with adjuvant therapy, improves survival and delays recurrence and metastasis, in cutaneous angiosarcoma patients. An anterolateral thigh flap facilitates the coverage of wide defects. Further investigations of advanced treatment modalities such as immunotherapy and/or gene therapy are required to deal with this highly aggressive tumor.

Clinical significance of local control of primary tumour in definitive radiotherapy for scalp angiosarcomas

INTRODUCTION

Scalp angiosarcoma is a rare and aggressive cancer. Definitive radiotherapy is a treatment option for localised scalp angiosarcoma patients. Although definitive surgical resection reportedly prolongs overall survival (OS), whether initial local treatment effect affects OS when definitive radiotherapy is administered is unclear. Therefore, this study analysed whether local recurrence within 6 months of irradiation correlates with OS and cancer-specific survival (CSS). Furthermore, how local control affects patients' quality of life was investigated.

MATERIALS AND METHODS

Thirty-one localised scalp angiosarcoma patients who had received definitive radiotherapy at our institution between October 2010 and July 2021 were analysed retrospectively. The most commonly used dose fractionation was 70 Gy in 35 fractions (83.9%). Local recurrence within 6 months of radiotherapy and other clinical factors were examined in univariate and subsequent multivariate analyses for correlation with OS and CSS.

RESULTS

The median follow-up period was 16 months (range, 6-45 months). Local recurrence was detected in 16 patients (51.6%), 12 of whom had recurrence within 6 months. In multivariate analyses, the presence of local recurrence within 6 months of radiotherapy was significantly associated with OS and CSS (p = 0.003, 0.0001, respectively). Ten of the 16 patients with local recurrence had severe symptoms such as bleeding, pain, difficulty opening the eye and malodour.

CONCLUSIONS

The initial local treatment effect was significantly associated with OS and CSS after definitive radiotherapy. Furthermore, local recurrence after radiotherapy resulted in a variety of symptoms, including bleeding and pain, which reduced the patient's quality of life.

Tumor microenvironment and its clinicopathological and prognostic associations in surgically resected cutaneous angiosarcoma

PURPOSE

Cutaneous angiosarcoma (CAS) is a rare but typically aggressive malignant vascular neoplasm of the skin. Tumor microenvironment (TME) of CAS and its associations with baseline clinicopathological features and patient outcomes are very important, especially when considering the recent advances in understanding of the tumor biology.

METHODS/PATIENTS

We retrospectively reviewed medical records of patients who underwent surgical resection for CAS at a tertiary Hospital. The pretreated specimens were evaluated by immunohistochemistry for programmed cell death protein 1 (PD-1) and its ligand (PD-L1), densities of tumor infiltrative lymphocytes (TILs) (CD3+, CD4+, CD8+, CD45RO+, FoxP3+), as well as c-MYC and Ki-67 expressions. Overall survival (OS) was estimated by Kaplan-Meier method and compared with Log-rank test.

RESULTS

A total of 21 CAS patients were identified. Median age was 67 (ranges: 20-81) years, 14 (66.7%) were male, and over 50% had lesions of scalp. Histopathological examination showed a predominantly spindle cell type (57.1%). All patients underwent surgery, 16 (76.2%) were treated further. PD-L1 was positively stained (> 1%) in tumor cells (42.9%) and TILs (23.8%). PD-1 expression (> 1%) was identified in TILs of 11 (52.4%) cases. PD-1/PD-L1 expressions were significantly associated with the higher densities of CD3+, CD4+, CD8+, CD45RO+, and Foxp3+ TILs, but not with patient characteristics or c-MYC or Ki-67 expression. Median OS was 18.5 months (95% CI 6.0-35.9), although no prognostic significance was observed with respect to any clinicopathological features.

CONCLUSION

We characterized TME and its clinical and prognostic association in CAS. PD-1/PD-L1 expressions were significantly associated with TILs subtypes but not with OS.

Prognostic factor analysis of definitive radiotherapy using intensity-modulated radiation therapy and volumetric modulated arc therapy with boluses for scalp angiosarcomas

Cutaneous angiosarcomas is a rare cancer with poor prognoses. The common radiotherapy techniques that have been reported so far are two pairs of lateral X-ray and electron fields. However, it is quite difficult to irradiate scalp angiosarcomas (SAs) homogeneously with this technique. In this study, safety, effectiveness, and risk factors were assessed for localized SAs ≥ 5 cm treated with intensity-modulated radiotherapy (IMRT) or volumetric modulated arc therapy (VMAT) with boluses. Sixty-eight angiosarcoma patients who had received radiotherapy in our institution between January 2007 and November 2020 were retrieved from our radiotherapy database. Of these patients, 27 localized SA patients were included in the retrospective analysis. The 2-year overall survival, local progression-free rate, and distant metastases-free survival were 41.8%, 48.4%, and 33.1%. All the patients experienced acute radiation dermatitis ≥ grade 2, with18 (66.7%) ≥ grade 3. No nodule lesion was a significant unfavorable predictive factor of acute radiation dermatitis ≥ grade 3. Tumor bleeding at the initiation of radiotherapy and tumor invasion to the face were significant predictive factors of overall survival, and tumor bleeding at the initiation of radiotherapy was also a significant predictive factor of local progression-free rate.

Cutaneous angiosarcoma: A case report

INTRODUCTION

Angiosarcoma is a very rare malignancy, which varies based on the location and organ affected. A clinicopathological form of cutaneous angiosarcoma (CAS) involves the head: scalp, face, and neck. We report a 59-year-old female patient with CAS on the temporoparietal region of the scalp.

CASE PRESENTATION

The patient presented with lesions in the head area, which appeared suddenly in the last 6 months, (before her surgery). Excision was performed under general anesthesia for bleeding as indicated on the right temporal region. The excision procedure was carried out three times at various stages, and then closed with skin grafts. Pathological examination of the three excised tissues showed progression, leading to CAS. Based on the clinical picture and anatomical assessment, a consultation with the surgical oncology department was necessary for further treatment.

DISCUSSION

Angiosarcoma has a high rate of progression. The onset of lesions, which are difficult to detect, does not often lead to progression. Other macroscopic features appear as bluish macules, which can be perceived as bruising. Wide surgical resection is the optimal treatment and is usually combined with radiotherapy and/or chemotherapy. This patient underwent gradual excision, based on bleeding in the right temporal lesion, along with progressive pain.

CONCLUSION

Surgical is the preferred management for our patients. Determination of multimodality therapy as treatment for CAS requires assessment of all factors related to age and patient condition. Follow-up evaluation is carried out after palliative therapy - to observe the general condition of the patient, tumor progression, tendency for metastases, and excision of any remaining lesions.

The Effectiveness of Different Treatment Modalities of Cutaneous Angiosarcoma: Results From Meta-Analysis and Observational Data From SEER Database

Introduction

Cutaneous angiosarcoma (cAS) is an aggressive vascular tumor that originates from vascular or lymphatic epithelial cells. To date, the cAS literature has been limited in a small number with single-center experiences or reports due to its rarity and the optimal treatment strategy is still in dispute. This study aimed to conduct a systematic review and compare the effect of available treatments retrieved from observational studies and Surveillance, Epidemiology, and End Results (SEER) program.

Methods

The authors performed a systematic review in the PubMed, Embase and MEDLINE database identifying the researches assessing the treatment for cAS patients. Clinical and treatment information of patients who had been diagnosed with a primary cAS were also obtained from the SEER program.

Results

Thirty-two studies were eligible but only 5 of which with 276 patients were included in meta-analysis since the unclear or unavailable information. The risk ratio of 5-year death for surgery, surgery with radiotherapy and surgery with chemotherapy were 0.84, 0.96, and 0.69. Meanwhile, in SEER database, there are 291 metastatic and 437 localized patients with cAS. The localized patients receiving surgery showed a significantly worse overall survival result when compared with the surgery combined with RT: hazard ratio: 1.6, 95% confidential interval: 1.05, 2.42, P = 0.03.

Conclusion

In conclusion, our study provided a detailed picture of the effectiveness of present treatments for localized and metastatic cAS patients. The CT could be inappropriate in localized patients. For metastatic patients, the surgery combined RT was recommended compared with surgery alone since its enhanced OS prognosis. Yet, more novel-designed clinical trials with specific targeted populations and rigorous conducting are needed for a solid conclusion on which would be a better treatment strategy.

A single-arm confirmatory trial of pazopanib in patients with paclitaxel-pretreated primary cutaneous angiosarcoma: Japan Clinical Oncology Group study (JCOG1605, JCOG-PCAS protocol)

Background

Paclitaxel is a standard of care for patients with primary cutaneous angiosarcoma of the scalp and face. However, no standard second-line treatment for paclitaxel-resistant patients has ever been established. Since primary cutaneous angiosarcoma expresses a high level of vascular endothelial growth factor receptor, the multitargeted tyrosine kinase inhibitor pazopanib seemed to be the most promising agent, and several retrospective studies have demonstrated its activity against this disease. However, the efficacy and safety of pazopanib in paclitaxel-resistant patients with primary cutaneous angiosarcoma have never been evaluated in a clinical trial.

Methods

In February 2018 the Dermatologic Oncology Group of Japan Clinical Oncology Group started a single-arm confirmatory trial to evaluate the efficacy and safety of pazopanib as a second-line treatment for patients with primary cutaneous angiosarcoma whose disease was resistant to paclitaxel or who were unable to tolerate paclitaxel (JCOG1605, JCOG-PCAS). Patients with primary cutaneous angiosarcoma not associated with lymphedema or radiation, progressing despite first-line paclitaxel monotherapy are included in the study. No prior systemic chemotherapy other than paclitaxel is permitted. Pazopanib is administered orally at an initial dosage of 800 mg once daily. Dose modifications for adverse events are made according to the dose reduction criteria described in the protocol. Treatment is continued until recurrence, disease progression, unacceptable toxic effects, patient refusal, or death. The primary endpoint is progression-free survival, secondary endpoints include overall survival, response rate, disease control rate, adverse events, and serious adverse events. We plan to recruit 30 participants in 5.5 years from 23 Japanese institutions. The follow-up period is set as 1 year after completion of accrual. The study protocol was approved by the Japan Clinical Oncology Group Protocol Review Committee in December 2017. Ethical approval for this study was granted by Ethics Committee of each institute.

Discussion

If the primary endpoint is met, pazopanib will be regarded as a standard of care for paclitaxel-resistant patients for whom no standard second-line treatment is established.

Trials registration

Registry number: UMIN000031438 [http://www.umin.ac.jp/ctr/index.htm]. Date of Registration: 23/Feb/2018. Date of First Participant Enrollment: 8/Mar/2018.

Prognostic Determinants Analysis and Nomogram for Bone Malignant Vascular Tumors: A Surveillance, Epidemiology and End Results (SEER) Analysis

Background

The aim and objective of our investigations were to explore the prognostic value of various clinical and pathological factors of bone malignant vascular tumors and establish a nomogram for their outcome predictions.

Material/Methods

All data of primary bone malignant vascular tumors (MVTs) patients were randomly selected from the Surveillance, Epidemiology and End Results (SEER) database. However, selected patients were clinically diagnosed with various cancers during 1988–2015. The potential prognostic factors were analyzed using SPSS (Windows, version 22.0). All prognostic factors were combined to formulate a nomogram to predict the overall survival (OS).

Results

A total of 266 selected patients were included in our study. In the univariate model, age (P<0.001), sex (p=0.0255), primary site (P<0.001), surgery (P<0.001), histologic type (P<0.001), metastasis (p=0.000), and pathological grade (P<0.001) were statistically significant for patient survival. The results of Cox analysis revealed that age (≥64) HR: 3.636, 95% CI [1.955–6.762], p=0.000, the primary site in skull HR: 2.6, 95% CI [1.584–4.268], p<0.001], without surgery HR: 1.473 95% CI [1.239–1.751], p<0.001, metastasis HR: 3.076 95% CI [1.983–4.771] p=0.000, man HR 1.802, 95% CI [1.032–3.004], p=0.045, and high malignant grade HR: 3.029, 95% CI [2.101–4.366], p=0.003 were independent unfavorable prognostic factors. Angiosarcoma had highest mortality rate among all vascular malignancies. The nomogram predicting overall survival achieved a C-index of 0.694 (95% CI 0.631, 0.745) in the SEER cohort.

Conclusions

Surgery can significantly increase OS survival time for bone MVTs, and low-grade malignancy is a significant factor for OS. However, advanced age, tumor metastasis, primary site in skull, AS, and male sex are predictors of poor prognosis.

Reirradiation for Recurrent Scalp Angiosarcoma: Dosimetric Advantage of PBT over VMAT and EBT

Purpose

Reirradiation in the scalp area can be challenging given the proximity to organs at risk (OARs), such as the eye and brain. Our aim is to evaluate the dosimetric differences of volumetric modulated arc therapy (VMAT) and electron beam therapy (EBT) compared with 3-dimensional proton beam therapy (PBT).

Patients and Methods

We evaluated a patient with recurrent angiosarcoma of the left temporal scalp after prior surgical resections and radiation therapy to 60 Gy in 30 fractions who needed reirradiation. We generated VMAT, EBT, and PBT plans using the Pinnacle Treatment Planning System (TPS). Both VMAT and EBT plans used a skin bolus, whereas no bolus was used for the proton plan. Doses to the OARs, including cochlea, eyes, lens, lacrimal glands, optic nerves, optic chiasm, pituitary gland, and underlying brain, were compared.

Results

The reirradiation treatment dose was 60 Gy(RBE). Target volume coverage was comparable in all plans. Compared with VMAT and EBT, the PBT plan showed reductions in mean and maximum doses to all OARs. Without the use of protons, several OARs would have exceeded dose tolerance utilizing VMAT or electrons. Dose reduction of up to 100% was achieved for central and contralateral OARs.

Conclusion

Compared with VMAT and EBT, PBT resulted in dose reductions to all OARs, while maintaining excellent target coverage. PBT showed a significant advantage in treating superficially located skin cancers, such as angiosarcoma, without the need for a bolus. PBT can be considered in the upfront treatment and certainly in the reirradiation setting.

Regional Lymph Node Metastasis of Scalp Angiosarcoma: A Detailed Clinical Observation Study of 40 Cases

BACKGROUND

The incidence of lymph node metastasis (LNM) of angiosarcomas is reported to be less than 15%, and elective neck management has not been indicated. This study evaluated the incidence and pattern of regional LNM in patients with scalp angiosarcomas using the clinical data of its full course to understand time-event sequences of scalp angiosarcomas.

METHODS

This retrospective study included all consecutive cases of pathology-confirmed angiosarcomas and analyzed 40 cases of scalp angiosarcomas. The survival plots were estimated using the Kaplan-Meier method, and the results are presented mainly in a descriptive manner.

RESULTS

The overall survival rate for the patients was 35.8% at 2 years. In contrast to previous reports, regional LNM was observed in more than half of the patients (52.5%) with scalp angiosarcoma. Meanwhile, a direct spread to distant organs occurred in only 27.5% of the patients. Regional LNM could predict clinical manifestation of systemic disease within 3 to 6 months. No differences in survival rates between patients with and without LNM were observed in this series. Occurrence of LNM seemed to be correlated with a high mitotic rate of primary tumors, but not with tumor grade or tumor dimension. The first-echelon lymph nodes from scalp angiosarcoma were peri-parotid, post-auricular, and level 2 lymph nodes.

CONCLUSIONS

For a localized scalp angiosarcoma, it seems reasonable for initial curative surgery to include prophylactic evaluation of regional lymph nodes for pathologic nodal staging, prognosis estimation, and the decision for systemic treatments.

IGF2BP3 (IMP3) expression in angiosarcoma, epithelioid hemangioendothelioma, and benign vascular lesions

Background

Insulin-like growth factor-2 messenger RNA-binding protein 3 (IGF2BP3 or IMP3) is an oncofetal protein that is expressed in various cancer types, and its expression is often associated with poor prognosis. IGF2BP3 expression has not been fully settled in vascular lesions.

Methods

We evaluated the expression of IGF2BP3 in malignant (angiosarcoma and epithelioid hemangioendothelioma [EHE]) and benign (hemangioma, granulation tissue cappilaries, and pyogenic granuloma) vascular lesions using immunohistochemistry. IGF2BP3 expression was scored as negative (0% of endothelial/neoplastic cells), equivocal (1–25%), or positive (> 26%).

Results

Eight of 30 (26.7%) cases of angiosarcoma and two of five (40%) cases of epithelioid hemangioendothelioma were positive for IGF2BP3. In contrast, hemangiomas (10 cases) and granulation tissue capillaries (12 cases) were all negative for IGF2BP3, and some cases of pyogenic granuloma (six of 14 cases) was scored as equivocal. In angiosarcoma, IGF2BP3 expression was independent of age, gender, location, morphological pattern, prognosis, presence of metastatic foci, and PD-L1 expression.

Conclusions

IGF2BP3 is a useful marker to distinguish between malignant and benign vascular lesions.

Clinical outcomes in primary scalp angiosarcoma

Scalp angiosarcoma is a rare, extremely aggressive cutaneous malignancy with poor patient prognosis. The present study reviewed the cases of 42 patients who presented scalp angiosarcoma and were treated at the Zhongshan Hospital of Fudan University between January 2002 and December 2013. The clinical characteristics, demographics, treatment regimens and outcomes of patients were analyzed, and the overall survival (OS) and recurrence-free survival (RFS) rates were calculated. A total of 42 patients were examined in this study. Surgery was the most common therapeutic measure, and was performed in 39 patients, alone (12 patients), in combination with chemotherapy (14 patients), radiotherapy (6 patients) or 3-modality-therapy (7 patients). The median follow-up time of patients was 28.5 months. The 5-year OS rate was 19%, and the 5-year RFS rate was 10%. Taken together, the results of the present study suggested that patients whose tumor presented a nodular localized lesion had a significantly improved OS rate (P=0.0078). Patients aged ≥70 years were associated with a lower 5-year OS (P=0.0071) and RFS rates (P=0.0095) vs. patients aged <70 years. Different treatments were not identified to be significantly associated with an improved OS or RFS. The present results also indicated that if the tumor presented nodular localized lesions, the patients exhibited a better prognosis than those with a diffuse lesion. Although younger patients had better clinical outcomes, the likelihood of recurrence and mortality remained high for all patients.

Cutaneous Angiosarcoma of Head and Neck - A Single-Centre Analysis

BACKGROUND:

Cutaneous angiosarcoma of the head and neck region is a subtype of cutaneous angiosarcoma with an unfavourable prognosis. Diagnosis is often delayed.

PATENTS AND METHODS:

The setting is an Academic Teaching Hospital Skin Cancer Center. Eight Caucasian patients could be identified, 5 men and 3 women. Delay to diagnosis was between 12 to 4 months (mean 7.8 ± 2.9 months). The diagnosis was confirmed in all cases by histopathology and immunohistochemistry. Hematoxylin-eosin, Giemsa, PAS, iron and reticulin stains were performed. Endothelial markers such as CD31, CD34, and Ki67 for proliferation assessment were used in all tumours. Other markers used included pan-cytokeratin (CK), CK7, CK20, ERG, CD 40 and c-MYC. Tumours were classified as localised versus multifocal or diffuse form. Tumour staging was performed according to the 8th edition of the AJCC. The mean age of patients was 79 years ± 26.4 years. The male to female ratio was 1.7. Tumour classification was diffuse in 2 patients, multilocular in one and localised in 5 patients. In 5 of 8 patients, a multimodal treatment was performed, one had radiotherapy alone, in another patient surgery was performed, and radiotherapy is planned. The mean OS was 26.4 months ± 24.5 months.

CONCLUSION:

Cutaneous angiosarcoma of the head and neck is an aggressive tumour with a poor prognosis. Although surgery remains a cornerstone of treatment, the tumour size at first presentation may be too large, and the elderly patients maybe not suitable for extensive surgery. Therefore, multimodal treatment with adjuvant radiotherapy and/ or chemotherapy is necessary. Multimodal treatment offers a better outcome than radiotherapy or chemotherapy alone. Stealth liposomal encapsulated doxorubicin is a therapeutic option for elderly patients with improved safety compared to conventional doxorubicin.