The treatment of soft-tissue sarcomas of the extremities: prospective randomized evaluations of (1) limb-sparing surgery plus radiation therapy compared with amputation and (2) the role of adjuvant chemotherapy

Short-term morbidity following primary closure, skin grafting and flap reconstruction after surgical resection of extremity soft-tissue sarcomas: Pushing the limits of limb preservation

INTRODUCTION

Understanding short-term morbidity following extremity soft-tissue sarcoma (ESTS) treatment remains complex due to diverse findings and the absence of a standardized wound complication assessment. This retrospective cohort study evaluated short-term morbidity following primary closure, skin grafting, and flap reconstruction.

MATERIALS AND METHODS

All ESTS patients treated in a sarcoma center in the Netherlands from 1-1-2010 until 1-8-2022 were included. Short-term morbidity, defined as a wound complication following surgery, was assessed by the Toronto Sarcoma Flap Score (TSFS). The TSFS is an ordinal scale, where 0 indicates the absence of complications, while 10 signifies reconstructive failure necessitating amputation. Hospital stay duration and readmission rates were also analyzed.

RESULTS

Limb preservation was achieved in 128 (97.7 %) of 131 patients. Wound complications occurred in 43 (44.3 %) of patients with primary closure, 8 (57.1 %) with skin grafting and 16 (80.0 %) with flap reconstruction, p = 0.01. Patients undergoing flap reconstructions had higher TSFSs (6 [IQR 7], versus 0 [IQR 3] for primary closure and 3 [IQR 6] for skin grafting), longer duration of hospital stays (14 [IQR 18] days versus 4 [IQR 3] days for primary closure and 5 [IQR 7] days for skin grafting, p < 0.01) and were more frequently readmitted (40.0 %, versus 17.5 % for primary closure and 21.4 % for skin grafting, p = 0.09).

CONCLUSION

High limb preservation rates were achieved. Reconstructive surgery allows for the closure of extensive soft-tissue defects following ESTS resection, but it adds to surgical complexity. Patients undergoing flap reconstruction seem to be at a higher risk of short-term morbidity.

Hypofractionated Preoperative Radiation Therapy for Extremity and Superficial Trunk Soft Tissue Sarcomas: Results of a Prospective, Phase 2 Trial

PURPOSE

Preoperative radiation therapy (RT) for resectable extremity soft tissue sarcomas has historically been delivered over 5 weeks and associated with a 35% major wound complication (WC) rate. We investigated the rate of WC in a cohort of soft tissue sarcoma patients treated with a moderately hypofractionated course of preoperative RT.

METHODS AND MATERIALS

MC1973 was a single-arm, prospective, phase 2, noninferiority trial completed at Mayo Clinic in Minnesota and Arizona. We administered preoperative RT to 42.75 Gy in 15 fractions. Patients underwent standard of care tumor resection afterward. The primary endpoint was a major WC occurring within 120 days of surgery. Wilcoxon Rank Sum tests, Fisher Exact tests, and Conchran-Armitage Trend tests were used to evaluate associations with WC. Kaplan-Meier analysis was used to report early survival-associated outcomes.

RESULTS

Between November 24, 2020 and January 30, 2024, 120 patients enrolled on trial. One patient withdrew before receiving treatment. Most common tumor location was proximal lower extremity (48.7%). After RT, 117 patients (97.5%) underwent tumor resection. Two patients treated with RT came off study before surgery because of death. A major WC developed in 27 of 117 patients (23.1%). Median time to WC resolution was 17.4 weeks. The rate of persistent WC at 6 months was 26%. On univariate analysis, leiomyosarcoma histology (n = 5) correlated with a higher WC rate (60%). Median follow-up was 21.1 months. Fourteen patients experienced acute grade 3 adverse events. One year disease-free survival was 86.0% (95% CI, 79.7%-92.9%). Two patients developed local recurrence. One fracture was observed.

CONCLUSIONS

The major WC rate was 23.1% with a preoperative regimen of 42.75 Gy in 15 fractions. This suggests moderate hypofractionation is not inferior compared with historical standards of major WC rate. Additional follow-up will allow evaluation of oncologic outcomes, long-term treatment-associated adverse events, and patient-reported outcomes.

Local Control in Soft Tissue Sarcomas

Soft tissue sarcoma is a rare heterogeneous group of tumors made up of over 100 histologic types and subtypes. Expert pathology review is crucial to confirm the correct diagnosis prior to treatment. Multidisciplinary discussion and management at an expert center is strongly recommended given the many nuances of treatment. Wide resection +/- preoperative radiotherapy is recommended in most extremity and trunk wall STS patients, while a minority may also require perioperative medical therapy. Macroscopic complete resection remains the standard of care for retroperitoneal sarcoma patients, with preoperative radiotherapy recommended in selected histologic types.

Reconstruction of elbow flexion after sarcoma excision by a unipolar pedicled latissimus dorsi flap

INTRODUCTION

The latissimus dorsi flap is widely used in plastic surgery for covering the upper limb but also for reconstruction the function of the elbow or shoulder. We describe a case of a sarcoma of the anterior compartment of the arm, the surgical removal then the covering and reconstruction of the elbow flexion. This case was carried out by a unipolar pedicled flap of the latissimus dorsi.

MATERIAL AND METHODS

Three steps were performed (excision, flap preparation and flap fixation). The functional results (muscle strength, MRC scale) and range of motion (ROM) were analyzed. We performed a small literature review to compare the results.

RESULTS

A complete excision (R0) was carried out with a good vitality of the latissimus dorsi flap. A rapid scarring was obtained, allowing an early start of adjuvant radiotherapy. Muscular strength was 33% less compared to preoperative, MRC scale was classified 4. ROM of the elbow was rated at -10/0/130. One year after the operation, the patient is still in remission.

CONCLUSION

Our functional results are comparable to those found in the literature. The muscle strength in our case appears to be superior, probably linked to a brachio-radialis muscle still functional. No difference in function has been found in the literature between a unipolar or a bipolar transfer of the latissimus dorsi. This case report confirms the reliable and effective nature of the latissimus dorsi flap. The use of this flap for reconstruction after sarcoma surgery has only few reports in the literature.

The Landmark Series: Neoadjuvant Radiotherapy in Extremity Soft Tissue Sarcoma-The Way to Hypofractionation

For patients with nonmetastatic soft tissue sarcoma (STS) who are at high risk of local recurrence, the standard of care for limb-conserving local management is combined radiotherapy and surgery. Radiotherapy for STS entails 5 weeks of conventionally fractionated radiotherapy (25 × 2 Gy) preoperatively or 6 or more weeks postoperatively. There is growing interest in the use of preoperative hypofractionated regimes, viz. shorter courses with higher daily doses, for STS. Recent studies have investigated ultrahypofractionation (UHF, ≥ 5 Gy per fraction) and moderate hypofractionation (MHF, > 2 Gy but < 5 Gy per fraction) for STS. Regimens that are designed to be isoeffective for tumor control indeed result in equivalent local relapse-free survival. However, as the daily dose increases, the impacts to normal tissues and potential for toxicities increase owing to differences in fraction-size sensitivity between STS and normal tissues (e.g., skin, subcutaneous tissue, vascular structures, and bone). This article reviews the key studies informing the debate about hypofractionation for STS. We evaluate the current data that reveal relatively small patient cohorts, short follow-up time, and inconsistent toxicity reporting. A randomized, controlled investigation of conventional fractionation, MHF, and UHF is needed. The current phase 2 data confirm that any such study should have co-primary endpoints of both local relapse-free survival as well as immediate- and long-term toxicities because the fundamental question being investigated with significant increase in daily fraction size while maintaining isoeffective total dose (~ 50 Gy equivalent) is: what are the dose impacts to late-responding normal tissues that may result in decrements to physical functioning for patients?

The Impact of Surgical Margin Distance on Local Recurrence and Survival in Patients with Soft Tissue Sarcoma

Background and Objectives: The primary objective of surgeons treating bone and soft tissue sarcomas (STS) is to achieve optimal local tumor control, ensuring a tumor-free margin and preventing local recurrence. However, the impact of surgical resection margin status on extremity STSs remains an area that requires further exploration. Therefore, this study aims to investigate the effects of surgical resection margin status on both local recurrence and overall survival rates. Materials and Methods: One hundred and eighty-five patients who underwent surgical resection with a diagnosis of soft tissue sarcoma were studied. The study recorded patient demographics, tumor characteristics, surgical margin distance (in millimeters), and disease-related outcomes. Results: The minimum follow-up period was 24 months (24-168). The mean time to local recurrence after resection was 103.2 months (95% CI 91.73 to 114.64). The mean local recurrence-free survival was found to be 7.23 months in patients with positive surgical margins, 87.42 months in patients with ≤1 mm, and 139.80 months in patients with >1 mm (p < 0.001). Patients with surgical margins ≤1 mm were more likely to have local recurrence than patients with >1 mm (0.41 [0.21-0.81], p = 0.010). The mean overall survival was 106.72 months (95% CI 95.98 to 117.46). Positive surgical margins were associated with decreased overall survival (3.58 [1.46-8.80], p = 0.005). There was a statistically significant difference between the histologic grade in terms of local recurrence (4.50 [95% CI 2.57 to 7.88]; p < 0.001) and overall survival (3.12 [95% CI 1.52 to 6.41]; p = 0.002). Conclusions: Achieving a negative surgical margin distance of more than 1 mm appears to be correlated with a reduced risk of local recurrence. Positive surgical margins are a risk factor that detrimentally impacts overall patient survival. However, determining the appropriate margin distance for all patients poses a significant challenge.

Advances in Radiation Oncology in Soft Tissue Sarcoma

PURPOSE

To review recent advances with radiation therapy (RT) for soft tissue sarcomas (STS).

RECENT FINDINGS

Newer data showcases hypofractionated preoperative RT for soft tissue sarcomas treated with surgery to be safe and effective, however, long-term follow up data is pending. Hypofractionated and dose-escalated RT in patients with unresectable STS is also being studied, for which we remain optimistic given advances in RT planning approaches. SFRT may also be considered in select cases to improve tumor control outcomes. Finally, for patients requiring high doses of RT adjacent to critical structures, re-irradiation, and to minimize risk of secondary malignancy in our younger population, particle therapy may be beneficial. We summarize a number of recent advances in RT for STS that can benefit patients with localized disease as well as for patients with advanced disease.

Principles of Surgical Treatment of Soft Tissue Sarcomas

Soft tissue sarcoma (STS) is a group of highly heterogeneous tumors of mesenchymal origin that have variable primary site locations and clinical behavior. Despite the broad diversity of STS, the standard of care involves surgical resection with or without radiation therapy (RT) to control local recurrence and systemic treatment in select cases. The complexities of STS require a critical understanding of the preoperative work-up process, surgical treatment, and postoperative management. Advanced imaging plays a vital role in the characterization of the soft tissue mass, preoperative biopsy planning, and disease staging. Surgical treatment prioritizes wide resection with negative margins, supported by newer margin classification systems for better prognosis. Further, advancements in surgical technique have enabled limb-salvage surgery to largely replace amputation in the management of these tumors. Additional surgical considerations, such as nerve preservation, vascular reconstruction, and complex tissue closure, further highlight the complexity of STS management. Lastly, postoperative follow-up is critical for the early detection of local or distant recurrences. For complex cases, such as unplanned excisions or invasive tumors, strategies like re-resection may be beneficial. Ongoing research into imaging, chemotherapy, and targeted therapies will further refine management strategies, especially in complex and recurrent cases. This review highlights the essential aspects of STS surgical management and underscores the need for coordinated, multidisciplinary care to enhance both survival and quality of life for affected patients.

Optimal Setup and Parameters of Diffusion-Weighted Magnetic Resonance Imaging for Translational Evaluation of a Tumor Progression Model for Soft Tissue Sarcomas

Purpose

Defining a microscopic tumor infiltration boundary is critical to the success of radiation therapy. Currently, radiation oncologists use margins to geometrically expand the visible tumor for radiation treatment planning in soft tissue sarcomas (STS). Image-based models of tumor progression would be critical to personalize the treatment radiation field to the pattern of sarcoma spread. Evaluation of these models is necessary to demonstrate feasibility in the clinical setting. This study presents an imaging protocol for the preclinical evaluation of a tumor progression model in extremity STS.

Methods and Materials

We recruited 7 healthy volunteers and acquired diffusion-weighted magnetic resonance imaging (DW-MRI) images of the thigh on a magnetic resonance imaging scanner used for imaging cancer patients in a radiation oncology department. We developed a protocol that includes positioning the patient, configuring the radiofrequency coils, and setting the DW-MRI sequence parameters. To find the optimal parameter configuration, the image signal-to-noise ratio (SNR) and the directional variability (DV) of the principal eigenvector of the diffusion tensor were calculated.

Results

The mean SNR across all trials and 12 thigh muscles was 41, with a range of 12 to 72. The mean DV was 13° and ranged from 11° to 23°. The longest scan time was 22 minutes and 58 seconds, and the shortest was 11 minutes and 46 seconds. For the high-resolution image with a voxel volume of 1.3 × 1.3 × 6 mm3 and 38 slices, the optimal parameters were found to be a repetition time of 8000 ms, 12 signal averages, and 6 gradient directions. This configuration resulted in a scan time of 11 minutes and 46 seconds, an SNR of 34, and a DV of 13°.

Conclusions

A DW-MRI scan duration acceptable for imaging cancer patients was achieved with an image quality suitable for reproducible modeling of tumor infiltration. The developed protocol can be used for preclinical evaluation in STS patients.

What is the incidence and non-union rate of radiation-associated fractures? - A systematic review of the literature

BACKGROUND

Radiation-associated fractures (RAFs) are a challenging complication in oncologic patients, yet their incidence remains unknown and optimal management lacks consensus.

AIM

This review aimed to evaluate the incidence of RAFs in the trunk, pelvis, and extremities as well as non-union rates of surgical and non-surgical treatment.

MATERIALS AND METHODS

A systematic review of PubMed and Embase databases was conducted. The study was registered on PROSPERO (ID: CRD42024513017). Studies were included if they reported RAFs in oncologic populations, had a sample size of at least five patients, and provided extractable data on RAF incidence or number. The STROBE checklist was utilized for evaluation of study quality. For eligible studies, quantitative analyses were conducted to determine weighted incidence of RAF and fracture non-union.

RESULTS

Thirty-five studies comprising 9,980 patients treated with radiation therapy were included. The weighted incidence of RAFs was calculated to be 6.5% across 8,061 patients. The weighted incidence of femoral RAF was 5.2%, while pelvic RAF incidence was 17.1%. Non-union rates after initial treatment varied from 4% to 100%, with an overall weighted incidence of 48%. Treatments included intramedullary nailing, fixation with screws/plate, prosthetic replacement, conservative treatment, and amputation, with varying success rates.

CONCLUSION

This review highlights RAFs as a significant complication of radiation therapy, with a weighted incidence of 6.5% and a non-union rate of 48%. Advanced radiation techniques have reduced RAF occurrences, but non-union remains a challenge, necessitating tailored treatment strategies. Further research is needed to optimize RAF management and improve patient outcomes.

UK guidelines for the management of soft tissue sarcomas

Soft tissue sarcomas (STS) are rare tumours arising in mesenchymal tissues and can occur almost anywhere in the body. Their rarity, and the heterogeneity of subtype and location, means that developing evidence-based guidelines is complicated by the limitations of the data available. This makes it more important that STS are managed by expert multidisciplinary teams, to ensure consistent and optimal treatment, recruitment to clinical trials, and the ongoing accumulation of further data and knowledge. The development of appropriate guidance, by an experienced panel referring to the evidence available, is therefore a useful foundation on which to build progress in the field. These guidelines are an update of the previous versions published in 2010 and 2016 [1, 2]. The original guidelines were drawn up by a panel of UK sarcoma specialists convened under the auspices of the British Sarcoma Group (BSG) and were intended to provide a framework for the multidisciplinary care of patients with soft tissue sarcomas. This iteration of the guidance, as well as updating the general multidisciplinary management of soft tissue sarcoma, includes specific sections relating to the management of sarcomas at defined anatomical sites: gynaecological sarcomas, retroperitoneal sarcomas, breast sarcomas, and skin sarcomas. These are generally managed collaboratively by site specific multidisciplinary teams linked to the regional sarcoma specialist team, as stipulated in the recently published sarcoma service specification [3]. In the UK, any patient with a suspected soft tissue sarcoma should be referred to a specialist regional soft tissues sarcoma service, to be managed by a specialist sarcoma multidisciplinary team. Once the diagnosis has been confirmed using appropriate imaging and a tissue biopsy, the main modality of management is usually surgical excision performed by a specialist surgeon, combined with pre- or post-operative radiotherapy for tumours at higher risk for local recurrence. Systemic anti-cancer therapy (SACT) may be utilised in cases where the histological subtype is considered more sensitive to systemic treatment. Regular follow-up is recommended to assess local control, development of metastatic disease, and any late effects of treatment.

Soft tissue tumors of the lower leg, foot and ankle: A cross-sectional observational study analysing 376 cases

Fewer than 5 % of soft tissue sarcomas arise in the foot and ankle. It can be difficult to distinguish between benign and malignant lesions which leads to a delay in diagnosis. Initial inappropriate procedures limit options for limb salvage and increasing rates of local recurrence. Our aim is to improve understanding of the presentation and management of these rare tumors to reduce delays in diagnosis and decrease the occurrence of inappropriate or unwarranted procedures. A prospectively maintained database of 376 new referrals to the West of Scotland regional musculoskeletal oncology service for soft tissue lesions of the foot, ankle, and lower leg over a 10-year period was analysed retrospectively. An assessment was made of patient demographics, presentation, anatomical location, diagnosis, classification, management, and outcomes for all patients. Of all new referrals, 53.5 % were diagnosed with primary benign soft tissue tumors and 16 % with primary malignant soft tissue tumors. The most common primary benign tumor in our population was schwannoma (15.9 %) and primary malignant tumor was undifferentiated sarcoma (26.7 %). In the foot alone, soft tissue sarcomas most commonly occurred in the forefoot (44.4 %). The most common presenting complaints were rest pain and focal swelling. Symptoms were present for on average 7 months prior to referral. Death from disease in sarcomas was 41.7 % over a 10 year follow up period, higher than other body areas. Soft tissue sarcomas in the foot and ankle remain a diagnostic challenge. Local biopsies should only be performed following discussion with an oncology surgeon. We have provided a management protocol in order to reduce the number of inappropriate procedures performed in this group and expedite referral to specialist centres, optimising clinical outcomes and reducing the cost of litigation to healthcare services.

A Narrative Review of the Assessment and Treatment of Physical Impairments Commonly Seen in Sarcoma Cancer Survivors Using a Rehabilitative Approach

BACKGROUND

Sarcomas are a rare, complex group of malignancies characterized by numerous clinical and pathological features. Sarcomas originate from various tissues such as fat, muscle, bone, nerves, blood vessels and connective tissues. Typically, the treatment of sarcomas consists of surgery, chemotherapy, and radiation therapy. The location, type, stage, and treatment of sarcomas contribute to the development of physical impairments affecting joint and limb function, peripheral nerves, strength, and mobility, diminishing physical function and quality of life. Traditionally, rehabilitative therapy has been implemented after cancer treatment to help improve physical impairments imparted from cancer therapy. Recent work in rehabilitative medicine has explored the implementation of rehabilitative therapy prior to beginning cancer treatment (pre-habilitation) to help mitigate the detrimental physical consequences seen in sarcoma patients.

OBJECTIVE

The objective of this narrative review is to examine the physical impairments affecting sarcoma patients after cancer therapy and the impact of rehabilitative medicine on physical function and quality of life when implemented before and after cancer treatment.

Hypofractionated Preoperative Radiation Should Not Yet Be Used as Standard of Care for Extremity and Truncal Soft Tissue Sarcoma

Hypofractionated radiation therapy regimens should not be used as standard of care for localized soft tissue sarcoma.

Preoperative versus postoperative radiotherapy for localized soft tissue sarcoma treated with curative intent in a French tertiary center "SARCLOC"

BACKGROUND

Soft tissue sarcomas of the extremities (E-STS) are rare and heterogeneous. Treatment combines surgery with preoperative or postoperative radiotherapy (RT) for deep, large, or high-grade tumors. We evaluate the effectiveness and toxicity in E-STS patients treated at our institution from 2015 to 2021.

MATERIALS AND METHODS

This retrospective, single-center study, compared clinical and therapeutic characteristics, toxicities, and surgical complications by radiotherapy type. Local recurrence-free survival (LRFS), overall survival (OS), and recurrence-free survival (RFS) were estimated using the Kaplan-Meier method.

RESULTS

We included 158 patients; 124 (78%) received preoperative RT. The two groups (preoperative RT vs. postoperative RT) differed significantly in terms of median tumor size (111 vs. 67.5 mm, p < 0.01), perivascular involvement (51% vs. 29%, p = 0.03), and bone contact (32% vs. 12%, p = 0.02), but not in grade (grade 2 or 3: 65% vs. 74%, p = 0.72). Median follow-up was 2.9 vs. 5.1 years. Two-year LRFS was 82% [95%CI: 74-88] for both groups; OS was 87% [95%CI: 80-92] vs. 88% [95%CI: 71-95]; and RFS was 72% [95%CI: 63-79] vs. 70% [95%CI: 52-83]. Postoperative complications were 53% vs. 35%, with wound disruption at 39% vs. 15% and infections at 29% vs. 6%. Grade 2 or higher dermatitis was 16% vs. 29%, and RT discontinuation rates were 4% vs. 12% for the two groups, respectively.

CONCLUSION

Despite poorer prognostic factors in the preoperative RT group, LRFS and OS were comparable to those in the postoperative RT group. Postoperative complications were more frequent with preoperative RT, and treatment discontinuation was more common postoperatively.

Isolated Limb Infusion for Limb-Threatening Sarcomas

BACKGROUND

Isolated limb infusion (ILI) treats unresectable extremity malignancies with high-dose regional chemotherapy limited to the limb. This study assessed long-term outcomes after ILI for limb-threatening sarcomas.

METHODS

A retrospective review analyzed patients with an extremity sarcoma who underwent ILI with melphalan and dactinomycin from 2008 to 2023 at a single institution.

RESULTS

The study identified 61 patients (52.5% female; median age, 73 years; range, 20-94 years). Of these patients, 68.9% had lower-extremity disease. The median follow-up period was 6.9 years. The overall response rate was 48.3% (complete response [CR], 21.7%; partial response [PR], 26.7%), and the disease control rate (DCR: CR + PR + stable disease [SD]) was 65%. The median progression-free survival (PFS) for the patients with CR/PR/SD/progressive disease (PD) was respectively 16.8/9.6/4.8/2.4 months (P < 0.0001). The responders (CR + PR) had significantly longer PFS than the non-responders (SD + PD) (hazard ratio [HR], 6.3; 95% confidence interval [CI], 3.1-12.9; P < 0.001). The median in-field PFS times for CR/PR/SD/PD were respectively 16.8/12/4.8/2.4 months (P < 0.001). The responders had a significantly longer risk of in-field PFS than the non-responders (HR, 5.9; 95% CI 2.9-12.0; P < 0.001). The median distant relapse PFS for CR/PR/SD/PD was not reached (NR)/NR/44.4/40.8 months (P = 0.02). The responders had a significantly longer distant relapse PFS than the non-responders (HR, 2.7; range, 1.1-6.8; P = 0.04). The median overall survival (OS) was 8.6 years for the responders and 4.1 years for the non-responders (P = 0.02). The disease-specific survival (DSS) rates were 87% at 1 year, 71% at 3 years, and 64% at 5 years. The median DSS was not reached for the responders and was 4.1 years for the non-responders (P = 0.003). The limb salvage rates at 6 months were 85% at 1 year, 80% at 3 years, and 70% at 5 years. The patients with PD had a higher risk of requiring amputation than the patients with CR + PR + SD (HR, 3.0; 95% CI 1.0-8.7; P = 0.04).

CONCLUSIONS

The 5-year limb salvage rates after ILI are notably high, reaching 70%. After ILI, the responders had significantly better in-field and distant relapse PFS, OS, and DSS.

Diagnosis and management of dedifferentiated liposarcoma: A multidisciplinary position statement

Dedifferentiated liposarcoma (DDLPS) is a malignant mesenchymal neoplasm in desperate need of novel therapeutic approaches. Often occurring in conjunction with well-differentiated liposarcoma (WDLPS), DDLPS can behave more aggressively and exhibits a significant risk for developing recurrence or metastatic disease when compared to its well-differentiated counterpart. A multidisciplinary approach is critically important, particularly for patients with localized disease, as disease presentations are often complex, and the management of patients has become increasingly nuanced as treatment approaches have become more refined. Expert pathology review and appropriate application of diagnostic molecular techniques are key components of DDLPS diagnosis and also reflect an improved understanding of the underlying pathogenesis of the disease. Systemic therapies remain limited for DDLPS, but novel therapies targeting important underlying molecular drivers have resulted in ongoing clinical trials aiming to improve outcomes for patients with advanced disease. In recognition of the increased activity and interest within the DDLPS field, a multidisciplinary group of nationally recognized experts in medical oncology, surgical oncology, radiation oncology, and pathology was convened to summarize key insights. This position paper highlights important points from the meeting and provides evidence-based recommendations for practicing clinicians.

Novel pharmacotherapies for the treatment of liposarcoma: a comprehensive update

INTRODUCTION

Liposarcomas are malignancies of adipocytic lineage and represent one of the most common types of soft tissue sarcomas. They encompass multiple histologies, each with unique molecular profiles. Treatment for localized disease includes resection, potentially with perioperative radiation or systemic therapy. Treatment for unresectable or metastatic disease revolves around palliative systemic therapy, for which improved therapies are urgently needed.

AREAS COVERED

We reviewed the literature on novel therapies in clinical development for liposarcomas within the past 5 years and discuss their potential impact on future treatment strategies.

EXPERT OPINION

Understanding of the molecular characteristics of liposarcoma subtypes has led to testing of several targeted therapies, including inhibitors of amplified gene products (CDK4 and MDM2) and upregulated proteins (XPO1). Immuno-oncology has played an increasing role in the treatment of liposarcomas, with checkpoint inhibition showing promise in dedifferentiated liposarcomas, and immune therapies targeting cancer testis antigens NY-ESO-1 and MAGE family proteins poised to become an option for myxoid/round cell liposarcomas. The search for novel agents from existing classes (tyrosine kinase inhibitors) with efficacy in liposarcoma also continues. Combination therapies as well as biomarker identification for patient selection of therapies warrant ongoing exploration.

Effects of Neoadjuvant Radiation and Recipient Vessel Characteristics on Microvascular Complication Rates in Reconstruction of Lower Extremity Soft Tissue Sarcoma Defects

BACKGROUND

 The treatment approach for soft tissue sarcomas (STS) of the lower extremity has shifted toward the use of neoadjuvant radiation combined with limb-sparing surgery (LSS). The resulting defects often require reconstruction with free tissue transfer for adequate outcomes. Data have demonstrated a potentially increased risk of microvascular complications for free flaps performed using irradiated recipient vessels. Similarly, certain anatomic areas of the lower extremity have a high proportion of unnamed perforators that are available as recipient vessels, increasing the technical difficulty. We aimed to determine if the characteristics of recipient vessels that were used for the reconstruction of STS defects influenced rates of microvascular complications in our patients.

METHODS

 A retrospective chart review of all patients who underwent reconstruction of lower extremity STS defects with free tissue transfer from 2009 to 2020 was conducted. Data regarding recipient vessel type (axial vessel vs. unnamed perforator), radiation status of the recipient vessels (irradiated vs. non-irradiated), and microvascular complications were compared across groups.

RESULTS

 A total of 204 free flaps were included. The overall microvascular complication rate was 13.7% (28 cases). Most microvascular complications were detected postoperatively (82.1%) rather than intraoperatively, with the majority involving venous congestion/thrombosis (20 cases, 71.4%). While there was a trend toward increased microvascular complications with the use of irradiated recipient vessels (27 cases, 96.4%), this did not reach statistical significance (OR = 1.98, p = 0.52). The use of perforating branches as recipient vessels did not confer an increased risk of microvascular complications (OR = 0.87, p = 0.75).

CONCLUSION

 The reconstruction of irradiated lower-extremity STS defects represents a particularly challenging issue. This analysis demonstrates that free tissue transfer can be safely performed using irradiated vessels without a significantly increased risk of microvascular complications. Furthermore, unnamed perforating branches can be successfully used for reconstruction in anatomically challenging areas of the lower extremity.

Radiotherapy leads to improved overall survival in patients undergoing resection for Undifferentiated pleomorphic sarcoma

BACKGROUND AND OBJECTIVES

Undifferentiated pleomorphic sarcoma (UPS) is a frequent subtype within the heterogeneous group of soft tissue sarcomas (STS). The use of radiotherapy (RT) has become an important component of a multimodal approach to treating STS. Key studies have demonstrated that the addition of RT improves rates of local control in STS, though the effect on overall survival (OS) is less clear. Furthermore, there is very limited and conflicting evidence regarding effect of RT on overall survival in UPS. The purposes of this investigation were to examine the association between RT and OS in UPS patients undergoing surgical resection and to determine independent prognostic indicators of OS in this patient population.

METHODS

This was a retrospective review of patients who underwent surgical treatment for primary UPS from 1993 to 2021. Associations between RT and OS were analyzed with Kaplan-Meier curves and log-rank testing. Cox proportional hazards regression analysis was used to determine independent prognostic factors of OS.

RESULTS

One hundred and fourteen patients who underwent surgical resection of primary UPS were included in the study. Ninety-six (84.2 %) patients received RT perioperatively. Use of RT was associated with improved OS on log-rank testing (hazard ratio (HR) 0.20; 95 % confidence interval (CI) 0.11-0.36; p < 0.001). On multivariate analysis, RT was an independent predictor of improved OS (HR 0.18; 95 % CI 0.09-0.39; p < 0.001) while metastasis at presentation (HR 4.82; 95 % CI 2.26-10.27; p < 0.001) and older age (HR 1.92; 95 % CI 1.20-3.36; p = 0.02) were predictive of decreased OS. Use of RT was not significantly associated with a lower rate of local recurrence in our cohort (p = 0.49).

CONCLUSIONS

Use of RT in combination with surgery was an independent prognostic indicator of improved overall survival in UPS patients. Older age and metastasis at presentation were associated with worse overall survival. Based on this and other available studies, treatment for UPS should involve limb-sparing resection when feasible with RT to ensure optimal survival.

Long-term outcomes among survivors of childhood osteosarcoma: A report from the Childhood Cancer Survivor Study (CCSS)

PURPOSE

Treatment strategies for osteosarcoma evolving between 1970 and 1999 improved 5-year survival and continue as standard of care today. This report evaluates the impact of these evolving therapies on long-term health outcomes.

METHODS

Five-year survivors of childhood osteosarcoma in CCSS treated from 1970 to 1999 were evaluated for late (>5 years from diagnosis) mortality, chronic health conditions (CHCs), and health status using piecewise-exponential and logistical models. Comparisons were made between survivors and siblings without cancer, and among survivors examining historical and current standard chemotherapies (e.g., methotrexate/doxorubicin/cisplatin [MAP] vs. others), specific chemotherapy agents and surgical approaches (amputation vs. limb salvage [LS]). Models were evaluated adjusting for attained age, sex, race, ethnicity, and age at diagnosis.

RESULTS

A total of 1257 survivors of osteosarcoma were followed on average for 24.4 years. Twenty-year all-cause late mortality was 13.3% (95% confidence interval [CI]: 11.7%-14.9%) overall and 11.7% (95% CI: 6.9%-16.5%) for the subset treated with MAP plus LS. Survivors were at higher risk of CHCs (rate ratio [RR] 3.7, 95% CI: 3.2-4.3) than the sibling cohort, most notably having more serious cardiac, musculoskeletal, and hearing CHCs. Within the survivor cohort, the risk of severe CHCs was twice as high with MAP versus no chemotherapy (RR 2.1, 95% CI: 1.3-3.4). Compared with primary amputation, serious musculoskeletal CHCs were higher after LS (RR 6.6, 95% CI: 3.6-13.4), without discernable differences in health status.

CONCLUSION

Contemporary osteosarcoma therapy with MAP plus LS, while improving 5-year disease-free survival, continues to be associated with a high burden of late mortality, CHCs, and health status limitations.

Progress in histology specific treatments in soft tissue sarcoma

INTRODUCTION

Soft tissue sarcomas (STS) represent a heterogenous group of rare tumors, primarily treated with surgery. Preoperative radiotherapy is often recommended for extremity high-risk STS. Neoadjuvant chemotherapy, typically based on doxorubicin with ifosfamide, has shown efficacy in limbs and trunk wall STS. Second-line chemotherapy, commonly utilized in the metastatic setting, is mostly histology-driven. Molecular targeted agents are used across various histologies, and although the use of immunotherapy in STS is still in its early stages, there is increasing interest in exploring its potential.

AREAS COVERED

This article involved an extensive recent search on PubMed. It explored the current treatment landscape for localized and metastatic STS, focusing on the combined use of radiotherapy and chemotherapy for both extremity and retroperitoneal tumors, and with a particular emphasis on the most innovative histopathology driven therapeutic approaches. Additionally, ongoing clinical trials identified via clinicaltrials.gov are included.

EXPERT OPINION

Recently there have been advancements in the treatment of STS, largely driven by the outcomes of clinical trials. However further research is imperative to comprehend the effect of chemotherapy, targeted therapy and immunotherapy in various STS, as well as to identify biomarkers able to predict which patients are most likely to benefit from these treatments.

Sarcoma Size and Limb Dimensions Predict Complications, Recurrence, and Death in Patients with Soft Tissue Sarcoma in the Thigh: A Multidimensional Analysis

BACKGROUND

Limb-sparing resections of thigh soft tissue sarcomas (STSs) can result in adverse outcomes. Identifying preoperative predictors for wound healing complications, tumor recurrence, and mortality is crucial for informed reconstructive decision-making. We hypothesized that preoperative measurements of thigh and tumor dimensions could serve as reliable indicators for postoperative complications, recurrence, and death.

PATIENTS AND METHODS

In this retrospective cohort study conducted from March 2016 to December 2021, we analyzed patients undergoing thigh STS excisions followed by reconstruction. Preoperative magnetic resonance imaging or computed tomography scans provided necessary thigh and tumor dimensions. Univariate and multivariate regression assessed relationships between these dimensions and postoperative outcomes, including complications, recurrence, and death.

RESULTS

Upon the analysis of 123 thighs, we found thigh width to be highly predictive of postoperative complications, even surpassing body mass index (BMI) and retaining significance in multivariate regression [odds ratio (OR) 1.19; 95% CI 1.03-1.39; p = 0.03]. Sarcoma-to-thigh width and thickness ratios predicted STS recurrence, with the thickness ratio retaining significance in multivariate regression (OR 1.03; 95% CI 1.001-1.05; p = 0.041). Notably, greater thigh thickness was independently protective against mortality in multivariate analysis (OR 0.80; 95% CI 0.65-0.98; p = 0.030).

CONCLUSIONS

Thigh width outperformed BMI in association with postoperative complications. This may create an opportunity for intervention, where weight loss can play a role during the neoadjuvant therapy period to potentially reduce complications. Sarcoma-to-thigh width and thickness ratios, particularly the latter, hold substantial predictive value in terms of STS recurrence. Moreover, thigh thickness is an independent predictor of survival.

Risk Stratification Tools to Aid Decisions on Adjuvant Chemotherapy Usage in Resected Soft Tissue Sarcomas: A Ten-Year Review of an Irish Sarcoma Center Experience

Background

Soft tissue sarcoma (STS) is comprised of approximately 80 subtypes, with an incidence of 4 - 5 per 100,000 annually in Europe. The National Comprehensive Cancer Network (NCCN) guidelines recommend consideration of neoadjuvant/adjuvant chemotherapy in tumors at high risk of recurrence based on the American Joint Committee on Cancer (AJCC) staging. Alternatively, the Sarculator is a risk prediction tool that has identified a threshold of risk, above which chemotherapy may provide an overall survival (OS) benefit. Using this nomogram, patients with a 10-year predicted OS < 60% are classified as high risk and should be considered for chemotherapy. The aim of this study was to assess the prognostic accuracy of these two risk prediction methods in an Irish population.

Methods

All newly diagnosed patients with resected STS discussed in the STS tumor board in Cork University Hospital between January 2012 and December 2021 were identified. Clinicopathological data were collected. Risk assessment using AJCC and Sarculator nomogram was performed on all patients with an extremity/trunk sarcoma. The OS was calculated including Kaplan-Meier method for time to event analysis.

Results

In total, 200 STS patients were reviewed, of whom 134 had truncal or extremity tumors. Sarculator score was calculated for 60 of these (well differentiated liposarcomas, desmoid tumors and dermatofibrosarcoma protuberans were excluded). Using the Sarculator nomogram to calculate 10-year predicted OS, 19 patients were categorized as high risk and 41 were categorized as low risk. Using AJCC staging, 25 patients were categorized as high risk and 35 as low risk. The 5-year OS rate in the Sarculator high-risk group was 60.2%, compared with 87.1% in the low-risk group (P = 0.009). The 5-year OS rate in the AJCC high-risk group was 67.6%, compared with 86.3% in the low-risk group (P = 0.083).

Conclusions

Our cohort is representative of the broad histological subtypes expected. In our population, Sarculator score results correlate with international outcomes and higher scores were associated with increased mortality. The Sarculator was more predictive of clinical outcome than AJCC staging, and its use would lower the proportion of patients being considered for adjuvant chemotherapy thereby sparing toxicity, which is important in the setting of uncertain clinical benefit.

Development and benchmarking of a Deep Learning-based MRI-guided gross tumor segmentation algorithm for Radiomics analyses in extremity soft tissue sarcomas

BACKGROUND

Volume of interest (VOI) segmentation is a crucial step for Radiomics analyses and radiotherapy (RT) treatment planning. Because it can be time-consuming and subject to inter-observer variability, we developed and tested a Deep Learning-based automatic segmentation (DLBAS) algorithm to reproducibly predict the primary gross tumor as VOI for Radiomics analyses in extremity soft tissue sarcomas (STS).

METHODS

A DLBAS algorithm was trained on a cohort of 157 patients and externally tested on an independent cohort of 87 patients using contrast-enhanced MRI. Manual tumor delineations by a radiation oncologist served as ground truths (GTs). A benchmark study with 20 cases from the test cohort compared the DLBAS predictions against manual VOI segmentations of two residents (ERs) and clinical delineations of two radiation oncologists (ROs). The ROs rated DLBAS predictions regarding their direct applicability.

RESULTS

The DLBAS achieved a median dice similarity coefficient (DSC) of 0.88 against the GTs in the entire test cohort (interquartile range (IQR): 0.11) and a median DSC of 0.89 (IQR 0.07) and 0.82 (IQR 0.10) in comparison to ERs and ROs, respectively. Radiomics feature stability was high with a median intraclass correlation coefficient of 0.97, 0.95 and 0.94 for GTs, ERs, and ROs, respectively. DLBAS predictions were deemed clinically suitable by the two ROs in 35% and 20% of cases, respectively.

CONCLUSION

The results demonstrate that the DLBAS algorithm provides reproducible VOI predictions for radiomics feature extraction. Variability remains regarding direct clinical applicability of predictions for RT treatment planning.

Local recurrence rates of superficial versus deep soft tissue sarcoma

INTRODUCTION

Soft tissue sarcomas are a group of malignancies that commonly occur in the extremities. As deep lesions may exist within the confines of the muscular fascia, we postulate that local recurrence rates are higher for superficial soft tissue sarcomas managed by the standard of care.

MATERIALS AND METHODS

A retrospective review was performed on 90 patients who underwent surgical resection of soft tissue sarcomas of the extremity from 2007 to 2015. Patients with minimum 2-year follow-up and adequate operative, pathologic, and clinical outcomes data were included.

RESULTS

Mean age was 54 ± 18 years with 49 (54.4%) patients being male. Lesions in 77.8% of cases were deep, and 22.2% were superficial to fascia. Following the index surgical resection, a total of 33 (36.7%) patients had positive margins. A total of 17 (18.9%) patients had a local recurrence. Overall, 3-year survival was 92.7%, and 5-year survival was 79.0%. Five-year recurrence-free survival of deep sarcomas was 91.1% versus 58.2% of superficial lesions (p = 0.006). Patients with higher tumor depth had lower odds of experiencing a local recurrence (HR 0.26 [95% CI 0.09-0.72]). Local recurence rates was also associated with positive surgical margins on initial resection (33.3% versus 12.3%) (p = 0.027).

CONCLUSIONS

In this series, superficial tumor depth was associated with local recurrence of soft tissue sarcomas of the extremity following surgical resection. Positive surgical margins was also associated with local recurrence.

Modern Multidisciplinary Management of Soft Tissue Sarcoma of the Extremity and Trunk

Soft tissue sarcomas (STS) of the extremity and trunk are heterogeneous and rare tumors that require coordinated multidisciplinary management. Surgical resection remains the backbone of treatment for localized tumors, with the addition of radiotherapy to surgery to achieve high rates of local control. Despite this, overall survival is limited because of significant distant metastatic risk and a lack of efficacious systemic therapies. Clinical trials have produced conflicting results on the impact of systemic therapy in the neoadjuvant and adjuvant settings for patients with localized disease, leaving systemic treatment decisions largely guided by shared decision making and prognostic prediction tools such as nomograms. This article will review the foundational data as well as latest developments in surgical, radiotherapy, and systemic management supporting current practice guidelines for localized STS of the extremity and trunk.

Significance of radiation therapy in the myxoid round-cell liposarcoma treatment regimen

BACKGROUND AND PURPOSE

Because myxoid liposarcomas are more radiosensitive than other soft tissue sarcomas, there have been several reports of 50 Gy preoperative radiation therapy combined with surgery, but the wound complication rate is reportedly high. We have performed preoperative irradiation at a reduced dose of 40 Gy and definitive radiation therapy for unresectable cases. This study aimed to report the tumor reduction rate and oncological results with a reduced dose of preoperative irradiation and the outcome of definitive irradiation for unresectable cases.

MATERIALS AND METHODS

Forty-one patients with myxoid liposarcoma treated in our institution between 2002 and 2021 were included. We examined the tumor volume shrinkage rate with preoperative radiation, compared complications and oncological outcomes between preoperative radiation and surgery-only cases, and investigated the prognosis and tumor shrinkage of definitive radiation cases.

RESULTS

The total dose irradiated was 40 Gy except in two cases. The mean tumor volume reduction rate was 52.0%. A decreased dose of preoperative radiation did not worsen clinical outcomes with fewer complications. The total dose of definitive radiation was approximately 60 Gy. The mean tumor volume reduction rate was 55.0%. The tumor shrinkage maintenance rate was 100% in a median follow-up period of 50.5 months.

CONCLUSION

Preoperative radiation therapy for myxoid liposarcoma near vital organs is a good approach because even with a reduced dose of 40 Gy, significant tumor reduction and excellent results were achieved. Definitive radiation therapy is the recommended treatment for older patients with serious comorbidities or inoperable patients.

The role of radiotherapy in multimodal treatment of non-rhabdomyosarcoma soft tissue sarcomas in children: A real life report from a tertiary center

OBJECTIVE

The current treatment of pediatric non-rhabdomyosarcoma soft tissue sarcomas (NRSTS) is a multimodal risk-based approach. Today, smaller fields and lower doses of radiotherapy (RT) have become standard. In this study, it was aimed to evaluate the treatment outcomes and toxicity profile in children with NRSTS that received RT as a part of multimodal therapy.

METHODS

Twenty-nine patients with pediatric NRSTS treated with neoadjuvant or adjuvant RT between 1998 and 2022 were evaluated retrospectively. Kaplan-Meier method was used for survival analyses.

RESULTS

Median follow-up was 36 months (range, 6-291 months). The median neoadjuvant and adjuvant RT doses were 50 Gy (range, 45-66 Gy) and 54 Gy (45-66 Gy), respectively. During follow-up, six (21%) patients developed a local recurrence and 10 (35%) had distant metastasis. The 5-year local control, overall survival (OS), local recurrence-free survival, and distant metastasis-free survival rate was 79%, 67%, 59%, and 61%, respectively. In multivariate analysis, a ≤5-cm tumor, gross tumor resection, Children's Oncology Group (COG) low-risk group, and absence of neoadjuvant chemotherapy were independent favorable prognostic factors for OS. Severe (≥ grade 3) late toxicity was observed in 6 (20%) patients.

CONCLUSIONS

RT is a crucial component in the multimodal risk-based treatment approach for pediatric NRSTS. However, late toxicity rates are still high and should be improved. Patients with a ≤5-cm tumor, COG low-risk group and treated with gross tumor resection have increased survival rates.

Alpha-Hederin induces incomplete autophagic injury in non-small cell lung cancer by interfering with the lysosomal acidification

Lung cancer is the most common oncological disease worldwide, with non-small cell lung cancer accounting for approximately 85% of lung cancer cases. α-Hederin is a monodesmosidic triterpenoid saponin isolated from the leaves of Hedera helix L. or Nigella sativa and has been extensively studied for its antitumor activity against a variety of tumor cells. It has been suggested that α-Hederin is a potential regulator of autophagy and has high promise for application. However, the specific mechanism and characteristics of α-Hederin in regulating autophagy are not well understood. In this study, we confirmed the potential of α-Hederin application in lung cancer treatment and comprehensively explored the mechanism and characteristics of α-Hederin in regulating autophagy in lung cancer cells. Our results suggest that α-Hederin is an incomplete autophagy inducer that targets mTOR to activate the classical autophagic pathway, inhibits lysosomal acidification without significantly affecting the processes of autophagosome transport, lysosome biogenesis, autophagosome and lysosome fusion, and finally leads to impaired autophagic flux and triggers autophagic damage in NSCLC.

MRI of Soft-Tissue Tumors: What to Include in the Report

MRI serves as a critical step in the workup, local staging, and treatment planning of extremity soft-tissue masses. For the radiologist to meaningfully contribute to the management of soft-tissue masses, they need to provide a detailed list of descriptors of the lesion outlined in an organized report. While it is occasionally possible to use MRI to provide a diagnosis for patients with a mass, it is more often used to help with determining the differential diagnosis and planning of biopsies, surgery, radiation treatment, and chemotherapy (when provided). Each descriptor on the list outlined in this article is specifically aimed to assist in one or more facets of the overall approach to soft-tissue masses. This applies to all masses, but in particular sarcomas. Those descriptors are useful to help narrow the differential diagnosis and ensure concordance with a pathologic diagnosis and its accompanying grade assignment of soft-tissue sarcomas. These include a lesion's borders and shape, signal characteristics, and contrast enhancement pattern; the presence of peritumoral edema and peritumoral enhancement; and the presence of lymph nodes. The items most helpful in assisting surgical planning include a lesion's anatomic location, site of origin, size, location relative to a landmark, relationship to adjacent structures, and vascularity including feeding and draining vessels. The authors provide some background information on soft-tissue sarcomas, including their diagnosis and treatment, for the general radiologist and as a refresher for radiologists who are more experienced in tumor imaging. ©RSNA, 2024 See the invited commentary by Murphey in this issue.

Technical considerations for isolated limb perfusion: A consensus paper

BACKGROUND

Isolated limb perfusion (ILP) is a well-established surgical procedure for the administration of high dose chemotherapy to a limb for the treatment of advanced extremity malignancy. Although the technique of ILP was first described over 60 years ago, ILP is utilised in relatively few specialist centres, co-located with tertiary or quaternary cancer centres. The combination of high dose cytotoxic chemotherapy and the cytokine tumour necrosis factor alpha (TNFα), mandates leakage monitoring to prevent potentially serious systemic toxicity. Since the procedure is performed at relatively few specialist centres, an ILP working group was formed with the aim of producing technical consensus guidelines for the procedure to streamline practice and to provide guidance for new centres commencing the technique.

METHODS

Between October 2021 and October 2023 a series of face to face online and hybrid meetings were held in which a modified Delphi process was used to develop a unified consensus document. After each meeting the document was modified and recirculated and then rediscussed at subsequent meeting until a greater than 90% consensus was achieved in all recommendations.

RESULTS

The completed consensus document comprised 23 topics in which greater than 90% consensus was achieved, with 83% of recommendations having 100% consensus across all members of the working group. The consensus recommendations covered all areas of the surgical procedure including pre-operative assessment, drug dosing and administration, perfusion parameters, hyperthermia, leakage monitoring and theatre logistics, practical surgical strategies and also post-operative care, response evaluation and staff training.

CONCLUSION

We present the first joint expert-based consensus statement with respect to the technical aspects of ILP that can serve as a reference point for both existing and new centres in providing ILP.

Urine Biopsy as Dynamic Biomarker to Enhance Clinical Staging of Bladder Cancer in Radical Cystectomy Candidates

PURPOSE

There is significant interest in identifying complete responders to neoadjuvant chemotherapy (NAC) before radical cystectomy (RC) to potentially avoid removal of a pathologically benign bladder. However, clinical restaging after NAC is highly inaccurate. The objective of this study was to develop a next-generation sequencing-based molecular assay using urine to enhance clinical staging of patients with bladder cancer.

METHODS

Urine samples from 20 and 44 patients with bladder cancer undergoing RC were prospectively collected for retrospective analysis for molecular correlate analysis from two clinical trials, respectively. The first cohort was used to benchmark the assay, and the second was used to determine the performance characteristics of the test as it correlates to responder status as measured by pathologic examination.

RESULTS

First, to benchmark the assay, known mutations identified in the tissue (MT) of patients from the Accelerated Methotrexate, Vinblastine, Doxorubicin, Cisplatin trial (ClinicalTrials.gov identifier: NCT01611662, n = 16) and a cohort from University of California-San Francisco (n = 4) were cross referenced against mutation profiles from urine (MU). We then determined the correlation between MU persistence and residual disease in pre-RC urine samples from a second prospective clinical trial (The pT0 trial; ClinicalTrials.gov identifier: NCT02968732). Residual MU status correlated strongly with residual disease status (pT0 trial; n = 44; P = .0092) when MU from urine supernatant and urine pellet were assessed separately and analyzed in tandem. The sensitivity, specificity, PPV, and NPV were 91%, 50%, 86%, and 63% respectively, with an overall accuracy of 82% for this second cohort.

CONCLUSION

MU are representative of MT and thus can be used to enhance clinical staging of urothelial carcinoma. Urine biopsy may be used as a reliable tool that can be further developed to identify complete response to NAC in anticipation of safe RC avoidance.

Prospective phase II trial of preoperative hypofractionated proton therapy for extremity and truncal soft tissue sarcoma: the PRONTO study rationale and design

BACKGROUND

Oncologic surgical resection is the standard of care for extremity and truncal soft tissue sarcoma (STS), often accompanied by the addition of pre- or postoperative radiation therapy (RT). Preoperative RT may decrease the risk of joint stiffness and fibrosis at the cost of higher rates of wound complications. Hypofractionated, preoperative RT has been shown to provide acceptable outcomes in prospective trials. Proton beam therapy (PBT) provides the means to decrease dose to surrounding organs at risk, such as the skin, bone, soft tissues, and adjacent joint(s), and has not yet been studied in patients with extremity and truncal sarcoma.

METHODS

Our study titled "PROspective phase II trial of preoperative hypofractionated protoN therapy for extremity and Truncal soft tissue sarcOma (PRONTO)" is a non-randomized, prospective phase II trial evaluating the safety and efficacy of preoperative, hypofractionated PBT for patients with STS of the extremity and trunk planned for surgical resection. Adult patients with Eastern Cooperative Group Performance Status ≤ 2 with resectable extremity and truncal STS will be included, with the aim to accrue 40 patients. Treatment will consist of 30 Gy radiobiological equivalent of PBT in 5 fractions delivered every other day, followed by surgical resection 2-12 weeks later. The primary outcome is rate of major wound complications as defined according to the National Cancer Institute of Canada Sarcoma2 (NCIC-SR2) Multicenter Trial. Secondary objectives include rate of late grade ≥ 2 toxicity, local recurrence-free survival and distant metastasis-free survival at 1- and 2-years, functional outcomes, quality of life, and pathologic response.

DISCUSSION

PRONTO represents the first trial evaluating the use of hypofractionated PBT for STS. We aim to prove the safety and efficacy of this approach and to compare our results to historical outcomes established by previous trials. Given the low number of proton centers and limited availability, the short course of PBT may provide the opportunity to treat patients who would otherwise be limited when treating with daily RT over several weeks. We hope that this trial will lead to increased referral patterns, offer benefits towards patient convenience and clinic workflow efficiency, and provide evidence supporting the use of PBT in this setting.

TRIAL REGISTRATION

NCT05917301 (registered 23/6/2023).

Clinical recommendations for treatment of localized angiosarcoma: A consensus paper by the Italian Sarcoma Group

Angiosarcoma (AS) represents a rare and aggressive vascular sarcoma, posing distinct challenges in clinical management compared to other sarcomas. While the current European Society of Medical Oncology (ESMO) clinical practice guidelines for sarcoma treatment are applicable to AS, its unique aggressiveness and diverse tumor presentations necessitate dedicated and detailed clinical recommendations, which are currently lacking. Notably, considerations regarding surgical extent, radiation therapy (RT), and neoadjuvant/adjuvant chemotherapy vary significantly in localized disease, depending on each different site of onset. Indeed, AS are one of the sarcoma types most sensitive to cytotoxic chemotherapy. Despite this, uncertainties persist regarding optimal management across different clinical presentations, highlighting the need for further investigation through clinical trials. The Italian Sarcoma Group (ISG) organized a consensus meeting on April 1st, 2023, in Castel San Pietro, Italy, bringing together Italian sarcoma experts from several disciplines and patient representatives from "Sofia nel Cuore Onlus" and the ISG patient advocacy working group. The objective was to develop specific clinical recommendations for managing localized AS within the existing framework of sarcoma clinical practice guidelines, accounting for potential practice variations among ISG institutions. The aim was to try to standardize and harmonize clinical practices, or at least highlight the open questions in the local management of the disease, to define the best evidence-based practice for the optimal approach of localized AS and generate the recommendations presented herein.

Proton Therapy in Non-Rhabdomyosarcoma Soft Tissue Sarcomas of Children and Adolescents

This paper provides insights into the use of Proton Beam Therapy (PBT) in pediatric patients with non-rhabdomyosarcoma soft tissue sarcomas (NRSTS). NRSTS are a heterogeneous group of rare and aggressive mesenchymal extraskeletal tumors, presenting complex and challenging clinical management scenarios. The overall survival rate for patients with NRSTS is around 70%, but the outcome is strictly related to the presence of various variables, such as the histological subtype, grade of malignancy and tumor stage at diagnosis. Multimodal therapy is typically considered the preferred treatment for high-grade NRSTS. Radiotherapy plays a key role in the treatment of children and adolescents with NRSTS. However, the potential for radiation-induced side effects partially limits its use. Therefore, PBT represents a very suitable therapeutic option for these patients. The unique depth-dose characteristics of protons can be leveraged to minimize doses to healthy tissue significantly, potentially allowing for increased tumor doses and enhanced preservation of surrounding tissues. These benefits suggest that PBT may improve local control while reducing toxicity and improving quality of life. While clear evidence of therapeutic superiority of PBT over other modern photon techniques in NRSTS is still lacking-partly due to the limited data available-PBT can be an excellent treatment option for young patients with these tumors. A dedicated international comprehensive collaborative approach is essential to better define its role within the multidisciplinary management of NRSTS. Shared guidelines for PBT indications-based on the patient's age, estimated outcome, and tumor location-and centralization in high-level referral centers are needed to optimize the use of resources, since access to PBT remains a challenge due to the limited number of available proton therapy facilities.

Radiotherapy versus limb-sparing surgery alone in low-grade soft-tissue sarcoma of the extremity and trunk wall: a systematic review and meta-analysis

Current guidelines recommend the use of radiotherapy in the management of intermediate and high-grade soft-tissue sarcoma of the extremity and trunk wall. Its use in low-grade sarcoma is less clear. To date there have been no pooled data analyses regarding its role in this context. Its use is not without complications and therefore must be justified. We aim to assess the oncological impact of radiotherapy versus limb-sparing surgery alone in this subset of sarcoma. Medline, EMBASE and Cochrane's databases were searched from 1982 to present. Studies on or having a subgroup analysis of low-grade soft tissue sarcoma, with a radiotherapy and a surgery only arm were included. Outcomes included local recurrence and overall survival. Patients were at least 16 years of age with primary de-novo sarcoma who had not undergone prior resection or treatment. Those undergoing concomitant therapy were excluded. Data extraction was performed independently by two reviewers. Results were pooled using a random-effects model and presented as a forest plot. Primary outcome measures included local recurrence and overall survival. Eleven unique studies were included, consisting of two RCTs and nine non-randomized studies. Overall, there were 12 799 patients. Four studies were included in meta-analysis and the overall pooled effect showed a limited role of radiotherapy in overall survival outcomes when compared to limb-sparing surgery alone HR 1.00 [0.83-1.20] P = 0.41. Descriptive analysis suggests there is limited role of radiotherapy in improving local recurrence outcomes. This study suggests there is limited role for radiotherapy versus limb-sparing surgery alone in low-grade soft-tissue sarcoma. These findings strongly suggest there is lack of high-quality data and that further research must be undertaken prior to forming any strong conclusions regarding the management of low-grade soft-tissue sarcoma. Demonstrating a role for radiotherapy may help improve the quality of excisional margins and thus potentiate limb-sparing surgery.

Extremity and Truncal Soft Tissue Sarcoma: Risk Assessment and Multidisciplinary Management

Extremity and truncal soft tissue sarcomas are a heterogeneous group of rare cancers that arise from mesenchymal tissues. Hence, the adoption of tailored risk assessment and prognostication tools plays a crucial role in optimizing the decision-making for which of the many possible treatment strategies to select. Management of these tumors requires a multidisciplinary strategy, which has seen significant development in recent decades. Surgery has emerged as the primary treatment approach, with the main goal of achieving microscopic negative tumor margins. To reduce the likelihood of local recurrence, loco-regional treatments such as radiation therapy and isolated limb perfusion are often added to the treatment regimen in combination with surgery. This approach also enables surgeons to perform limb-sparing surgery, particularly in cases where a positive tumor margin is expected. Chemotherapy may also provide a further benefit in decreasing the probability of local recurrence or reducing distant metastasis in selected patients. Selecting the optimal treatment strategy for these rare tumors is best accomplished by an experienced multi-disciplinary team.

Are We Ready for Life in the Fast Lane? A Critical Review of Preoperative Hypofractionated Radiotherapy for Localized Soft Tissue Sarcoma

This critical review aims to summarize the relevant published data regarding hypofractionation regimens for preoperative radiation therapy (RT) prior to surgery for soft tissue sarcoma (STS) of the extremity or superficial trunk. We identified peer-reviewed publications using a PubMed search on the MeSH headings of "soft tissue sarcoma" AND "hypofractionated radiation therapy." To obtain complication data on similar anatomical radiotherapeutic scenarios we also searched "hypofractionated radiation therapy" AND "melanoma" as well as "hypofractionated radiation therapy" AND "breast cancer." We then used reference lists from relevant articles to obtain additional pertinent publications. We also incorporated relevant abstracts presented at international sarcoma meetings and relevant clinical trials as listed on the ClinicalTrials.gov website. Detailed data are presented and contextualized for ultra-hypofractionated and moderately hypofractionated regimens with respect to local control, wound complications, and amputation rates. Comparative data are also presented for late toxicities including: fibrosis, joint limitation, edema, skin integrity, and bone fracture or necrosis. These data are compared to a standard regimen of 50 Gy in 25 daily fractions delivered over 5 weeks. This analysis supports the continued use of a standard regimen for preoperative RT for STS of 25 × 2 Gy over 5 weeks without concurrent chemotherapy. Use of concurrent chemotherapy with preoperative RT for STS should be reserved for well-designed clinical trials. A randomized trial of ultra-hypofractionated and moderately hypofractionated pre op RT for STS is warranted, but it is critical for the primary endpoint (or co-primary endpoint) to be late toxicity to: bone, soft tissue, joint, and skin.

Prognostic Factors Associated with Tumor Recurrence and Overall Survival in Soft Tissue Sarcomas of the Extremities in a Colombian Reference Cancer Center

Introduction: Soft tissue sarcomas (STS) are low-incidence tumors whose clinical and histopathological factors are associated with adverse oncological outcomes. This study evaluated prognostic factors (PF) associated with tumor recurrence and overall survival (OS) in patients diagnosed with STS of the extremities, treated at the Instituto Nacional de Cancerología (INC), Bogotá, Colombia. Materials and Methods: An analytical observational study of a historical cohort was carried out, including patients diagnosed with STS and managed surgically in the Functional Unit for Breast and Soft Tissue Tumors of the INC from January 2008 to December 2018. Results: A total of 227 patients were included; 74.5% had tumors greater than 5 cm. Most patients (29.1%) were in stage IIIB at diagnosis. Age was associated with higher mortality (HR = 1.01; CI95%: 1-1.02; p = 0.048). Tumor persistence at admission to the INC (HR = 2.34; CI95%: 1.25-4.35; p = 0.007) and histologic grade III (HR = 5.36; CI95%: 2.29-12.56; p = <0.001) showed statistical significance in the multivariate analysis for recurrence of any type, as did the PFs associated with a higher risk of local recurrence (HR = 2.85; CI95%: 1.23-6.57; p = 0.014 and HR = 6.09; CI95%: 2.03-18.2; p = 0.001), respectively. Tumor size (HR = 1.03; CI95%: 1-1.06; p = 0.015) and histologic grade III (HR = 4.53; CI95%: 1.42-14.49; p = 0.011) were associated with a higher risk of distant recurrence. Conclusions: This cohort showed that in addition to histologic grade and tumor size, tumor persistence at the time of admission has an impact on disease recurrence, so STS should be managed by a multidisciplinary team with experience in this pathology in high-volume reference centers.

Clinico-Demographic Profile Of Soft Tissue Sarcoma- 5 Year Experience From A Tertiary Care Centre Of Eastern India

Soft tissue sarcomas (STS) are a diverse group of malignant mesenchymal neoplasm.But, due to their low prevalence, very little data is available worldwide as well as in India regarding their clinico-epidemiological pattern.In this study we analysed the clinico-demographic profile of STS patients attending a tertiary care centre of Eastern India over the last 5 years. We analyzed the prospectively maintained database of a tertiary care centre of West Bengal in Eastern India, and collected the data regarding the demography, clinical profile, pathology and treatment of STS patients who attended our OPD between 2017-2021. The objective was to assess the demographic and clinical data of STS patients of Eastern India and compare it with those of the reported literature from rest of the country as well as outside world. Most of the cases (27%) were between 41-50 years of age group with a slight male predominance (Male: Female = 1.01:1). Spindle cell sarcoma was the most common (24.3%) histology followed by undifferentiated pleomorphic sarcoma (15%) and extremities were the most common site of involvement (47.7%). 71% patients presented with stage III and advanced disease.81% patients underwent radical surgery,14% patient received neo-adjuvant and 60% received adjuvant radiotherapy.91% patients received systemic chemotherapy. To conclude, this study is one of its first from Eastern India and will act as a stepping stone for future studies concentrating on clinico-epidemiological profile, early diagnosis and treatment of STS.

Identifying risk factors and analyzing reconstructive outcomes in patients with lower-extremity soft-tissue sarcoma

PURPOSE

Reconstructing defects after resecting soft-tissue sarcoma (STS) can be challenging. The aim of this retrospective study was to analyze the reconstructive outcomes and identify the potential risk factors in patients undergoing reconstruction after excision of lower-extremity STS.

METHODS

Patients with lower-extremity STS were included. This database was compiled of patients from a single, large National Cancer Institute-accredited academic hospital. In total, 302 patients were included between January 2016 to January 2022. Univariate and multivariate analyses were performed to calculate odds ratios (ORs) for developing complications for each patient and surgical characteristic.

RESULTS

The following factors were independent predictors of any complication: benign pulmonary disease (OR = 4.2; p = 0.02), preoperative radiotherapy (RT; OR = 2.5; p = 0.047), a tumor in the medial thigh (OR = 1.9; p = 0.03), body mass index (BMI) > 30 kg/m2 (OR = 1.05; p = 0.037), and full-thickness skin graft (OR = 5.4; p = 0.01). In the preoperative RT subgroup, reconstructing a defect via undermining and layered closure alone was an independent predictor of dehiscence (OR = 2.1; p = 0.02) and seroma (OR = 3.1; p = 0.02), whereas pedicled flaps (OR = 0.08; p = 0.001) and free flaps (OR = 0.05; p = 0.001) were independent protectors against any complication.

CONCLUSION

Information derived from this analysis will assist with accurate preoperative patient counseling, which is crucial for informed decision-making and expectation management in lower-extremity STS. BMI and pulmonary function should be optimized to the extent possible to reduce postoperative complications. Patients treated preoperatively with RT should be reconstructed with a pedicled or free flap to optimize recovery.

Amputation in patients with extremity soft tissue sarcoma: the experience of an East Asian referral center

BACKGROUND

This study aimed to investigate the characteristics and clinical outcomes in a series of patients with extremity soft tissue sarcoma (STS) who underwent amputation at a large East Asian referral center.

PATIENTS AND METHODS

Of the 652 patients who underwent surgery for extremity STS, data of 37 consecutive patients who underwent amputation were reviewed retrospectively. The median follow-up period was 96.0 months (range, 15-216). The patients were classified in to three cohorts. The primary localized (PL) group included patients who underwent amputation as a primary surgical procedure with curative intent. The recurrent localized (RL) group included patients who underwent amputation as a revision procedure after failure of previous limb sparing surgeries. The metastatic group included patients who underwent amputation as a palliative procedure.

RESULTS

There were 22 cases of amputation in 596 STS patients and the amputation rate was 3.6% (22/596). Further, 1.8% (9/490) of patients with primary localized STS underwent amputation. Patients with localized STS who underwent amputation had a 5-year disease-specific survival (DSS) rate of 89.9% (95% Confidence Interval (CI), 87.1-92.7%), a local-recurrence-free survival (LRFS) of 84.1% (95% CI, 80.5-87.6%), and a metastasis-free survival (MFS) of 84.6%. (95% CI, 81.1-88.0%) Compared with previous studies, our results showed higher DSS and MFS rates with similar LRFS.

CONCLUSIONS

The amputation rate of extremity STS in our institute in East Asia was similar but slightly lower than that reported in Western studies. The oncologic outcome of amputation reported in this study was higher than that indicated in Western studies and oncologic outcome of amputation was not statistically different from those of limb salvage surgery. However, considering the small cohort in single institute study, there is a possibility of selection bias and future multi-center study is necessary. From our results, amputation is still a feasible option for appropriately selected patients unsuitable for limb-conserving surgery.

Patterns of Local Recurrence and Risk of Skin Recurrence in Soft Tissue Sarcomas After Surgical Resection

PURPOSE

Although there is a theoretical risk of skin seeding during surgical resection of soft tissue sarcomas (STSs), current consensus guidelines recommend against routine use of bolus during radiation therapy (RT). However, the risk of skin recurrence has not been systematically assessed. We aimed to assess the patterns of local recurrence (LR) in patients with STS treated with surgery with or without RT.

METHODS AND MATERIALS

We performed a retrospective analysis of adults with STSs evaluated at our institution between 2007 and 2021. For patients who developed LR, the depth was evaluated. Progression-free survival and overall survival were analyzed from time of first LR using the Kaplan-Meier method. Cumulative incidence of distant metastasis was calculated with competing risk analysis from date of LR.

RESULTS

Of the 206 patients evaluated, 20 had LR (9.7%). Among patients with LR, 5 patients (25.0%) were treated with surgery alone and 15 patients (75.0%) with surgery and RT. In patients treated with RT, 46.7% had preoperative RT, 53.3% had postoperative RT, and bolus was used in 46.7%. Surgical margins were close (<1 mm) in 4 patients (20.0%) and positive in 10 patients (50.0%). LR occurred in the deep subfascial tissue in 9 patients (45%), subcutaneous tissue in 10 patients (50.0%), and skin in 1 patient (5.0%). The patient with a skin recurrence was treated with surgery alone, and the tumor involved the skin at presentation. In patients treated with RT, LR occurred within the RT field in 13 patients (86.7%). At 1 year after LR, progression-free survival was 70.3%, overall survival was 81.7%, and cumulative incidence of distant metastasis was 5.9%.

CONCLUSIONS

Skin recurrences were rare after surgical resection of STSs and only occurred in a tumor that involved the skin at initial presentation. These findings support current recommendations against routine use of bolus in STSs not involving the skin at presentation.