Systemic Adjuvant Chemotherapy for Soft Tissue Sarcomas of the Extremities

Long-Term Outcomes After Radiotherapy for Retroperitoneal and Deep Truncal Sarcoma

PURPOSE

To determine the long-term outcomes after multimodality treatment of retroperitoneal, pelvic, and deep truncal sarcomas and to identify the factors associated with local control (LC), distant metastasis (DM), and overall survival (OS).

METHODS AND MATERIALS

A total of 85 patients with retroperitoneal, pelvic, and deep truncal sarcomas were treated with radiotherapy (RT) between 1987 and 2005. A retrospective analysis of LC, DM, and OS was conducted using log-rank and Cox regression statistical methods.

RESULTS

The 2- and 5-year LC, DM, and OS rates were 66% and 51%, 38% and 58%, and 70% and 34%, respectively. Negative surgical margins and a higher radiation dose were associated with greater LC rates on both univariate and multivariate analyses, and female gender was significantly associated with greater LC on multivariate analysis only. None of the analyzed risk factors was significantly associated with DM, although patients with high-grade tumors showed a trend toward an increased risk of DM. Gross residual disease after resection and high tumor grade were associated with worse OS rates on univariate and multivariate analyses, and male gender was significantly associated with worse OS on multivariate analysis only. A time-dependent analysis of LC in relation to DM demonstrated that patients with local failure had a hazard ratio of 19.7 for DM compared with patients without local failure (p < 0.0001). Of the 85 patients, 5 and 8, respectively, had clinically significant acute and late toxicity.

CONCLUSION

The results of this study emphasize the importance of LC in patients with retroperitoneal sarcoma. Radiation dose escalation or radiosensitization strategies to enhance LC are warranted.

Immunization by particle-mediated transfer of the granulocyte-macrophage colony-stimulating factor gene into autologous tumor cells in melanoma or sarcoma patients: report of a phase I/IB study

The primary objective of this phase I study was to determine the safety of an autologous tumor vaccine given by intradermal injection of lethally irradiated granulocyte-macrophage colony-stimulating factor (GM-CSF) gene-transfected autologous melanoma and sarcoma cells. Secondary objectives included validation of the gene delivery technology (particle-mediated gene transfer), determining the host immune response to the tumor after vaccination, and monitoring patients for evidence of antitumor response. Sixteen patients were treated with either of two different doses of GM-CSF-treated tumor cells. One patient received treatment with both doses of tumor cells. No treatment-related local or systemic toxicity was noted in any patient. Patients administered 100% treated cells (i.e., with a preparation of tumor cells that had all been exposed to GM-CSF DNA transfection) had a more extensive lymphocytic infiltrate at the vaccine site than did patients given 10% treated cells (a preparation of tumor cells in which 10% had been exposed to GM-CSF transfection) or nontreated tumor. The generation of a systemic immune response to autologous tumor by a delayed-type hypersensitivity response to the intradermal placement of nontransfected tumor cells was noted in one patient. One patient had a transient partial response of metastatic tumor sites. The entire procedure, from tumor removal to vaccine placement, was accomplished in less than 6 hr in all patients. Four of 17 patient tumor preparations produced greater than 3.0 ng of GM-CSF per 10(6) cells per 24 hr in vitro. The one patient with greater than 30 ng of GM-CSF per 10(6) cells per 24 hr in vitro had positive DTH, a significant histologic inflammatory response, and clinically stable disease. This technique of gene transfer was safe and feasible, but resulted in clinically relevant levels of gene expression in only a minority of patients.

Treatment and local control of primary extremity soft tissue sarcomas

BACKGROUND AND OBJECTIVES

Modern series of adult extremity soft tissue sarcomas utilize combinations of modalities in all patients. Remaining questions: 1) is it necessary to strive for wide margins in the multimodality era; 2) to use adjuvant therapy in every high-grade sarcoma? 3) Does previous partial or marginal resection seriously interfere with the definitive resection?

METHODS

In a retrospective review of 194 extremity soft tissue sarcomas (1977-1994), limb preservation was possible in 181/194 (93%) of cases. Patients with narrow margins received adjuvant radiation. Some patients were referred after partial (n = 39) or "complete" (n = 63) excision.

RESULTS

Local recurrence was observed in 181/141 (13%) of patients treated with wide or compartmental resection, and in 10 of 42 (24%) of those treated with conservative resection plus radiation (P = 0.14). The 5-year survival rate for grade III, >/=5-cm sarcomas was not significantly different (P = 0.82) with adjuvant (46%) or without (48%) adjuvant systemic chemotherapy. Five-year survival varied (P = 0.0001) according to grade. Patients referred with partial, or "complete" (63%, 38/63, had residual tumor at reoperation) excision had a local recurrence rate of 8% and 6%, and 5-year survival rates of 75% and 84%, respectively.

CONCLUSIONS

1) It is important to strive for wide margins even when adjuvant radiation is intended. 2) When a wide margin is possible, adjuvant radiation may not be necessary. 3) Adjuvant systemic chemotherapy may be considered for high-grade tumors, preferably within a prospective protocol. 4) A partial or "complete" excision of the tumor before referral to a tertiary center does not appear to compromise the limb preservation, local control, or survival rates of these patients.

Anterior compartment resection of the thigh in soft-tissue sarcomas

AIMS

Soft-tissue sarcomas of the anterior thigh present technical problems due to the proximity of the femoral vessels, and the disability caused by a standard anterior compartment resection.

METHODS

We treated 44 consecutive patients with primary sarcomas in the anterior thigh with wide resection (n = 15), and modified (n = 26) or standard (n = 3) compartment resection. No patient had amputation as primary treatment.

RESULTS

The overall rate of local recurrence was 6/44 (14%). Local recurrence was observed in 1/3 patients with standard anterior compartment resection and 5/41 (12%) of those with wide excision or modified compartment resection. It was noted in 1/6 (17%) patients with adjuvant radiation and 5/38 (13%) of those treated with surgery alone. One of six patients with local recurrence required amputation. The 5-year survival rate was 66% varying significantly according to grade.

CONCLUSIONS

Limb preservation was possible in 98% of patients. Wide resection or modified compartment resection was feasible in the majority (93%) of patients resulting in improved function.

Resectability and survival in retroperitoneal sarcomas

BACKGROUND

Retroperitoneal sarcomas historically have presented difficulties in their management due to a high rate of unresectability, which affects the survival of these patients.

METHODS

We retrospectively reviewed the charts of 87 consecutive patients with retroperitoneal sarcomas treated in the period 1977-1994.

RESULTS

The resectability rate was 100% for the primary tumors (n = 55) and 87% for the locally recurrent tumors (n = 32). The 5-year survival rate was 63% (66% for the primary tumors and 57% for those with local recurrence). The 10-year survival rate was 46% (57% for primary tumors and 26% for those referred with locally recurrent tumor). The overall local recurrence rate was 31% (25% for the primary tumors and 41% for those referred with local recurrence); it was 56% after local excision and 15% after wide resection (p = 0.0003). The 10-year disease-free survival of patients with local excision (n = 25) was 7%, and that of patients with wide resection (n = 54) 59% (p = 0.0001).

CONCLUSIONS

The overall resectability rate of retroperitoneal sarcomas was 95%. Wide resection produced a significantly higher survival rate compared with that of local excision. The survival rate for the primary tumors, varying significantly with the histologic grade, approached the rate reported for primary soft-tissue sarcomas of the extremity.

Resectability of retroperitoneal sarcomas: a matter of surgical technique?

The management of retroperitoneal sarcomas has been hampered by the difficulty in complete resection, the resectability rate in the literature being about 53%. In a review of the last 88 consecutive patients with retroperitoneal sarcomas the resectability rate was 95%. At a mean follow-up of 48 months, the local recurrence rate was 17% following wide resection and 59% following local excision (P = 0.0002). For patients with minimum follow-up of 5 years, the local recurrence rate was 39% for those with primary tumours and 57% for those referred with local recurrence. Local recurrence diminished the rate of long-term survival. The 5- and 10-year survival rates for the primary retroperitoneal sarcomas (n = 55) were 66% and 57% and for those referred with locally recurrent sarcoma (n = 33) 57% and 26%, respectively. The 5-year survival rate varied significantly with the grade of the tumour, from 88% for Grade I to 44% for Grade III tumours (P = 0.006). In conclusion, with modern surgical techniques the resectability rate of retroperitoneal sarcomas is about 95%, and the survival rate of the primary tumours approximates that of the primary soft tissue sarcomas of the extremities.

Primary soft tissue sarcoma of the extremities in adults

The modern literature on adult extremity sarcoma implies that adjuvant therapy (usually irradiation) is mandatory for adequate local control, at least in patients with high-grade tumours undergoing limb-sparing procedures. In 152 primary extremity soft tissue sarcomas, wide or radical resection was employed (116 patients) including amputation in nine patients (6 per cent), or local excision followed by adjuvant postoperative radiation therapy (36). Local recurrence alone occurred in 5 per cent of patients, and in combination with distant metastases in 9 per cent. The total rate of local recurrence was 10 per cent after wide resection (with or without chemotherapy) and 25 per cent after conservative resection and radiotherapy (with or without chemotherapy). Limb sparing was possible in 94 per cent of patients. The majority (76 per cent) had surgical resection alone as local treatment with satisfactory results. Wide resection, when feasible, provides acceptable local control and may be preferable to local excision plus radiation therapy.