The biological significance of failure at the primary site on ultimate survival in soft tissue sarcoma

Tumor size and surgical margins are important prognostic factors of synovial sarcoma - A retrospective study

Background

Synovial Sarcoma (SS) is a rare soft tissue sarcoma. Mean time to get a SS diagnosis from the onset of symptoms is 10 years, furthermore, SS is associated with late metastasis. Surgery is the main treatment option, whose quality deeply affects SS outcomes, and it can be associated to preoperative or post-operative radiotherapy. Chemotherapy is considered very effective in Children, while in adults its efficacy is still under debate. The aim of this study was to investigate the oncologic results in SS treatment and to identify the risk factors for local and systemic control of the disease.

Methods

From 1994 to 2018, 211 patients affected by SS were treated in 3 Referral Centres of Orthopaedic Oncology. One hundred seventy-seven patients were included in the study, the median follow-up length was 96 months (5-374).

Results

Overall Survival on the Kaplan Meier Analyses was 80%, 70% and 56% at 5, 10 and 20 years. In multivariate analyses, OS correlated with tumour size and negative surgical margins. Chemotherapy use wasn't associated with better survival although patients who underwent CT had bigger and more aggressive tumours.

Conclusions

Our findings suggests that surgery with negative margins is the most important factor in Synovial Sarcoma. Adjuvant treatments as chemotherapy and radiation therapy didn't change the disease's course.

Re-excision after unplanned excision of soft tissue sarcoma: A systematic review and metanalysis. The rationale of systematic re-excision

In Soft Tissue Sarcomas (STS) referral centre many patients have already had an incomplete tumour resection. In the majority of specimen, tumoral residual is detected and linked to a worsen prognosis. Systematic surgical re-resection of the scar tissue area is often performed. Some authors suggested to postpone re-resections until a clinically evident local recurrence is detected. A searching strategy was applied to Pubmed-Central and Ovid Medline. Odds ratio (OR) for local recurrence (LR), distant metastasis (MTS) or overall survival (OS) were calculated comparing patients who had tumour residual to people who hadn't. OR of local recurrences, distant metastasis and OS were calculated in planned vs unplanned-excisions groups. OR to develop a metastasis and OS after a local recurrences were calculated. Residual tumour led to an OR for LR of 3,56, OR of MTS was 3,42; OR of decreased OS was 3,42. Having a LR lead to a OR of 1,55 for MTS and to a OR of decreased OS of 2,32. Patients who underwent a re-excision compared to planned surgery did not have an increased OR of LR and had an OR to develop a MTS of 0,56. Our data confirm that there is a strong correlation between local recurrences, distant relapses and overall survival. Although there is a selection bias; this analysis highlights the optimal oncological outcome in patients who underwent re-resection. The rationale for systematic re-resection after unplanned excision of soft tissue sarcomas is very strong and this treatment remains the gold standard of care in these patients.

Preoperative Factors Associated with Infiltrative Histologic Growth Patterns in Extremity Soft Tissue Sarcoma

Soft tissue sarcoma (STS) with an infiltrative histologic growth pattern, when compared to STS with an expansile pattern, may pose difficulties in local control. Preoperative assessment of the presence of infiltrative histologic growth pattern would be helpful in deciding treatment strategies. A review of 144 patients who underwent surgery for extremity STS was performed. Microscopically, the histologic growth pattern was defined as infiltrative if the penetration of the tumor cells into the surrounding tissue was observed. Possible clinicopathologic factors that might be associated with infiltrative histologic growth pattern were investigated with regard to patient demographics, tumor characteristics, and MRI findings. Of the 144 tumors, 71 (49%) showed infiltrative histologic growth pattern. On multivariate analysis, histological subtypes other than liposarcoma (OR = 4.57, p = 0.02) and infiltrative border on MRI (OR = 2.48, p = 0.01) were independent factors associated with infiltrative histologic growth pattern. Predictive index based on these two factors showed a significant improved accuracy (ROC-AUC = 0.647) for predicting infiltrative histologic growth pattern compared to either factor alone. Our data suggests that liposarcoma histology and tumor border on MRI can predict histologic growth pattern in extremity STS.

Clear cell sarcoma of soft tissue: a retrospective review and analysis of 31 cases treated at Istituto Ortopedico Rizzoli

INTRODUCTION

Clear cell sarcoma (CCS) of soft tissue is a rare melanocytic soft tissue sarcoma with different cytogenetic and natural history than that of melanoma. Objective of this study was to determine outcome predictors in patients treated in our Institute. This objective included the effectiveness of surgical intervention and disease progression after surgery.

MATERIALS AND METHODS

Thirty-one patients were diagnosed at our institute with clear cell sarcoma through tissue pathology and immunohistochemistry. Patients received multimodality treatment (surgery, radiotherapy and chemotherapy). Five-year survival rates and prognostic predictors were determined.

RESULTS

Sixteen patients were males and 15 females with a median age of 37 years (8-72-years). Twenty-eight tumors were located in extremities and 3 in the trunk area. Eight patients had metastases at their first presentation (6 local lymph nodes and 2 pulmonary metastases). Five and ten-year disease-specific survival rates were 56% and 41%. Two-year disease-specific survival rates for lymph node and pulmonary metastasis groups were 40% and 0%. All metastatic patients died within 5 years follow-up. Five and ten-year disease-specific survival rates for localized tumor cases were 72% and 53%. Male gender, less than 30-years of age, trunk tumor location and size greater than 5 cm were poor prognostic factors according to univariate analysis. Tumor location in the trunk was the only negative prognostic determinant in multivariate model.

CONCLUSIONS

Although surgical treatment may be beneficial for tumors without systemic involvement, new chemotherapeutic agents and molecular targeted therapy should be implemented to improve the oncologic outcome in both early and late stage disease.

Dendritic cell immunotherapy in soft tissue sarcoma

Soft tissue sarcomas represent a rare but diverse family of tumors affecting patients of all ages. Conventional chemotherapy rarely eradicates metastatic disease and newer targeted agents are successful in only very specific histologic subgroups. Therefore, scientists and clinicians are investigating immunotherapy techniques, primarily involving cellular immunity focused on the T-cell response to tumor antigens. In both animal models and human sarcoma trials, dendritic cells have been shown to induce an effective antitumor immune response. Radiotherapy, particularly when delivered in a hypofractionated manner prior to sarcoma excision, may potentiate the function of the dendritic cells through the induction of apoptosis. The synergistic effect may carry over to other cancer types and warrants further multidisciplinary investigation.

Do surgical margin and local recurrence influence survival in soft tissue sarcomas?

BACKGROUND

Established prognostic factors influencing survival in soft tissue sarcomas include tumor stage, histopathologic grade, size, depth, and anatomic site. The presence of tumor near or at the margin of resection increases the risk of local recurrence but whether a positive surgical margin or local recurrence affect overall survival is controversial.

QUESTIONS/PURPOSES

We explored the impact of microscopic margin on local recurrence, metastasis, and overall survival in patients with intermediate- to high-grade soft tissue sarcomas of the extremities. We then determined whether local recurrence decreases overall survival.

METHODS

We retrospectively reviewed the medical records of 248 patients who had soft tissue sarcomas of the extremities treated surgically from 1995 to 2008. We estimated survival, local recurrence, and distant metastasis and examined factors potentially influencing these outcomes. The minimum followup was 0.4 years (median, 4.4 years; range, 0.4-13 years).

RESULTS

The 5-year cumulative incidence of local recurrence was 4.1%. Patients who presented with positive margins or a margin of 2 mm or less had a worse survival than patients who had margins of greater than 2 mm and wide margins (5-year survival, 47% versus 70% and 72%). In addition to surgical margin, developing metastasis, tumor response of less than 90% necrosis, high histopathologic grade, high AJCC stage (Stage III), increasing age, and male gender were associated with decreased overall survival. Local recurrence independently predicted decreased overall survival.

CONCLUSIONS

Microscopic surgical margin and local recurrence after surgical treatment should be included as risk factors predicting decreased overall survival for intermediate- to high-grade soft tissue sarcomas of the extremities.

The impact of previous surgical manipulation of subcutaneous sarcoma on oncologic outcome

We prospectively followed 106 consecutive patients referred for surgical treatment of nonmetastatic subcutaneous soft tissue sarcoma to assess whether prior surgical manipulation had an impact on local control and/or disease-free survival. 10 patients had no previous surgical treatment; 11 had only a previous biopsy, 75 had a previous attempted excision, and 10 were referred after the tumor had recurred locally. Histologic grade was inversely associated with overall survival and disease-free survival. Of the 75 patients with previous attempted excision, 22 (29%) had gross residual disease, 27 (36%) had microscopic residual disease, and 26 (35%) had no identifiable residual disease. The 5-year metastasis-free survival was 88%. Local control was obtained in 100% of patients without previous surgical manipulation, 89% of those with previous surgery, and 60% of those who were referred after a local relapse had been recognized. Cox proportional hazards analysis revealed that larger tumor size negatively impacted disease-free survival in those patients who were treated with previous attempted excision. Of those patients with tumors 4 cm or larger and a previous unplanned sarcoma excision, disease-free survival was lower than in those patients referred without previous attempted excision.

LEVEL OF EVIDENCE

Prognostic study, Level I-2 (prospective study). See the Guidelines for Authors for a complete description of levels of evidence.

Primary adult soft tissue sarcoma: time-dependent influence of prognostic variables

PURPOSE

To define prognostic factors for postrelapse survival and their time-dependent influence for adult soft tissue sarcoma (STS).

PATIENTS AND METHODS

We analyzed 2,123 patients with completely resected localized primary STS treated from 1982 to 1999. Variables studied included tumor site, size, depth, grade, and resection margin but not treatment other than resection. Landmark time frames were used to assess the influence of disease-free interval (DFI) on disease-specific survival (DSS). DSS was estimated with the Kaplan-Meier method. Univariate and multivariate analyses were performed using log-rank test and the Cox proportional hazards regression model. Time-dependent stepwise regression analysis evaluated the time-dependent influence of each variable.

RESULTS

Two thirds of recurrences developed within 2 years of initial resection. Tumor size (P <.001), grade (P <.001), and microscopic resection margin (P <.001) independently predicted DSS for all STS. Size and grade independently predicted early (DFI <or= 3 years) and margin late (DFI > 3 years) DSS. Risk of tumor-related death was the same across all sites 3 years postresection and decreased significantly for extremity/trunk STS when DFI exceeded 3 years (P <.001). Influence of initial high-risk factors for tumor-related mortality in extremity/trunk STS decreased by 40% 3 years postresection, but their influence over DSS for non-extremity/trunk sites remained constant over time. Likelihood of complete resection after recurrence (all sites) increased with DFI (9% and 33% for DFI < 6 and > 36 months, respectively).

CONCLUSION

Tumor size, grade, and resection margin predict outcome for completely resected STS, and their influence for DSS is time- and site-dependent. The influence of prognostic factors changes over the natural history of extremity/trunk STS. Time to recurrence exerts significant influence over complete resection rates for recurrent disease.

Additional wide resection of malignant soft tissue tumors

Forty-five patients with soft tissue sarcomas received additional wide resections after they were treated with simple excision by a primary physician. Of the patients in the current study, 26 were male and 19 were female; all were treated between 1986 and 1998 for malignant soft tissue tumors. The mean followup was 7.1 +/- 3.4 years. The mean time from first excision to additional wide resection was 8 weeks, and for 90% of the patients it was within 12 weeks. In deciding the surgical margin for an additional operation, enhanced computed tomography scans and magnetic resonance images were done. Four (8.8%) patients had local recurrences that required a second resection and had no evidence of disease at latest followup. Four (8.8%) patients had distant metastases but did not have local recurrences. Three patients died of lung metastases. The overall 5-year survival rate of the patients was 93%, and the overall 5-year disease-free rate was 84%. It seems that tumors treated adequately by wide resection in an additional operation have results as good as tumors treated with a primary wide resection.

Management of soft-tissue sarcomas: an overview and update

Soft-tissue sarcomas (STS) are relatively uncommon, especially when considered as individual histological subtypes (of which there are more than 50). Their incidence increases with age, although they are disproportionately common among children. When diagnosed and managed in a non-specialist environment, outcome is generally significantly poorer than if patients are managed by a multidisciplinary team in a tertiary centre of excellence. Prompt referral of patients with clinically suspicious masses is strongly advocated, before any type of intervention is attempted. This brief, opinion-based overview emphasises the team approach and provides a synopsis of the strategies used at our institution for pre-operative assessment and biopsy, surgical management, and the delivery of radiation therapy when appropriate (focusing on limb preservation and optimisation of function). Predictable variations in the natural history of these tumours, based on accurate histological subclassification, merit wider recognition. The role of systemic chemotherapy for soft-tissue sarcoma is still evolving, but at present the main aims are improved local control, disease-free survival, and quality of life. There are overall survival benefits for specific histological types, but this is a relatively small subgroup. Novel therapies, based on disease mechanisms at the molecular level, show promise for future advances.