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Röper B, Heinrich C, Kehl V, Rechl H, Specht K, Wörtler K, Töpfer A, Molls M, Kampfer S, von Eisenharth-Rothe R, Combs SE. Study of Preoperative Radiotherapy for Sarcomas of the Extremities with Intensity-Modulation, Image-Guidance and Small Safety-margins (PREMISS). BMC Cancer 2015; 15:904. [PMID: 26573139 PMCID: PMC4647667 DOI: 10.1186/s12885-015-1633-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 08/28/2015] [Indexed: 11/17/2022] Open
Abstract
Background The aim of the trial is to demonstrate that with the use of modern IMRT/IGRT and reduction of safety margins postoperative wound complications can be reduced. Methods/ Design The trial is designed as a prospective, monocentric clinical phase II trial. The treatment is performed with helical IMRT on the Tomotherapy HiArt System© or with RapidArc© IMRT as available. All treatments are performed with 6 MV photons and daily online CT-based IGRT. A dose of 50 Gy in 2 Gy single fractions (5 fractions per week) is prescribed. Restaging including MRI of the primary tumor site as well as CT of the thorax/abdomen is planned 4 weeks after RT. PET-examinations or any other imaging can be performed as required clinically. In cases of R1 resection, brachytherapy is anticipated in the 2nd postoperative week. Brachytherapy catheters are implanted into the tumor bed depending on the size and location of the lesion. Surgery is planned 5–6 weeks after completion of neoadjuvant RT. All patients are seen for a first follow-up visit 2 weeks after wound healing is completed, thereafter every 3 months during the first 2 years. The endpoints of the study are evaluated in detail during the first (2 weeks) and second (3 months) follow-up. Functional outcome and QOL are documented prior to treatment and at year 1 and 2. Treatment response and efficacy will be scored according to the RECIST 1.1 criteria. A total patient number of 50 with an expected 20 % rate of wound complications were calculated for the study, which translates into a 95 % confidence interval of 10.0-33.7 % for wound complication rate in a binomial distribution. Discussion The present study protocol prospectively evaluates the use of IMRT/IGRT for neoadjuvant RT in patients with soft tissue sarcomas of the extremity with the primary endpoint wound complications, which is the major concern with this treatment sequence. Besides complications rates, local control rates and survival rates, as well as QOL, functional outcome and treatment response parameters (imaging and pathology) are part of the protocol. The data of the present PREMISS study will enhance the current literature and support the hypothesis that neoadjuvant RT with IMRT/IGRT offers an excellent risk-benefit ratio in this patient population. Trial registration NCT01552239
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Affiliation(s)
- Barbara Röper
- Department of Radiation Oncology, Klinikum rechts der Isar, Ismaninger Straße 22, 81675, München, Germany.
| | - Christine Heinrich
- Department of Radiation Oncology, Klinikum rechts der Isar, Ismaninger Straße 22, 81675, München, Germany.
| | - Victoria Kehl
- Department of Biometrics, Institut für Medizinische Statistik und Epidemiologie, Technische Universität München (TUM), Ismaninger Strasse 22, 81675, München, Germany.
| | - Hans Rechl
- Department of Orthopaedic Surgery, Klinikum rechts der Isar, Ismaninger Strasse 22, 81675, München, Germany.
| | - Katja Specht
- Department of Pathology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, 81675, München, Germany.
| | - Klaus Wörtler
- Department of Radiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, 81675, München, Germany.
| | - Andreas Töpfer
- Department of Orthopaedic Surgery, Klinikum rechts der Isar, Ismaninger Strasse 22, 81675, München, Germany.
| | - Michael Molls
- Department of Radiation Oncology, Klinikum rechts der Isar, Ismaninger Straße 22, 81675, München, Germany
| | - Severin Kampfer
- Department of Radiation Oncology, Klinikum rechts der Isar, Ismaninger Straße 22, 81675, München, Germany
| | | | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Ismaninger Straße 22, 81675, München, Germany. .,Institute of Innovative Radiotherapy (iRT), Department of Radiation Sciences (DRS), Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764, Neuherberg, Germany.
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Styring E, Billing V, Hartman L, Nilbert M, Seinen JM, Veurink N, Vult von Steyern F, Rydholm A. Simple guidelines for efficient referral of soft-tissue sarcomas: a population-based evaluation of adherence to guidelines and referral patterns. J Bone Joint Surg Am 2012; 94:1291-6. [PMID: 22810399 DOI: 10.2106/jbjs.k.01271] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Optimal treatment of soft-tissue sarcoma requires multidisciplinary management at a sarcoma center. However, these rare tumors are often misinterpreted as benign and many are inadequately treated outside a sarcoma center, with an increased risk of local recurrence that often requires further extensive surgical treatment. To improve referral and centralization of soft-tissue sarcoma management in the southern Sweden health care region, an open-access outpatient clinic at our sarcoma center and simple referral guidelines have been established for the past thirty years. The guidelines call for referral of all deep-seated soft-tissue tumors and of all ≥5-cm superficial tumors before open biopsy or surgery. We evaluated adherence to these guidelines and characterized referral patterns. We also studied the consequences of our strategy with regard to the relative numbers of benign and malignant diagnoses among referred patients. METHODS Adherence to guidelines, referral pathways, and time to referral to the sarcoma center were analyzed in a population-based series of 100 consecutive patients with soft-tissue sarcoma in the extremities or trunk wall. We also analyzed diagnosis and management of benign and malignant tumors in a second cohort consisting of 464 consecutive patients referred to the sarcoma center because of a soft-tissue tumor. RESULTS Ninety-seven of the 100 patients with soft-tissue sarcoma were referred to the sarcoma center. All fifty-eight of the deep-seated soft-tissue sarcomas and twenty-eight of the forty-two superficial tumors were referred before open biopsy or surgery. Three-quarters of the patients with soft-tissue sarcoma first presented to a general practitioner. One-quarter of these patients were directly referred to the sarcoma center, which cut the referral time in half compared with patients initially referred to a local hospital. One-quarter of all patients referred to the outpatient clinic were diagnosed with a malignancy, with the majority of the malignancies being soft-tissue sarcoma. CONCLUSIONS Our simple referral guidelines and open-access outpatient clinic resulted in nearly complete referral of patients with soft-tissue sarcoma to the sarcoma center. The "excess work" associated with referral of benign tumors according to our strategy was limited to the diagnosis of three benign tumors for each malignant tumor. We consider this surplus evaluation of benign tumors acceptable and probably necessary to achieve a high referral rate of soft-tissue sarcoma before initial surgery. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- E Styring
- Departments of Orthopedics, Institute of Clinical Sciences, Skåne University Hospital in Lund, SE-22185 Lund, Sweden
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Zhou H, Chen CB, Lan J, Liu C, Liu XG, Jiang L, Wei F, Ma QJ, Dang GT, Liu ZJ. Differential proteomic profiling of chordomas and analysis of prognostic factors. J Surg Oncol 2010; 102:720-7. [DOI: 10.1002/jso.21674] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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