Body weight and risk of soft-tissue sarcoma

Nutritional Predictors of Wound Infection in Patients with Lower Extremity Soft Tissue Sarcoma

BACKGROUND

Soft tissue sarcoma (STS) frequently requires high-risk surgery that predisposes patients to complex wounds. Past studies have identified a variety of tumor characteristics as risk factors for wound infection (WI); however, physiologic characteristics have not yet been studied in this population. Thus, the objective of this study is to identify any nutritional indicators and physiologic characteristics associated with the development of WI.

PATIENTS AND METHODS

633 patients from a large tertiary care center institution were identified with lower extremity STS removed from 1992 to 2017. The primary outcomes of interest were WI at patient's surgical site within 90 days of surgery and additional procedure due to wound infection. Patients' laboratory values, comorbidities, and other characteristics were assessed using multivariable analysis to determine risk factors for WI. Receiver operator characteristic (ROC) curves were used for analysis of plasma glucose and albumin levels to determine a useful risk threshold. Significance was determined to be p < 0.05.

RESULTS

Postoperative plasma glucose levels were significantly higher among patients with WI compared with those without (p < 0.001) and showed predictivity in ROC analysis (AUC 0.77, 95% CI 0.72-0.82). Preoperative albumin (p < 0.001) and prognostic nutritional index score (p = 0.002) were significantly lower among patients with WI. Partial thromboplastin time (PTT), international normalized ratio (INR), white blood cell count (WBC), and platelet count values had no effect on WI. Smoking elevated risk for WI (OR 1.64, p < 0.01). Significant risk factors were the same when assessed for those with WI undergoing additional procedures.

CONCLUSIONS

Postoperative plasma glucose levels, preoperative albumin levels, and smoking status are useful nutritional variables in predicting WI in STS excisional procedures.

The Impact of Obesity on Tumor Glucose Uptake in Breast and Lung Cancer

Obesity confers an increased incidence and poorer clinical prognosis in more than 10 cancer types. Paradoxically, obesity may provide protection from poor outcomes in lung cancer. Mechanisms for the obesity-cancer links are not fully elucidated, with altered glucose metabolism being a promising candidate. Using 18F-fluorodeoxyglucose positron-emission-tomography/computed tomography images from The Cancer Imaging Archive, we explored the relationship between body mass index (BMI) and glucose metabolism in several cancers. In 188 patients (BMI mean [SD] = 27.7 [5.1], range = 17.4-49.3 kg/m2), higher BMI was associated with greater tumor glucose uptake in breast cancer (r = 0.36; P = .02) and with lower tumor glucose uptake in non-small cell lung cancer (r = -0.26; P = .048) using two-sided Pearson correlations. No relationship was observed in soft tissue sarcoma or squamous cell carcinoma. Harnessing the National Cancer Institute's open-access database, we demonstrate altered tumor glucose metabolism as a potential mechanism for the detrimental and protective effects of obesity on breast and lung cancer, respectively.

Morbid Obesity Is Associated With an Increased Risk of Wound Complications and Infection After Lower Extremity Soft-tissue Sarcoma Resection

BACKGROUND

Obesity is associated with wound complications after lower extremity surgery. Excision of soft-tissue sarcomas is urgent, and unlike the elective surgery, obesity cannot be modified preoperatively. The purpose of this study was to evaluate the effect of obesity on treatment outcome.

METHODS

Six hundred fifty-three patients (343 men; mean age, 56 ± 18 years) with a lower extremity soft-tissue sarcoma were reviewed. The mean body mass index (BMI) was 27.1 ± 5.7 kg/m, with 189 obese patients (29%) having a BMI of ≥30 kg/m and 27 morbidly obese patients (4%) having a BMI of ≥40 kg/m. Complications and functional and oncologic outcomes were compared between groups.

RESULTS

Two hundred eighty-five patients (40%) sustained a postoperative complication, most commonly a dehiscence (n = 175; 24%) and infection (n = 147; 21%). On multivariate analysis, morbid obesity was associated with wound complications (P = 0.002) and infection (P = 0.01). Morbid obesity was not associated with local tumor recurrence (P = 0.56). No difference was found in the mean Toronto Extremity Salvage Score (P = 0.11) or Musculoskeletal Tumor Society (P = 0.41) scores between the groups.

DISCUSSION

Morbid obesity was associated with postoperative wound complications and infection. However, after surgery, obese patients can expect no difference in oncologic outcome, with an excellent functional result.

Plasma levels of polychlorinated biphenyls (PCB) and the risk of soft tissue sarcoma

BACKGROUND

Soft tissue sarcoma (STS) is a heterogeneous group of rare neoplasms whose aetiology is largely unknown. Dioxin and dioxin-like compounds, including 2,3,7,8-tetrachlorodibenzo-p-dioxin (2,3,7,8-TCDD) and polychlorinated biphenyls (PCBs), are potential risk factors for STS.

OBJECTIVES

To investigate the relation of 17 PCBs congeners, assessed in human plasma, with STS risk.

METHODS

We conducted a case-control study in Italy, including 52 STS cases and 99 hospital-based controls. Selected PCB were extracted by high-performance liquid chromatography (HPLC) and measured with gas chromatography-mass spectrometry (GC-MS). Odds ratios (OR), and the corresponding 95% confidence intervals (CI), were estimated through multivariate logistic regression models.

RESULTS

The most frequently detected PCB congeners were 138, 170, 180 and 149 (detected in 40-77% of controls). The OR for the sum of all 17 PCB congeners was 1.20 (95% CI 0.50-2.92). In categorical analysis no consistent association was found for individual congeners and for groups based on Wolff's classification or the degree of chlorination. For continuous estimates, borderline positive associations emerged for Wolff's groups 2A (OR 1.23, 95% CI 0.97-1.55), 2B (OR 1.34, 95% CI 1.00-1.77, and 3 (OR 1.19, 95% CI 0.96-1.49), for moderately (OR 1.20, 95% CI 0.96-1.51) and highly (OR 1.18, 95% CI 0.99-1.41) chlorinated PCBs, and for congeners 170 (OR 1.26, 95% CI 0.98-1.63), 180 (OR 1.26, 95% CI 0.97-1.64) and 138 (OR 1.45, 95% CI 1.02-2.04).

DISCUSSION

Most associations between PCBs and STS risk were not significant, but, given the limited sample size, we cannot exclude moderate associations.

Obesity is associated with larger soft-tissue sarcomas, more surgical complications, and more complex wound closures (obesity leads to larger soft-tissue sarcomas)

BACKGROUND AND OBJECTIVES

Does a link exist between obesity and soft-tissue sarcoma outcomes? We hypothesized that soft-tissue sarcomas in patients with obesity may lead to larger tumors at detection, with an increased risk for a more complex surgical excision, wound healing-related complications, higher stage at presentation, and decreased survival.

METHODS

One hundred thirty-nine and patients with soft-tissue sarcoma were retrospectively evaluated over 10 years. Patients were divided into 2 cohorts based on the World Health Organization body mass index (BMI) obesity grouping. A BMI ≥ 30 kg/m² was classified as obese and a BMI < 30 kg/m² was classified as nonobese.

RESULTS

Eighty-five nonobese and 54 obese individuals were evaluated. The median tumor diameter was 50% larger (P = .024) and the overall complication rate was 1.7-fold higher in patients with obesity (P = .0032). Patients with obesity also had a statistically significantly higher rate of complex wound closures. In multivariable logistic regression, obesity remained a highly significant factor favoring complications after the surgical treatment of soft-tissue sarcoma (odds ratio = 3.66, 95% confidence interval = 1.54-8.71; P = .0033). No statistically significant differences were noted on comparing groups for the incidence of metastatic spread or survival.

CONCLUSIONS

These findings suggest that obesity is associated with larger tumors, a higher incidence of wound complications, and greater use of complex wound-closure methods.

Obesity Does Not Exacerbate the Protumorigenic Systemic Environment in Sarcoma Subjects

Sarcomas are a rare but fatal tumor type that accounts for <1% of adult solid malignancies and ~15% of childhood malignancies. Although the use of immunotherapy is being actively investigated for other solid tumors, advances in immunotherapy for sarcoma patients are lacking. To better understand the systemic immune environment in sarcoma patients, we performed a detailed multiplex analysis of serum cytokines, chemokines, and protumorigenic factors from treatment-naive subjects with localized, high-grade sarcoma. Because obesity is a major healthcare issue in the United States, we additionally examined the effects of obesity on serum protein profiles in our sarcoma subject cohort. We found that the systemic host environment is profoundly altered to favor tumor progression, with epidermal growth factor, angiopoietin-2, vascular endothelial growth factor A, IL-6, IL-8, and MIP-1β all increased relative to tumor-free controls (all p < 0.05). Surprisingly, we found that obesity did not exacerbate this protumorigenic profile, as epidermal growth factor and IL-8 decreased with increasing subject body mass index (both p < 0.05 versus normal or overweight subjects). The Th2-related cytokines IL-4, IL-5, and IL-13 were also decreased in the presence of obesity. Thus, although the systemic environment in sarcoma subjects favors tumor progression, obesity does not further aggravate the production of protumorigenic factors.

Etiologic, environmental and inherited risk factors in sarcomas

Sarcomas are a rare group of mesenchymal tumors affecting a younger population. The etiology remains unknown in most cases. Environmental factors that increase sarcoma risk include radiation exposure and chemical carcinogens. Several familial cancer syndromes confer sarcoma predisposition, such as the Li-Fraumeni Syndrome (LFS). In this increasingly genomic focussed era of medicine, it will be clinically important to understand the genetic basis of sarcoma risk.

Obesity does not affect survival outcomes in extremity soft tissue sarcoma

BACKGROUND

Obesity is a growing epidemic and has been associated with an increased frequency of complications after various surgical procedures. Studies also have shown adipose tissue to promote a microenvironment favorable for tumor growth. Additionally, the relationship between obesity and prognosis of soft tissue sarcomas has yet to be evaluated.

QUESTIONS/PURPOSES

We sought to assess if (1) obesity affects survival outcomes (local recurrence, distant metastasis, and death attributable to disease) in patients with extremity soft tissue sarcomas; and (2) whether obesity affected wound healing and other surgical complications after treatment.

METHODS

A BMI of 30 kg/m(2) or greater was used to define obesity. Querying our prospective database between 2001 and 2008, we identified 397 patients for the study; 154 were obese and 243 were not obese. Mean followup was 4.5 years (SD, 3.1 years) in the obese group and 3.9 years (SD, 3.2 years) in the nonobese group; the group with a BMI of 30 kg/m(2) or greater had a higher proportion of patients with followups of at least 2 years compared with the group with a BMI less than 30 kg/m(2) (76% versus 62%). Outcomes, including local recurrence, distant metastasis, and overall survival, were analyzed after patients were stratified by BMI. Multivariable survival models were used to identify independent predictors of survival outcomes. Wilcoxon rank sum test was used to compare continuous variables. Based on the accrual interval of 8 years, the additional followup of 5 years after data collection, and the median survival time for the patients with a BMI less than 30 kg/m(2) of 3 years, we were able to detect true median survival times in the patients with a BMI of 30 kg/m(2) of 2.2 years or less with 80% power and type I error rate of 0.05.

RESULTS

Patients who were obese had similar survival outcomes and wound complication rates when compared with their nonobese counterparts. Patients who were obese were more likely to have lower-grade tumors (31% versus 20%; p = 0.021) and additional comorbidities including diabetes mellitus (26% versus 7%; p < 0.001), hypertension (63% versus 38%; p < 0.001), and smoking (49% versus 37%; p = 0.027). Regression analysis confirmed that even after accounting for certain tumor characteristics and comorbidities, obesity did not serve as an independent risk factor in affecting survival outcomes.

CONCLUSIONS

Although the prevalence of obesity continues to increase and lead to many negative health consequences, it does not appear to adversely affect survival, local recurrence, or wound complication rates for patients with extremity soft tissue sarcomas.

LEVEL OF EVIDENCE

Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Oral contraceptive use, parity, and constitutional characteristics in soft tissue sarcoma: a Swedish population-based case-control study 1988-2009

PURPOSE

The study was designed to investigate the influence of surrogate factors associated with sex (SH) and growth hormones (GH) on the risk of developing soft tissue sarcomas (STS).

BACKGROUND AND METHODS

The etiology of soft tissue sarcoma is largely unknown. We have studied the effect of hormone related factors on STS in the Swedish population between 1988 and 2009 using a population-based matched case-control design.

RESULTS

Our study is the largest on this topic to date, including 634 cases in a primary matched analysis and 855 cases in an unmatched sensitivity analysis. We identified protective effects connected to constitutional characteristics, hormonal and reproductive factors. Being shorter than your peers at age 11 was associated with an odds ratio (OR) of 0.51 (0.36-0.74). Having used oral contraceptives (OC), OR 0.75 (0.49-1.15), and high parity, OR 0.16 (0.04-0.63), comparing three or more children to two or less, also appeared to reduce the risk of STS. The risk was further reduced with the duration of OC use (p = 0.01), comparing use for 11 years or more to use for 3 years or less yielded an OR of 0.10 (0.02-0.41). No effect was observed for ever having had perimenopausal hormone therapy OR 1.02 (0.70-1.47). The effect of BMI varied significantly with subtype (p = 0.03) and tumor location (p < 0.001).

CONCLUSIONS

We observed surrogates of SH, GH, and insulin-like growth factor 1 to be associated with STS development. These findings are important as they may connect STSs to the group of hormone-dependent tumors, potentially revealing common treatment and prevention targets.

Ionizing radiation exposure and the development of soft-tissue sarcomas in atomic-bomb survivors

BACKGROUND

Very high levels of ionizing radiation exposure have been associated with the development of soft-tissue sarcoma. The effects of lower levels of ionizing radiation on sarcoma development are unknown. This study addressed the role of low to moderately high levels of ionizing radiation exposure in the development of soft-tissue sarcoma.

METHODS

Based on the Life Span Study cohort of Japanese atomic-bomb survivors, 80,180 individuals were prospectively assessed for the development of primary soft-tissue sarcoma. Colon dose in gray (Gy), the excess relative risk, and the excess absolute rate per Gy absorbed ionizing radiation dose were assessed. Subject demographic, age-specific, and survival parameters were evaluated.

RESULTS

One hundred and four soft-tissue sarcomas were identified (mean colon dose = 0.18 Gy), associated with a 39% five-year survival rate. Mean ages at the time of the bombings and sarcoma diagnosis were 26.8 and 63.6 years, respectively. A linear dose-response model with an excess relative risk of 1.01 per Gy (95% confidence interval [CI]: 0.13 to 2.46; p = 0.019) and an excess absolute risk per Gy of 4.3 per 100,000 persons per year (95% CI: 1.1 to 8.9; p = 0.001) were noted in the development of soft-tissue sarcoma.

CONCLUSIONS

This is one of the largest and longest studies (fifty-six years from the time of exposure to the time of follow-up) to assess ionizing radiation effects on the development of soft-tissue sarcoma. This is the first study to suggest that lower levels of ionizing radiation may be associated with the development of soft-tissue sarcoma, with exposure of 1 Gy doubling the risk of soft-tissue sarcoma development (linear dose-response). The five-year survival rate of patients with soft-tissue sarcoma in this population was much lower than that reported elsewhere.

A sarcoma at the site of previous extravasation of adriamycin

We report the case of a 66-year-old man presenting with a high-grade pleomorphic sarcoma at the left elbow 16 years after the extravasation of adriamycin given for a malignant ifbrous histiocytoma of the tibia.We suggest that this sarcoma originated in a multistep way over many years, out of the chronic inflammatory tissue that developed due to a non-specific cellular damage at the nuclear level, interfering with normal cell replication necessary for normal healing tissue healing. As a result, the non-healed chronic inflammatory tissue transformed over several years into a preneoplastic mesenchymal tumour and later into a high-grade pleomorphic sarcoma.

Relation of body mass index to cancer risk in 362,552 Swedish men

BACKGROUND

Obesity has been linked with increased risk for cancers of the colon, kidney, breast, endometrium and gallbladder. For other cancer sites, the relationship with obesity is less well quantified, and the effect of weight change on cancer risk is unclear.

METHODS

We examined the health records of 362,552 Swedish men who underwent at least one physical examination from 1971 to 1992, and were followed until death or the end of 1999. Incident cancer cases were identified by linkage to the Swedish cancer registry. Poisson regression models were used to estimate relative risks of cancer for both body-mass index (BMI) at baseline exam and, in a subgroup of 107,815 men, change in BMI after six years of follow-up, adjusting for age and smoking status.

RESULTS

Compared to men of normal weight, obese men had a significantly increased risk of all cancers combined (RR = 1.1; 95% CI = 1.0-1.2). The risks were most pronounced for esophageal adenocarcinoma (RR = 2.7; 95% CI = 1.3-5.6), renal cell carcinoma (RR = 1.8; 95% CI = 1.4-2.4), malignant melanoma (RR = 1.4; 95% CI = 1.1-1.7), and cancers of the colon (RR = 1.7; 95% CI = 1.5-2.0), rectum (RR = 1.4; 95% CI = 1.1-1.7), and liver (RR = 3.6; 95% CI = 2.6-5.0). Risk of esophageal squamous cell carcinoma was elevated for underweight men whose BMI was less than 18.5 (RR = 3.1; 95% CI = 1.1-8.3). An excess risk for cancers of the pancreas and connective tissue was observed only among nonsmokers. Compared to men whose weight remained stable, men with more than a 15% increase in BMI after six years of follow-up had an elevated risk of pancreas and renal cell cancers.

CONCLUSIONS

Obesity and weight gain increase the risk for several forms of cancer in men, and underscore the need for further study into carcinogenic mechanisms and preventive interventions.

Primary multidisciplinary management of extremity soft tissue sarcomas

Soft tissue sarcomas (STS) are a rare and heterogeneous group of malignancies that most commonly present as large painless masses deep in the muscular compartments of the extremities. Investigation and treatment of these patients must be undertaken at a tertiary referral unit. Staging studies must include a high-quality magnetic resonance imaging (MRI) scan of the local site and a computed tomography (CT) scan of the chest to investigate for possible metastatic disease. Review of biopsy material must be undertaken by an experienced musculoskeletal pathologist. Currently, histologic diagnosis and grade are assigned to the tumor, but in tumors such as synovial sarcoma and Ewing's family of tumors, molecular evaluation is becoming crucial for diagnostic, prognostic, and therapeutic reasons. Surgical resection of sarcomas with negative surgical margins remains the mainstay of treatment. Surgical treatment alone is indicated for small superficial masses that are not adjacent to bone or neurovascular structures. However, in large deep masses where surgical margins are likely to be close in order to preserve important neurovascular structures and bone, combined treatment using surgical resection and radiation results in acceptable local control rates and reasonable patient function. It is incumbent on the management team to decide on timing of radiotherapy as a practice. This decision is based on several factors but potential complications must be taken into account. In this regard the long-term effects on normal tissues must be considered. Functional outcome has become an essential consideration when recommending treatment. If promising techniques become available to reduce the incidence of wound complications or to decrease the dose of radiation to normal tissue, preoperative radiation should be considered in light of its lower incidence of long-term effects that result in reduction in patient function.

Cancer risk in women with previous breast cancer

BACKGROUND

Excess risks of several second neoplasms following breast cancer have been reported. However, these risks have still to be quantified.

PATIENTS AND METHODS

We considered 9,729 breast cancer patients registered by the Swiss Cancer Registries of Vaud and Neuchâtel (covering about 786,000 inhabitants) and followed up from 1974 to 1998.

RESULTS

Overall, 443 second primary neoplasms (other than second primary breast cancers) were observed versus 389 expected [standardised incidence ratio (SIR): 1.14; 95% confidence interval (CI) 1.04-1.25]. The SIRs were above unity for endometrium (SIR = 1.5), ovary (1.3), colorectum (1.1), gallbladder (1.4), cutaneous malignant melanoma (1.4), kidney (1.4), lymphomas (1.4) and leukaemias (1.2), as well as for selected tobacco-related neoplasms. The largest excess risk was found for soft tissue sarcomas (STS) with 10 cases observed versus 3.1 expected (SIR = 3.2; 95% CI 1.5-5.9). Of these, eight occurred in potentially irradiated areas.

CONCLUSIONS

This analysis confirms the existence of a modest excess in several neoplasms occurring after breast cancer. The substantial excess of STS confirms the strong association between irradiation and STS.

Menstrual and reproductive factors and risk of soft tissue sarcomas

BACKGROUND

Soft tissue sarcomas (STS) are a heterogeneous group of neoplasms whose etiology remains largely undefined. A role for female hormones in the development of STS has been suggested. To investigate this possibility, the authors analyzed data from a hospital-based case-control study conducted in Northern Italy between 1983 and 1998.

METHODS

Cases were 104 women aged < 79 years with incident STS who were admitted to the cancer institutes and major teaching and general hospitals. Controls were 505 women admitted to the same network of hospitals for acute, nonneoplastic, nongynecologic, and nonimmune-related conditions.

RESULTS

The multivariate odds ratio (OR) for women aged >/= 15 years compared with those aged < 12 years at menarche was 1.94 (95% confidence intervals [95% CI], 0.80-4.74). No association with STS risk was observed for menstrual cycle pattern, age at menopause, parity, and abortions. Late age at first pregnancy and birth were found to be related to an increased risk of STS, with an OR of 3.16 (95% CI, 0. 96-10.44) and 2.79 (95%% CI, 0.79-9.90) for women aged >/= 30 years at first pregnancy and birth compared with those aged < 20 years. The trend in risk was significant for age at first pregnancy. No relation with the risk of STS emerged for age at last birth and time since first or last birth.

CONCLUSIONS

The risk of STS was found to be weakly related to late age at first pregnancy or birth, but not to other menstrual and reproductive factors.