Analysis of the prognostic significance of microscopic margins in 2,084 localized primary adult soft tissue sarcomas

A pattern of local failure after preoperative 5 × 5 Gy in soft tissue sarcomas: A long-term real-world experience

Introduction

Preoperative radiotherapy (RT) is used to improve local control (LC) and facilitate limb-sparing procedures in patients with localized soft tissue sarcomas (STS). While conventional preoperative RT delivers 50-50.4 Gy in 25-28 fractions, alternative hypofractionated regimens are under investigation. A 5x5 Gy regimen has been investigated in STS, but its long-term LC rates appear suboptimal. The aim of this study is to analyze the characteristics of patients with local recurrence (LR) after 5x5 Gy and to identify potential RT-related factors affecting efficacy.

Methods

We retrospectively analyzed patients who received 5x5 Gy and underwent surgery for localized extremity and truncal STS in three clinical trials and institutional records. Patient, tumor, and treatment characteristics were evaluated. We assessed the quality of RT plans and recurrence patterns.

Results

Among 174 patients who experienced LR after 5x5 Gy, pleomorphic sarcoma (23 %), myxofibrosarcoma (17.8 %), and malignant peripheral nerve sheath tumor (12 %) were the most common pathologic diagnoses. No LR was observed in patients with myxoid liposarcoma. Almost all analyzed plans met the quality criteria. Most patients (86.2 %) had in-volume recurrences, suggesting inadequate tumor cell eradication rather than insufficient margins or poor target coverage. Dose equivalence analysis suggested that 5x5 Gy (EQD2 = 37.5 Gy for STS, assuming alpha/beta ratio of 4 Gy) may be insufficient, especially for radioresistant subtypes.

Conclusions

The primary factor contributing to LR after 5x5 Gy appears to be insufficient total dose. Future clinical trials should explore dose escalation beyond 5 Gy per fraction, except in myxoid liposarcoma where 5x5 Gy remains effective.

PNI is useful for predicting the prognosis of patients with soft tissue sarcoma: A retrospective study

BACKGROUND

It is known that preoperative Prognostic Nutritional Index (PNI) is useful in predicting prognosis in gastrointestinal diseases and that preoperative improvement of nutritional status improves prognosis. However, there have been few large-scale reports examining the prognostic value of PNI in soft tissue sarcomas. Therefore, the aim of this study is to investigate whether the PNI can be useful for predicting overall survival in soft tissue sarcoma.

METHODS

Between January 2006 and March 2022 at our hospital, 111 patients with pathologically diagnosed soft tissue sarcoma were included, retrospectively. Several nutritional or inflammatory biomarkers such as PNI were calculated from the pretreatment blood sample results. The patients were classified into two groups (low and high groups) based on the median value of each parameter. Overall survival was analyzed by the Kaplan‒Meier method and log-rank test. Univariate and multivariate analyses using the Cox proportional hazards model were used to investigate prognostic factors for overall survival.

RESULTS

The median overall survival was 24.3 months (mean 37.3 months), and the high PNI group had a significantly longer overall survival than the low PNI group (p < 0.0001). PNI was the most significant univariate factor for overall survival among other nutritional and inflammatory parameters (HR: 5.64, 95% CI: 2.26-14.12, p = 0.0002). The multivariate proportional hazards model was built using variables with prognostic potential as suggested by previous analysis with respect to patient characteristics and PNI. As potential confounding factors, we included PNI, stage, age, and tumor location. PNI was also an independent prognostic factor in multivariate analysis (HR: 7.02, CI: 2.52-19.40, p = 0.0002).

CONCLUSION

PNI is a useful prognostic factor among various parameters for overall survival in patients with soft tissue sarcoma.

Prognostic Value of Inflammatory and Nutritional Indicators in Non-Metastatic Soft Tissue Sarcomas

Background

Soft tissue sarcoma (STS) has lacked reliable prognostic indicators. This study evaluates blood-based inflammatory and nutritional indexes to identify good predictors for STS outcomes. These indicators included neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR), systemic inflammation response index (SIRI), lymphocyte-to-monocyte ratio (PNI), albumin-to-globulin ratio (AGR), and platelet-to-albumin ratio (PAR).

Methods

A total of 93 were included, and blood indexes were measured preoperatively. Univariate and multivariate regression analyses identified significant predictors, and model performance was assessed using the Akaike Information Criterion (AIC), Bayesian Information Criterion (BIC), Concordance Index (C-index), and Likelihood Ratio Chi-Square (LR_χ2).

Results

Univariate analysis indicated that NLR, PLR, LMR, SIRI, AGR, and PAR show potentially significant differences (P<0.01), except for PNI. Further analysis showed that SIRI and AGR have a high C-index, LR_χ2, and -2 log-likelihood, lower AIC and BIC, indicating a better model fit for overall survival (OS) and disease-free survival (DFS). The combination index of the SIRI+AGR+Enneking stage achieved the best accuracy (C-index: 0.751 for DFS; C-index: 0.755 for OS). Multivariate regression showed higher Enneking staging (HR=2.720, P=0.038), lower AGR (HR=2.091, P=0.014), and higher SIRI (HR=2.078, P=0.034) as independent prognostic factors for DFS. Meanwhile, low AGR (HR=3.729, P=0.034), and high SIRI (HR=3.729, P=0.016) remained independent prognostic factors for OS.

Conclusion

Preoperative SIRI is a better predictive index compared to NLR, PLR, and LMR. Preoperative SIRI and AGR are independent risk factors for both DFS and OS. The combination index of the SIRI+AGR+Enneking stage provides a more robust prediction of clinical prognosis in STS patients.

Evaluation of a targeted anti-αvβ3 integrin near-infrared fluorescent dye for fluorescence-guided resection of naturally occurring soft tissue sarcomas in dogs

PURPOSE

Complete resection is a key prognostic factor for survival in patients with soft tissue sarcoma (STS), in humas and companion animals alike. Fluorescence-guided surgery could improve resection accuracy. As dogs are frequently affected by STS, they serve as a model to test an anti-αvβ3 integrin targeting near-infrared fluorescent (NIRF) dye (AngiostampTM800) for fluorescence-guided surgery in STS to evaluate its safety and feasibility in dogs, and if it translates into a clinically relevant benefit compared to the standard of care with regards to completeness of surgery and local recurrence. Furthermore, we aimed to correlate target expression and NIRF-signal intensity.

METHODS

Twenty dogs with STS were randomly allocated to either receive Angiostamp™ (NIRF group) or physiologic saline (control group) preoperatively. The researchers were blinded for treatment, and resections were adapted based on the NIRF-signal, if needed. Margin status was histologically determined at the 1 and 3 cm margin. The tumor-to-background ratio was measured in native tissue biopsies and formalin-fixed tissue. The fluorescent area was compared to the corresponding tumor areas as confirmed by histology using the Dice coefficient. Target expression was quantified by immunohistochemistry and correlated to NIRF-signal ratios.

RESULTS

A fluorescent signal was detected in all 10 tumors of the NIRF group, with a tumor-to-background ratio of 7.4 ± 5.8 in native biopsies and 13.5 ± 10.9 in formalin-fixed tissue. In the NIRF group, resection margins were adapted in 5/10 cases, leading to complete resection and preventing R1 in four of these cases. In the NIRF and control group 9/10 and 8/10 resections were R0, with one local recurrence in each group and one sarcoma-related death in the NIRF group. The NIRF-signal correlated with the histologically confirmed tumor area (Dice coefficient 0.75 ± 0.17). Target expression was higher in tumor compared to peritumoral tissue (p < 0.0003) and showed a moderate correlation with the NIRF-signal (r = 0.6516, p < 0.0001).

CONCLUSION

Fluorescence-guided surgery using Angiostamp™ can pinpoint residual disease in the tumor bed and contributes to an improved resection accuracy in canine STS.

Hypofractionated Preoperative Radiation Therapy for Soft Tissue Sarcoma: A Systematic Review

PURPOSE

Hypofractionated radiation therapy is being used more frequently for many common cancer sites. Conventionally fractionated radiation therapy treatment regimens have remained the standard of care when radiation therapy is indicated for soft tissue sarcoma (STS). The aim of this study was to systematically review published data on the use of preoperative hypofractionated radiation therapy as part of a curative treatment paradigm in patients with STS. Herein, we summarize current evidence for the use of hypofractionated radiation therapy in the preoperative treatment of STS.

METHODS AND MATERIALS

We conducted a database search for prospectively or retrospectively collected data on patients with a diagnosis of STS treated with hypofractionated radiation therapy. Studies evaluating STS of all histologic subtypes affecting extremities or trunks were included in the search. Articles were screened by 2 independent reviewers for inclusion in this review. Patient, treatment, toxicity, and outcome data were recorded and collated from selected studies.

RESULTS

Twenty-five articles are included in this review. Nine prospective trials have been published since 2020. Dose fractionations range from 25 to 40 Gy in 5 fractions or 28-42.75 Gy in 8-15 fractions. Local control and overall survival outcomes are consistent with historical data for conventionally fractionated radiation therapy. Acute toxicity and wound complication rates are in keeping with acceptable results. Late toxicity data are limited and require longer follow-up. Rates of pathologic complete response are promising across all studies.

CONCLUSIONS

There is a growing body of evidence supporting hypofractionation as safe and effective in the preoperative treatment of STS. This review highlights potential areas that could be further investigated to optimize preoperative treatment for STS.

Detection properties of indium-111 and IRDye800CW for intraoperative molecular imaging use across tissue phantom models

Significance

Intraoperative molecular imaging (IMI) enables the detection and visualization of cancer tissue using targeted radioactive or fluorescent tracers. While IMI research has rapidly expanded, including the recent Food and Drug Administration approval of a targeted fluorophore, the limits of detection have not been well-defined.

Aim

The ability of widely available handheld intraoperative tools (Neoprobe and SPY-PHI) to measure gamma decay and fluorescence intensity from IMI tracers was assessed while varying characteristics of both the signal source and the intervening tissue or gelatin phantoms.

Approach

Gamma decay signal and fluorescence from tracer-bearing tumors (TBTs) and modifiable tumor-like inclusions (TLIs) were measured through increasing thicknesses of porcine tissue and gelatin in custom 3D-printed molds. TBTs buried beneath porcine tissue were used to simulate IMI-guided tumor resection.

Results

Gamma decay from TBTs and TLIs was detected through significantly thicker tissue and gelatin than fluorescence, with at least 5% of the maximum signal observed through up to 5 and 0.5 cm, respectively, depending on the overlying tissue type or gelatin.

Conclusions

We developed novel systems that can be fine-tuned to simulate variable tumor characteristics and tissue environments. These were used to evaluate the detection of fluorescent and gamma signals from IMI tracers and simulate IMI surgery.

Outcome and survival analysis of pulmonary metastasectomy for primary sarcoma with pulmonary metastases

Background

Sarcomas are rare malignancies, accounting for approximately 1% of all cancers. Pulmonary metastases are the most preferential site for distant metastasis in malignant soft tissue sarcomas. Despite the lack of evidence from large randomized trials to support treatment guidelines, surgical resection of resectable metastatic tumors remains the current standard of care. This study aimed to explore the survival status of patients with soft tissue sarcoma after resection of pulmonary metastases.

Methods

This study is a retrospective analysis of patients who mestastasectomy by means of lobar or sublobar resections at National Taiwan University Hospital and its branches. The statistical and investigation period was from February 2007 to December 2020.

Results

Among 110 samples during the investigation period, the overall 5-year survival rate was 62.9%, which was higher than the 15%-50.9% reported previously. A disease-free interval of more than 12 months and the occurrence of local recurrence of sarcoma at the time of resection of pulmonary metastases are associated with overall survival. Most of the samples were treated with minimally invasive surgery (VATS), and therefore, most patients had a shorter hospital stay and better postoperative recovery.

Conclusion

For pulmonary metastatic sarcoma, pulmonary metastasectomy is a relatively safe treatment method with short hospital stay and short ICU stay. The results of this study suggest that VATS is preferred over thoracotomy, but further observations are needed to confirm these findings.

A preliminary study of primary retroperitoneal sarcoma at a tertiary University Hospital in Bangkok, Thailand: a retrospective observational study

Background

Retroperitoneal sarcoma (RPS) is rare and difficult to treat with a high recurrent rate. Very little data regarding primary RPS exists in Thailand.

Objectives

To study the outcome of treatment of primary RPS at a tertiary University Hospital in Bangkok, Thailand.

Methods

All patients who had RPS undergoing the first surgical resection at King Chulalongkorn Memorial Hospital from June 2003 to December 2019 were retrospectively enrolled in the study. Perioperative management, results of treatment, postoperative complications, and outcome were analyzed.

Results

Thirty-eight patients entered the study. Large abdominal mass was the most common presentation (90%). Liposarcoma was the most common histology (58%). Twenty patients (53%) had preoperative core needle biopsy and 21 (55%) underwent preoperative radiotherapy (RT). The tumor size ranged from 3 cm to 48 cm (median 22 cm). Five patients (13%) had total mass removal only while 33 (87%) had complete gross resection with ≥1 visceral organ resection. Surgical margins classified as R0, R1, and R2 were 61%, 34%, and 5%, respectively. Five patients (16%) had postoperative complications. There was no 30-day postoperative mortality. The local recurrence rate was 34%. Survival analysis revealed a 5-year overall survival rate of 37% and 5-year disease-free survival rate of 29%. The 5-year and 10-year recurrent rates were 71% and 95%, respectively. Multivariate analysis showed that preoperative radiation was the only factor reducing recurrence (19% vs. 53%, OR: 0.21, P = 0.011).

Conclusion

The preliminary study of outcome of the treatment of primary RPS at our institution showed a fair prognosis of this rare malignancy despite our aggressive surgical approaches. Preoperative radiation may help reduce recurrence in selected primary RPS patients.

Improving Sarcoma Outcomes: Target Trial Emulation to Compare the Impact of Unplanned and Planned Resections on the Outcome

This study follows the Target Trial Emulation (TTE) framework to assess the impact of unplanned resections (UEs) and planned resections (PEs) of sarcomas on local recurrence-free survival (LRFS), metastasis-free survival (MFS), cancer-specific survival (CSS), and overall survival (OS). Sarcomas, malignant tumors with mesenchymal differentiation, present a significant clinical challenge due to their rarity, complexity, and the frequent occurrence of UEs, which complicates effective management. Our analysis utilized real-world-time data from the Swiss Sarcoma Network, encompassing 429 patients, to compare the impact of UEs and PEs, adjusting for known prognostic factors through a multivariable Cox regression model and propensity score weighting. Our findings reveal a significantly higher risk of local recurrence for UEs and a short-term follow-up period that showed no marked differences in MFS, CSS, and OS between the UE and PE groups, underlining the importance of optimal initial surgical management. Furthermore, tumor grade was validated as a critical prognostic factor, influencing outcomes irrespective of surgical strategy. This study illuminates the need for improved referral systems to specialized sarcoma networks to prevent UEs and advocates for the integration of TTE in sarcoma research to enhance clinical guidelines and decision-making in sarcoma care. Future research should focus on the prospective validations of these findings and the exploration of integrated care models to reduce the incidence of UEs and improve patient outcomes.

Giant Myxofibrosarcoma in the Lower Limb: An Overview of Diagnostic and Clinical Management

Myxofibrosarcoma (MFS), an aggressive soft tissue sarcoma, is one of the undifferentiated pleomorphic sarcomas; it has a low incidence, affecting people in the sixth to eighth decades of life. It usually involves the extremities and is painless with a slow-growing pattern. Based on the case of a 52-year-old female patient who presented with a painful, massive, rapid-growing, ulcerated tumor of the anterior surface of the left thigh, we performed a literature review regarding the current standard of care for patients with MFS. Computed tomography examination, followed by magnetic resonance imaging and surgical biopsy with histopathological examination, confirmed the diagnosis and the presence of lung and inguinal lymph node metastases. Due to the rapid-growing pattern and the local aggressiveness, our tumor board team recommended emergency excisional surgery, with subsequent reconstructive procedures followed by referral to an oncological center. This review emphasizes the importance of proper and rapid diagnosis, followed by multidisciplinary management, for MFS cases with atypical presentation and distal metastases to improve overall outcomes.

Radical resection and hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of high risk recurrent retroperitoneal sarcoma-A pilot study in a tertiary Asian centre

BACKGROUND

Peritoneal sarcomatosis (PS) is a difficult entity to treat with limited options and guarded prognosis. We aimed to determine if the addition of hyperthermic intraperitoneal chemotherapy (HIPEC) could offer superior local recurrence-free survival in patients with retroperitoneal sarcoma at high risk of developing PS as opposed to extended resection alone.

METHODS

This is a single arm, phase II intervention study where all patients with recurrent localized retroperitoneal sarcoma considered at high risk of developing PS were considered for enrolment (ClinicalTrials.gov identifier: NCT03792867). Upon enrolment, patients underwent vigorous preoperative testing to ensure fitness for the procedure. During surgery, patients underwent extended resection and HIPEC with doxorubicin. Patients were followed-up every 2 weeks (± 10 days) for the first month and subsequently every three months (± 1 month) up to a year post-surgery, and were assessed for potential chemotherapy toxicity and post-treatment complications. After a year from resection and HIPEC, patients were followed-up either during routine clinic review or contacted via telephone every year (± 1 month) for 3 years.

RESULTS

Six patients were recruited but one patient dropped out due to adverse and unexpected intraoperative events. The remaining patients completed the procedure uneventfully. Post-HIPEC, all patients recurred with a disease-free interval ranging from six to 24 months. Three patients died due to complications from recurrent disease whereas the remaining three patients are alive as of their last visit. The overall survival at time at reporting ranged between 22 to 56 months.

CONCLUSION

The procedure is feasible with no major morbidity to patients. However, we are unable to recommend for it to be implemented as a routine procedure at this current stage due to lack of improved survival outcomes. Further multi-institutional studies may be conducted to yield better results.

Neoadjuvant Therapies Do Not Reduce Epidermal Growth Factor Receptor (EGFR) Expression or EGFR-Targeted Fluorescence in a Murine Model of Soft-Tissue Sarcomas

PURPOSE

ABY-029, an epidermal growth factor receptor (EGFR)-targeted, synthetic Affibody peptide labeled with a near-infrared fluorophore, is under investigation for fluorescence-guided surgery of sarcomas. To date, studies using ABY-029 have occurred in tumors naïve to chemotherapy (CTx) and radiation therapy (RTx), although these neoadjuvant therapies are frequently used for sarcoma treatment in humans. The goal of this study was to evaluate the impact of CTx and RTx on tumor EGFR expression and ABY-029 fluorescence of human soft-tissue sarcoma xenografts in a murine model.

PROCEDURES

Immunodeficient mice (n = 98) were divided into five sarcoma xenograft groups and three treatment groups - CTx only, RTx only, and CTx followed by RTx, plus controls. Four hours post-injection of ABY-029, animals were sacrificed followed by immediate fluorescence imaging of ex vivo adipose, muscle, nerve, and tumor tissues. Histological hematoxylin and eosin staining confirmed tumor type, and immunohistochemistry staining determined EGFR, cluster of differentiation 31 (CD31), and smooth muscle actin (SMA) expression levels. Correlation analysis (Pearson's correlation coefficients, r) and linear regression (unstandardized coefficient estimates, B) were used to determine statistical relationships in molecular expression and tissue fluorescence between xenografts and treatment groups.

RESULTS

Neoadjuvant therapies had no broad impact on EGFR expression (|B|≤ 7.0, p ≥ 0.4) or on mean tissue fluorescence (any tissue type, (|B|≤ 2329.0, p ≥ 0.1). Mean tumor fluorescence was significantly related to EGFR expression (r = 0.26, p = 0.01), as expected.

CONCLUSION

Results suggest that ABY-029 as an EGFR-targeted, fluorescent probe is not negatively impacted by neoadjuvant soft-tissue sarcoma therapies, although validation in humans is required.

Update on Dosing and Fractionation for Neoadjuvant Radiotherapy for Localized Soft Tissue Sarcoma

OPINION STATEMENT

Neoadjuvant radiotherapy (RT) over 5-6 weeks with daily doses of 1.8-2.0 Gy to a total dose of 50-50.4 Gy is standard of care for localized high-grade soft tissue sarcomas (STS) of the extremities and trunk wall. One exception is myxoid liposarcomas where the phase II DOREMY trial applying a preoperative dose of 36 Gy in 2 Gy fractions (3-4 weeks treatment) has achieved excellent local control rates of 100% after a median follow-up of 25 months.Hypofractionated preoperative RT has been investigated in a number of phase II single-arm studies suggesting that daily doses of 2.75-8 Gy over 1-3 weeks can achieve similar oncological outcomes to conventional neoadjuvant RT. Prospective data with direct head-to-head comparison to conventional neoadjuvant RT investigating oncological outcomes and toxicity profiles is eagerly awaited.For the entire group of retroperitoneal sarcomas, RT is not the standard of care. The randomized multi-center STRASS trial did not find a benefit in abdominal recurrence-free survival by the addition of preoperative RT. However, for the largest histological subgroup of well-differentiated and grades I and II dedifferentiated liposarcomas, the STRASS trial and the post-hoc propensity-matched STREXIT analysis have identified a possible benefit in survival by preoperative RT. These patients deserve to be informed about the pros and cons of preoperative RT while the longer follow-up data from the STRASS trial is awaited.

Functional outcomes of reconstructive flap surgery for soft tissue sarcoma: Long-term outcomes of functional restoration using innervated muscle transplantation

Functional outcomes associated with prognostic factors and innervated muscle transplantation after wide soft tissue sarcoma resection remain unclear. We retrospectively examined the functional outcomes of reconstructive flap surgery for soft tissue sarcoma. Twenty patients underwent innervated muscle transplantation with pedicled or free flaps for functional reconstruction of resected muscles. Thirteen latissimus dorsi muscles and one vastus lateralis muscle combined with an anterolateral thigh flap were transferred as free flaps using the epi-perineural suture technique. Six latissimus dorsi muscles were transferred as pedicled flaps with neural continuity. Postoperative functional outcomes were assessed using the Musculoskeletal Tumor Society (MSTS) scores for the upper and lower extremities of 22 and 24 patients, respectively. The mean MSTS score for all patients was 82.3 at 12 months postoperatively. The mean scores for patients who underwent reconstruction with pedicled and free flaps were 89.2 and 77.1, respectively. The MSTS scores for the lower extremity, tumor size ≥5 cm, and free flap reconstruction were significantly lower than those for the upper extremity, tumor size <5 cm, and pedicled flap reconstruction (P = 0.02, 0.37, and 0.008, respectively). The postoperative MSTS score for innervated muscle transplantation was 76.7 at 12 months and was significantly higher (83.7) at 24 months (P = 0.003). Functional outcomes were significantly associated with tumor location, tumor size, and reconstructive flap type based on the MSTS scores. Innervated muscle transplantation improved functional outcomes at 24 months postoperatively via sufficient recovery of the innervated muscle, not the compensatory recovery of the remaining muscle.

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.

Amputation surgery associated with shortened survival in patients with localized soft tissue sarcoma

BACKGROUND

The objectives of this study were to clarify whether localized extremity soft tissue sarcoma (STS) patients who underwent amputation surgery experienced worsened survival and to identify those patients for whom amputation surgery worsened survival.

METHODS

Using the Surveillance, Epidemiology, and End Results database, we identified 8897 patients with localized extremity STS between 1983 and 2016. Of these 6431 patients, 733 patients underwent amputation surgery (Amputation group), and 5698 underwent limb-sparing surgery (Limb-sparing group).

RESULTS

After adjusting for patient background by propensity score matching, a total of 1346 patients were included. Patients in the Amputation group showed worsened survival (cancer-specific survival (CSS): hazard ratio (HR) = 1.42, 95% confidence interval (CI) 1.15-1.75, overall survival (OS): HR = 1.41, 95%CI 1.20-1.65). In subclass analysis, patients with high-grade STS, spindle cell sarcoma and liposarcoma in the Amputation group showed shortened survival (high-grade-CSS: HR = 1.44, 95%CI 1.16-1.77, OS: HR = 1.38, 95%CI 1.18-1.62; spindle cell sarcoma-CSS: HR = 4.75, 95%CI 1.56-14.4, OS: HR = 2.32, 95%CI 1.45-3.70; liposarcoma-CSS: HR = 2.91, 95%CI 1.54-5.50, OS: HR = 2.32, 95%CI 1.45-3.70).

CONCLUSIONS

Survival was shortened in localized extremity STS patients who received amputation surgery.

What is the diagnostic accuracy of fluorescence-guided surgery for margin assessment in appendicular bone and soft tissue tumors? - A systematic review of clinical studies

BACKGROUND

Fluorescence-guided surgery (FGS) is a novel technique to successfully assess surgical margins intraoperatively. Investigation and adoption of this technique in orthopaedic oncology remains limited.

METHODS

The PRISMA guidelines were followed for this manuscript. Our study was registered on PROSPERO (380520). Studies describing the use of FGS for resection of bone and soft tissue sarcomas (STS) on humans were included. Diagnostic performance metrics (sensitivity, specificity, positive predictive value [PPV], negative predictive value [NPV] and accuracy) and margin positivity rate were the outcomes assessed.

RESULTS

Critical appraisal using the Joanna Brigs Institute checklists showed significant concerns for study quality. Sensitivity of FGS ranged from 22.2 % to 100 % in three of the four studies assessing his metrics; one study in appendicular tumors in the pediatric population reported 0 % sensitivity in the three cases included. Specificity ranged from 9.38 % to 100 %. PPV ranged from 14.6 % to 70 % while NPV was between 53.3 % and 100 %. The diagnostic accuracy ranged from 21.62 % to 92.31 %. Margin positivity rate ranged from 2 % to 50 %, with six of the seven studies reporting values between 20 % and 50 %.

CONCLUSIONS

FSG is a feasible technique to assess tumor margins in bone and STS. Reported performance metrics and margin positivity rates vary widely between studies due to low study quality and high heterogeneity in dying protocols.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Toward the use of diffuse reflection spectroscopy for intra-operative tissue discrimination during sarcoma surgery

Significance

Accurately distinguishing tumor tissue from normal tissue is crucial to achieve complete resections during soft tissue sarcoma (STS) surgery while preserving critical structures. Incomplete tumor resections are associated with an increased risk of local recurrence and worse patient prognosis.

Aim

We evaluate the performance of diffuse reflectance spectroscopy (DRS) to distinguish tumor tissue from healthy tissue in STSs.

Approach

DRS spectra were acquired from different tissue types on multiple locations in 20 freshly excised sarcoma specimens. A k -nearest neighbors classification model was trained to predict the tissue types of the measured locations, using binary and multiclass approaches.

Results

Tumor tissue could be distinguished from healthy tissue with a classification accuracy of 0.90, sensitivity of 0.88, and specificity of 0.93 when well-differentiated liposarcomas were included. Excluding this subtype, the classification performance increased to an accuracy of 0.93, sensitivity of 0.94, and specificity of 0.93. The developed model showed a consistent performance over different histological subtypes and tumor locations.

Conclusions

Automatic tissue discrimination using DRS enables real-time intra-operative guidance, contributing to more accurate STS resections.

Survival outcomes of malignant peripheral nerve sheath tumors (MPNSTs) with and without neurofibromatosis type I (NF1): a meta-analysis

INTRODUCTION

Malignant peripheral nerve sheath tumors (MPNSTs) are malignancies that demonstrate nerve sheath differentiation in the peripheral nervous system. They can occur sporadically or be associated with neurofibromatosis type 1 (NF1), an autosomal dominant neurocutaneous disorder, with up to 13% of patients developing MPNSTs in their lifetimes. Previous studies have suggested conflicting findings regarding the prognosis of NF1 for patients with MPNSTs. The elucidation of NF1 as an independent prognostic factor on mortality has implications for clinical management. We aim to investigate the role of NF1 status as an independent prognostic factor of overall survival (OS) and disease-specific survival (DSS) in MPNSTs.

METHODS

An electronic literature search of PubMed and MEDLINE was performed on studies reporting OS or DSS outcomes of MPNSTs with and without NF1. A grey literature search by reviewing bibliographies of included studies and review articles was performed to find pertinent studies. Data was extracted and assessed in accordance with the PRISMA guidelines. A meta-analysis was performed to calculate hazard ratios (HRs) using a random-effects model. The primary and secondary outcomes were all-cause and disease-specific mortality, respectively, with NF1 as an independent prognostic factor of interest.

RESULTS

A total of 59 retrospective studies involving 3602 patients fulfilled the inclusion criteria for OS analysis, and 23 studies involving 704 MPNST patients were included to evaluate DSS outcomes. There was a significant increase in the hazard of all-cause mortality (HR 1.63, 95% CI 1.45 to 1.84) and disease-specific mortality (HR 1.52, 95% CI 1.24 to 1.88) among NF1 as compared to sporadic cases. Subgroup analyses and meta-regression showed that this result was consistent regardless of the quality of the study and year of publication.

CONCLUSION

NF1 is associated with a substantially higher risk of all-cause and disease-specific mortality. This finding suggests that closer surveillance is required for NF1 patients at risk of developing MPNSTs.

Care Pathway Analysis to Inform the Earliest Stages of Technology Development: Scoping Oncological Indications in Need of Innovation

OBJECTIVES

Identifying unmet needs for innovative solutions across disease contexts is challenging but important for directing funding and research efforts and informing early-stage decisions during the innovation process. Our aim was to study the merits of care pathway analysis to scope disease contexts and guide the development of innovative devices. We used oncologic surgery as a case study, for which many intraoperative imaging techniques are under development.

METHODS

Care pathway analysis is a mapping process, which produces graphical maps of clinical pathways using important outcomes and subsequent consequences. We performed care pathway analyses for glioblastoma, breast, bladder, prostate, renal, pancreatic, and oral cavity cancer. Differences between a "perfect" care pathway and the current care pathway in terms of percentage of inadequate margins, associated recurrences, quality of life, and 5-year overall survival were calculated to determine unmet needs. Data from The Netherlands Cancer Registry and literature were used.

RESULTS

Care pathway analysis showed that highest percentages of inadequate margins were found in oral cavity cancer (72.5%), glioblastoma (48.7%), and pancreatic cancer (43.9%). Inadequate margins showed the strongest increase in recurrences in cancer of oral cavity, and bladder (absolute increases of 43.5% and 41.2%, respectively). Impact on survival was largest for bladder and oral cavity cancer with positive margins.

CONCLUSIONS

Care pathway analysis provides overviews of current clinical paths in multiple indications. Disease contexts can be compared via effectiveness gaps that show the potential need for innovative solutions. This information can be used as basis for stakeholder involvement processes to prioritize care pathways in need of innovation.

The Impact of Edema on MRI Radiomics for the Prediction of Lung Metastasis in Soft Tissue Sarcoma

INTRODUCTION

This study aimed to evaluate whether radiomic features extracted solely from the edema of soft tissue sarcomas (STS) could predict the occurrence of lung metastasis in comparison with features extracted solely from the tumoral mass.

MATERIALS AND METHODS

We retrospectively analyzed magnetic resonance imaging (MRI) scans of 32 STSs, including 14 with lung metastasis and 18 without. A segmentation of the tumor mass and edema was assessed for each MRI examination. A total of 107 radiomic features were extracted for each mass segmentation and 107 radiomic features for each edema segmentation. A two-step feature selection process was applied. Two predictive features for the development of lung metastasis were selected from the mass-related features, as well as two predictive features from the edema-related features. Two Random Forest models were created based on these selected features; 100 random subsampling runs were performed. Key performance metrics, including accuracy and area under the ROC curve (AUC), were calculated, and the resulting accuracies were compared.

RESULTS

The model based on mass-related features achieved a median accuracy of 0.83 and a median AUC of 0.88, while the model based on edema-related features achieved a median accuracy of 0.75 and a median AUC of 0.79. A statistical analysis comparing the accuracies of the two models revealed no significant difference.

CONCLUSION

Both models showed promise in predicting the occurrence of lung metastasis in soft tissue sarcomas. These findings suggest that radiomic analysis of edema features can provide valuable insights into the prediction of lung metastasis in soft tissue sarcomas.

Prognostic Factors in Extremity Soft Tissue Sarcomas Treated with Radiotherapy: Systematic Review of the Literature

Soft tissue sarcomas of the extremities are rare tumors with various prognostic factors. Their management is debatable due to their inconsistent results within the literature and the lack of large prospective studies. The objective of this systematic review is to analyze the available scientific data on prognostic factors concerning the characteristics of the patients, the disease and the treatments performed, as well as their potential complications, on studies with a median follow-up of 5 years at minimum. A search of articles following the "PRISMA method" and using the PubMed search engine was conducted to select the most relevant studies. Twenty-five articles were selected, according to preestablished criteria. This review provides a better understanding of the prognosis and disease outcome of these tumors. Many factors were described comparing the frequency of occurrence according to the studies, which remain heterogeneous between them. Significant factors that could orient patients to radiotherapy were highlighted. These positive prognostic factors provide valuable insight to optimize radiotherapy treatments for patients treated for soft tissue sarcoma of the extremities.

Endoprosthetic reconstruction for lower extremity soft tissue sarcomas with bone involvement

BACKGROUND AND OBJECTIVES

Bone resection and endoprosthetic reconstruction (EPR) in the setting of soft tissue sarcoma (STS) management is rare and incurs unique challenges. We aim to report on the surgical and oncological outcomes of this relatively previously undocumented cohort.

METHODS

This is a single-center retrospective review of prospectively collected data for patients who required EPRs following resection of STSs of the lower extremity. Following inclusion criteria, we assessed 29 cases of EPR for primary STS of the lower limb.

RESULTS

The mean age was 54 years (range 18-84). Of the 29 patients, there were 6 total femur, 11 proximal femur, 4 intercalary, and 8 distal femur EPRs. Fourteen of 29 patients (48%) underwent re-operations for surgical complications, with 9 relating to infection (31%). When a matched cohort analysis was performed comparing our cohort to STSs that did not necessitate EPR, a reduced rate of overall survival and metastasis-free survival was found in those requiring EPR.

CONCLUSION

This series identifies a high rate of complication from EPRs performed for STS. Patients should be cautioned about the high rate of infection, surgical complications, and lower overall survival in this setting.

Near-infrared (NIR) imaging with indocyanine green (ICG) may assist in intraoperative decision making and improving surgical margin in bone and soft tissue tumor surgery

BACKGROUND AND OBJECTIVES

Negative surgical margins are significant in improving patient outcomes. However, surgeons can only rely on visual and tactile information to identify tumor margins intraoperatively. We hypothesized that intraoperative fluorescence imaging with indocyanine green (ICG) could serve as an assistive technology to evaluate surgical margins and guide surgery in bone and soft tissue tumor surgery.

METHODS

Seventy patients with bone and soft tissue tumors were enrolled in this prospective, non-randomized, single-arm feasibility study. All patients received intravenous indocyanine green (0.5 mg/kg) before surgery. Near-infrared (NIR) imaging was performed on in situ tumors, wounds, and ex vivo specimens.

RESULTS

60/70 tumors were fluorescent at NIR imaging. The final surgical margins were positive in 2/55 cases, including 1/40 of the sarcomas. Surgical decisions were changed in 19 cases by NIR imaging, and in 7/19 cases final pathology demonstrated margins were improved. Fluorescence analysis showed that the tumor-to-background ratio (TBR) of primary malignant tumors was higher than that of benign, borderline, metastatic, and tumors ≥5 cm in size had higher TBR than those <5 cm.

CONCLUSIONS

ICG fluorescence imaging may be a beneficial technique to assist in surgical decision making and improving surgical margins in bone and soft tissue tumor surgery.

Multiple Flap Transfer for Multiple Local Recurrence of Soft Tissue Sarcoma

Background and Objectives: Surgical management of local recurrence of soft tissue sarcomas (STS) is still challenging. In this article, we report on multiple flap reconstructions for multiple local recurrences of STS. Their feasibility will be validated by examining clinical cases. Materials and Methods: Patients who underwent multiple flap reconstructions for multiple local recurrences of STS between April 1997 and October 2021 were included in this retrospective study. Patient demographics, tumor characteristics, surgical characteristics, and postoperative complications were examined. Results: Twenty operations of eight patients were identified. The location of the defects was the back in two, the buttock in two, the groin in two, and the lower extremities in two. The average total number of wide resections was 4.0 and the average total number of flap reconstructions was 2.5. The average follow-up period was 109.4 months. The average size of the defect was 102.4 cm2 and the average flap size was 15.7 × 10.8 cm. The histological diagnoses were malignant fibrous histocytoma (MFH) in eight operations, osteosarcoma in two operations, myxoid liposarcoma in two operations, undifferentiated pleomorphic sarcoma (UPS) in six operations, and myxofibrosarcoma (MFS) in one operation. Of twelve subsequent operations, the resection of the previously transferred flap was performed in six operations (50%). The occurrence of take back, flap complications, and donor-site complications in the primary operation group was 25%, 25%, and 12.5%, respectively. The occurrence of take back, flap complications, and donor-site complications in the second and subsequent operation group was 0%, 0%, and 16.7%, respectively. Conclusions: Multiple operations including wide resections followed by flap reconstructions for multiple local recurrences are feasible. Reconstructive surgeons should choose the options of the flaps considering the future local recurrence for tumors with a high risk of recurrence.

Primary Bladder Sarcoma: A multi-institutional experience from the Rare Cancer Network

PURPOSE OR OBJECTIVE

Primary sarcoma of the urinary bladder (SUB) is a rare but aggressive form of bladder cancer (BCa). Available evidence on SUB is limited to case reports and small series. The aim of the present multi-institutional study was to assess the clinical features, treatments, and outcomes of patients with SUB.

MATERIALS AND METHODS

Using a standardized database, 7 institutions retrospectively collected the demographics, risk factors, clinical presentation, treatment modalities and follow-up data on patients with SUB between January 1994 and September 2021. The main inclusion criteria included BCa with soft tissue tumor histology and sarcomatoid differentiation.

RESULTS

Fifty-three patients (38 men and 15 women) were identified. Median follow-up was 18 months (range 1-263 months). Median age at presentation was 69 years (range 16-89 years). Twenty-six percent of patients had a prior history of pelvic radiotherapy (RT), and 37% were previous smokers. The main presenting symptoms at diagnosis were hematuria (52%), pelvic pain (27%), and both hematuria and pelvic pain (10%). American Joint Committee on Cancer (AJCC) 8 th edition stage II, III and IV at diagnosis were 21%, 63% and 16%, respectively. Treatment modalities included surgery alone (45%), surgery plus neo- or adjuvant-chemotherapy (17%), surgery plus neo- or adjuvant-RT (11%), RT with concurrent chemotherapy (4%), neo-adjuvant chemotherapy plus surgery plus adjuvant RT (2%) and palliative treatment (21%). Rates of local and distant recurrences were 49% and 37%, respectively. Five-year overall survival and progression-free survival (PFS) were 66.5% and 37.6%, respectively. No statistically significant differences in PFS between the treatment modalities were observed.

CONCLUSIONS

Primary SUB is a heterogeneous disease group, commonly presenting at advanced stages and exhibiting aggressive disease evolution. In contrast to urothelial carcinoma, the primary pattern of recurrence of SUB is local, suggesting the need for multimodal approaches. Continuous international collaborative efforts seem warranted to provide guidance on how to best tailor treatments based on SUB-specific indices.

What Is the Significance of Indeterminate Pulmonary Nodules in High-Grade Soft Tissue Sarcomas? A Retrospective Cohort Study

BACKGROUND

Sarcomas are rare, aggressive cancers which frequently metastasise to the lungs. Following diagnosis, patients typically undergo staging by means of a CT scan of their chest. This often identifies indeterminate pulmonary nodules (IPNs), but the significance of these in high-grade soft tissue sarcoma (STS) is unclear. Identifying whether these are benign or malignant is important for clinical decision making. This study analyses the clinical relevance of IPNs in high-grade STS.

METHODS

All patients treated at our centre for high-grade soft tissue sarcoma between 2010 and 2020 were identified from a prospective database. CT scans and their reports were reviewed, and survival data were collected from patient records.

RESULTS

389 suitable patients were identified; 34.4% had IPNs on their CT staging scan and 20.1% progressed into lung metastases. Progression was more likely with IPNs ≥ 5 mm in diameter (p = 0.006), multiple IPNs (p = 0.013) or bilateral IPNs (p = 0.022), as well as in patients with primaries ≥ 5 cm (p = 0.014), grade 3 primaries (p = 0.009) or primaries arising deep to the fascia (p = 0.041). The median time to progression was 143 days. IPNs at diagnosis were associated with an increased risk of developing lung metastases and decreased OS in patients with grade 3 STS (p = 0.0019 and p = 0.0016, respectively); this was not observed in grade 2 patients.

CONCLUSIONS

IPNs at diagnosis are associated with significantly worse OS in patients with grade 3 STS. It is crucial to consider the primary tumour as well as the IPNs when considering the risk of progression. Surveillance CT scans should be carried out within 6 months.

The Prognostic Relevance of MRI Characteristics in Myxofibrosarcoma Patients Treated with Neoadjuvant Radiotherapy

To improve local control, neoadjuvant radiotherapy (nRT) followed by surgery is the standard of care in myxofibrosarcoma (MFS) because of its infiltrative growth pattern. Nevertheless, local recurrence rates are high. Data on prognostic factors for poor clinical outcomes are lacking. This retrospective study thus investigates the prognostic relevance of magnetic resonance imaging (MRI) characteristics before and after nRT in 40 MFS patients, as well as their association with disease-free survival (DFS) and overall survival (OS). A vascular pedicle, defined as extra-tumoral vessels at the tumor periphery, was observed in 12 patients (30.0%) pre-nRT and remained present post-nRT in all cases. Patients with a vascular pedicle had worse DFS (HR 5.85; 95% CI 1.56-21.90; p = 0.009) and OS (HR 9.58; 95% CI 1.91-48.00; p = 0.006). An infiltrative growth pattern, referred to as a tail sign, was observed in 22 patients (55.0%) pre-nRT and in 19 patients (47.5%) post-nRT, and was associated with worse DFS post-nRT (HR 6.99; 95% CI 1.39-35.35; p = 0.019). The percentage of tumor necrosis estimated by MRI was increased post-nRT, but was not associated with survival outcomes. The presence of a tail sign or vascular pedicle on MRI could support the identification of patients at risk for poor clinical outcomes after nRT.

Microvascular Free Flap Reconstruction of Thigh Defects After Tumor Resection in the Setting of Radiation

BACKGROUND

Soft tissue reconstruction of the thigh defects can usually be achieved with local options. Free tissue transfer may be indicated in very large defects with exposed vital structures and/or a history of radiation therapy where the healing potential of local option is poor. In this study, we evaluated our experience on microsurgical reconstruction of oncological and irradiated thigh defects to assess the risk factors for complications.

METHODS

Institutional review board-approved retrospective case series study using electronic medical records from 1997 to 2020 was conducted. All patients with irradiated thigh defects derived from oncological resections who underwent microsurgical reconstruction were included. Patient demographics and clinical and surgical characteristics were recorded.

RESULTS

Twenty free flaps were transferred in 20 patients. Mean age was 60 ± 11.8 years, and median follow-up time was 24.3 months (interquartile range [IQR], 71.4-9.2 months). The most common type of cancer was liposarcoma (n = 5). Neoadjuvant radiation therapy was performed in 60%. Most commonly used free flaps were latissimus dorsi muscle/musculocutaneous flap (n = 7) and anterolateral thigh flap (n = 7) Nine flaps were transferred immediately after resection. Overall, 70% of arterial anastomoses were end-to-end, whereas 30% were end-to-side. Deep femoral artery branches were chosen as the recipient artery in the 45%. Median length of hospital stay was 11 days (IQR, 16.0-8.3 days), and median time to start weight-bearing was 20 days (IQR, 49.0-9.5 days). All were successful except for 1 patient who required additional pedicled flap coverage. The overall major-complication rate was 25% (n = 5, hematoma = 2, venous congestion requiring emergent exploration surgery = 1, wound dehiscence = 1, surgical site infection = 1). Cancer recurred in 3 patients. One required amputation due to cancer recurrence. Age (hazard ratio [HR], 1.14; P = 0.0163), tumor volume (HR, 18.8; P = 0.0006), and resection volume (HR, 2.24; P = 0.0019) were statistically significantly associated with having a major complication.

CONCLUSIONS

Based on the data, microvascular reconstruction of irradiated post-oncological resection defects shows high flap survival rate and success. Given the large size of flap required, the complex nature and size of these wounds, and history of radiation, wound healing complications are common. Despite this, free flap reconstruction should be considered in irradiated thighs with large defects. Studies with larger cohort and longer follow-up are still required.

Soft Tissue Sarcomas in Octogenarian Patients: Are Treatment Options and Oncological Outcomes Different? A SEER Retrospective Study

AIMS

As the US population continues to age, oncological strategies and outcomes for soft tissue sarcomas (STSs) should continue to be examined for varying age groups. The aim of this study was analyse and compare treatment strategies and oncological outcomes for octogenarian patients with STSs.

MATERIALS AND METHODS

Data from the Surveillance, Epidemiology and End Results (SEER) national database were used. Varying treatment modalities were studied when utilised for specific tumour staging with respect to the eighth edition of the American Joint Committee on Cancer.

RESULTS

In total, 24 666 patients were included for analysis, where 3341 (14%) were 80 years old or older. The octogenarian group was diagnosed with more advanced disease (stages II-IV), relative to their younger counterparts (85% versus 75%, P < 0.001). However, a smaller proportion of the older patients underwent surgical resection (74% versus 86%, P < 0.001). Likewise, the octogenarians received less chemotherapy (4% versus 21%, P < 0.001) and radiotherapy (29% versus 42%, P = 0.010). Surgical resection and chemotherapy significantly improved overall survival for those older patients with stage II STS, whereas surgical resection and radiotherapy improved mortality in this cohort with both stage III and IV STS. Overall survival at 1 and 5 years of follow-up was lower within the octogenarian group compared with the younger group (1 year: 68% versus 88%, P < 0.001 and 5 years: 7% versus 58%, P < 0.001).

CONCLUSIONS

Octogenarian patients, in most cases, are diagnosed with stage III or metastatic disease. Surgical resection of the primary tumour was beneficial in both age cohorts, with radiotherapy correlating to better overall survival when used in those patients with higher stage STS. Chemotherapy was associated with better mortality in the younger cohort with respect to tumour stage. The octogenarian overall survival at 1 and 5 years was lower than for younger patients.

Serum lactate dehydrogenase as a novel prognostic factor for patients with primary undifferentiated pleomorphic sarcomas

PURPOSE

Among soft tissue sarcomas, undifferentiated pleomorphic sarcoma (UPS) has relatively higher potential of recurrence and metastasis. As serum lactate dehydrogenase (LDH) is associated with tumor progression and unfavorable outcomes in multiple malignancies, we designed this study to explore the relationship between preoperative serum LDH and prognosis in UPS patients.

METHODS

We extracted the data of UPS patients who underwent primary surgery in Shanghai Cancer Center, Fudan University. Receiver-operating characteristic (ROC) curve was used to figure out the best cutoff value of LDH to classify them into high- or low-expression groups. Univariate and multivariate analyses were performed using Cox proportional hazards regression to identify independent prognostic factors. Kaplan-Meier analysis was used to compare differences in overall survival (OS) and time to recurrence (TTR) between patients with high- or low-serum LDH.

RESULTS

Multivariate analyses demonstrated that preoperative serum LDH was an independent factor for OS. Kaplan-Meier curves showed that patients with relatively high-serum LDH (P = 0.0004) had poorer OS compared with those with low-serum LDH. There was a trend that patients with relatively high-serum LDH had poorer TTR than those without (P = 0.1249). In addition, there were obvious trends that patients with decreased serum LDH after surgery showed better OS (P = 0.0954) and TTR (P = 0.1720) than those with elevated serum LDH. Moreover, high preoperative serum LDH was associated with female patients (P = 0.0004), positive margin (P < 0.0001), worse survival (P = 0.0061), higher mitotic index (P = 0.0222) and necrosis (P = 0.0225).

CONCLUSIONS

Preoperative serum LDH is an independent factor for OS in UPS patients, and it correlates with future surgical margin.

Development of a Nomogram to Predict the Outcome for Patients with Soft Tissue Sarcoma

Soft tissue sarcomas (STSs) are common cutaneous or subcutaneous neoplasms in dogs. Most STSs are initially treated by surgical excision, and local recurrence may develop in almost 20% of patients. Currently, it is difficult to predict which STS will recur after excision, but this ability would greatly assist patient management. In recent years, the nomogram has emerged as a tool to allow oncologists to predict an outcome from a combination of risk factors. The aim of this study was to develop a nomogram for canine STSs and determine if the nomogram could predict patient outcomes better than individual tumour characteristics. The current study provides the first evidence in veterinary oncology to support a role for the nomogram to assist with predicting the outcome for patients after surgery for STSs. The nomogram developed in this study accurately predicted tumour-free survival in 25 patients but failed to predict recurrence in 1 patient. Overall, the sensitivity, specificity, positive predictive, and negative predictive values for the nomogram were 96%, 45%, 45%, and 96%, respectively (area under the curve: AUC = 0.84). This study suggests a nomogram could play an important role in helping to identify patients who could benefit from revision surgery or adjuvant therapy for an STS.

Rare paratesticular localization of dedifferentiated liposarcoma: Case report and review of the literature

RATIONALE

Dedifferentiated liposarcoma is defined as a malignant tumor that changes its shape from a well-differentiated liposarcoma to a non-liposarcomatous form. Most paratesticular liposarcomas manifest as an inguinal, painless, slow-growing mass. The standard treatment is extensive surgical excision, radiotherapy being proposed for cases with positive margins, those with recurrence, or in cases of the existence of unfavorable prognostic factors.

PATIENT CONCERNS

We present the case of a young patient diagnosed initially with left hydrocele, which after 2 years proved to mask a differentiated liposarcoma of the spermatic cord. The initial clinical manifestations were represented by the increase in volume of the left groin-scrotal region and pain at this level.

DIAGNOSIS

Microscopic examination in hematoxylin-eosin staining highlighted the presence of lipoblasts and fibroblasts in association with areas of hemorrhage and tumor necrosis. The performed immunohistochemical tests confirmed the diagnosis of dedifferentiated liposarcoma. To support and confirm the presence of the mouse double minute 2 homolog gene mutation, chromogenic in situ hybridization analysis was performed.

INTERVENTIONS

The initial treatment was the surgical one. After 2 weeks, the patient received zolendronic acid for hypercalcemia which was caused by the osseous metastasis.

OUTCOMES

The patient died secondary to acute renal failure caused by hypercalcemia despite the treatment received.

LESSONS

This case underlines the importance of both the correct management of oncological patients, as well as immunohistochemical and genetic tests in the identification of prognostic factors, with the ultimate goal of administering an appropriate oncological treatment.

Diagnosis of Marginal Infiltration in Soft Tissue Sarcoma by Radiomics Approach Using T2-Weighted Dixon Sequence

BACKGROUND

Determination of preoperative soft tissue sarcoma (STS) margin is crucial for patient prognosis.

PURPOSE

To evaluate diagnostic performance of radiomics model using T2-weighted Dixon sequence for infiltration degree of STS margin.

STUDY TYPE

Retrospective.

POPULATION

Seventy-two STS patients consisted of training (n = 58) and test (n = 14) sets.

FIELD STRENGTH/SEQUENCE

A 3.0 T; T2-weighted Dixon images.

ASSESSMENT

Pathologic result of marginal infiltration in STS (circumscribed margin; n = 27, group 1, focally infiltrative margin; n = 31, group 2-A, diffusely infiltrative margin; n = 14, group 2-B) was the reference standard. Radiomic volume and shape (VS) and other (T2) features were extracted from entire tumor volume and margin, respectively. Twelve radiomics models were generated using four combinations of classifier algorithms (R, SR, LR, LSR) and three different inputs (VS, T2, VS + T2 [VST2] features) to differentiate the three groups. Three radiologists (reader 1, 2, 3) analyzed the marginal infiltration with 6-scale confidence score.

STATISTICAL TESTS

Area under the receiver operating characteristic curve (AUC) and concordance rate.

RESULTS

Averaged AUCs of R, SR, LR, LSR models were 0.438, 0.466, 0.438, 0.466 using VS features, 0.596, 0.584, 0.814, 0.815 using T2 features, and 0.581, 0.587, 0.821, 0.821 using VST2 features, respectively. The LR and LSR models constructed with T2 or VST2 features showed higher AUC and concordance rate compared to radiologists' analysis (AUC; 0.730, 0.675, 0.706, concordance rate; 0.46, 0.43, 0.47 in reader 1, 2, 3).

DATA CONCLUSION

Radiomics model constructed with features from tumor margin on T2-weighted Dixon sequence is a promising method for differentiating infiltration degree of STS margin.

EVIDENCE LEVEL

4 TECHNICAL EFFICACY: Stage 2.

Management of Recurrent Retroperitoneal Sarcoma

Recurrence after resection of retroperitoneal sarcoma is common and varies by histological subtype. Pattern of recurrence is similarly affected by histology (e.g., well-differentiated liposarcoma is more likely to recur locoregionally, whereas leiomyosarcoma is more likely to develop distant metastases). Radiotherapy may provide effective locoregional control in limited circumstances and the data on the impact of chemotherapy are scant. Surgery for locally recurrent disease is associated with the greatest survival benefit; however, data are retrospective and from a highly selected subgroup of patients. Limited retrospective data have also suggested a survival association with the resection of limited distant metastases. Given the complexity of these patients, multidisciplinary evaluation at a high-volume sarcoma center is critical.

Brachytherapy in the Treatment of Soft-Tissue Sarcomas of the Extremities-A Current Concept and Systematic Review of the Literature

INTRODUCTION

Evidence on the use of brachytherapy in soft-tissue sarcoma (STS) is sparse. Therapy regimens are determined more by local interdisciplinary tumor conferences than by standardized protocols. Patient-specific factors complicate the standardized application of therapy protocols. The individuality of the treatment makes it difficult to compare results.

MATERIALS AND METHODS

A comprehensive literature search was conducted, whereby the literature from a period of almost 44 years (1977-2021) was graded and included in this systematic review. For this purpose, PubMed was used as the primary database. Search string included "soft-tissue sarcoma", "brachytherapy", and "extremity." Four independent researchers reviewed the literature. Only full-text articles written in English or German were included.

RESULTS

Of the 175 identified studies, 70 were eligible for analysis based on the inclusion and exclusion criteria. The key points to compare were local complications, recurrence rate and correlation with margins of resection, and the use of brachytherapy regarding tumor grading.

CONCLUSION

Brachytherapy represents an important subset of radiotherapy techniques used in STSs, whose indications and applications are constantly evolving, and for which a local control rate of 50% to 96% has been reported as monotherapy, depending on risk factors. However, the best benefit is seen in the combination of further resection and brachytherapy, and most authors at many other centers agree with this treatment strategy.

Hemi-Resection of Carpal and Extensor Resection Reconstructed With Wrist Joint Arthrodesis and Palmaris Longus Tendon Graft for Synovial Sarcoma on the Dorsal Side of the Wrist: A Case Report

Bone and soft-tissue sarcomas infrequently develop in the hand and wrist. Given the complex anatomy of this area, wide resection with adequate margins often impairs hand function because of the resection of essential structures, including tendons, bones, and tissues adjacent to the sarcoma. Here, we present a case of primary synovial sarcoma adjacent to the dorsal side of the carpal bones, which were resected with hemi-resection of the carpus and resection of extensor tendons, followed by wrist joint arthrodesis and palmaris longus tendon grafting. Hand function was satisfactory despite some disability, and no evidence of local recurrence was observed at the 24-month postoperative follow-up. This method may be effective for not only achieving tumor resection with a negative margin but also preserving hand function.

Perineum Spindle Cell Sarcoma in Neurofibromatosis Type 1

Soft tissue neoplasm is common among patients with neurofibromatosis type 1 (NF-1). We present a case of a middle-aged woman with NF-1 who presented with a painless, insidiously increasing perineal mass for the past eight months. She underwent colonoscopy, computed tomography staging, magnetic resonance imaging of the pelvis, core-needle biopsy, and later wide local excision of left perineum swelling. Histopathological examination showed a high-grade spindle cell sarcoma, which is a rare association among NF-1. Spindle cell sarcoma is a group of malignant soft tissue tumors with locally destructive growth with spindle-shaped neoplastic cells. The solitary spindle cell sarcoma of the perineum is rare, and wide local resection with a clear margin is the only treatment at present-the scarcely available evidence limiting the use of adjuvant chemotherapy, immunotherapy, and radiotherapy.

Management and outcomes of adolescent and young adult sarcoma patients: results from the French nationwide database NETSARC

BACKGROUND

The initial management of patients with sarcoma is a critical issue. We used the nationwide French National Cancer Institute-funded prospective sarcoma database NETSARC to report the management and oncologic outcomes in adolescents and young adults (AYAs) patients with sarcoma at the national level.

PATIENTS AND METHODS

NETSARC database gathers regularly monitored and updated data from patients with sarcoma. NETSARC was queried for patients (15-30 years) with sarcoma diagnosed from 2010 to 2017 for whom tumor resection had been performed. We reported management, locoregional recurrence-free survival (LRFS), progression-free survival (PFS), and overall survival (OS) in AYA treated in French reference sarcoma centers (RSC) and outside RSC (non-RSC) and conducted multivariable survival analyses adjusted for classical prognostic factors.

RESULTS

Among 3,227 patients aged 15-30 years with sarcoma diagnosed between 2010 and 2017, the study included 2,227 patients with surgery data available, among whom 1,290 AYAs had been operated in RSC, and 937 AYAs in non-RSC. Significant differences in compliance to guidelines were observed including pre-treatment biopsy (RSC: 85.9%; non-RSC 48.1%), pre-treatment imaging (RSC: 86.8%; non-RSC: 56.5%) and R0 margins (RSC 57.6%; non-RSC: 20.2%) (p < 0.001). 3y-OS rates were 81.1% (95%CI 78.3-83.6) in AYA in RSC and 82.7% (95%CI 79.4-85.5) in AYA in non-RSC, respectively. Whereas no significant differences in OS was observed in AYAs treated in RSC and in non-RSC, LRFS and PFS were improved in AYAs treated in RSC compared to AYAs treated in non-RSC (Hazard Ratios (HR): 0.58 and 0.83, respectively).

CONCLUSIONS

This study highlights the importance for AYA patients with sarcoma to be managed in national sarcoma reference centers involving multidisciplinary medical teams with paediatric and adult oncologists.

Intraoperative Evaluation of Soft Tissue Sarcoma Surgical Margins with Indocyanine Green Fluorescence Imaging

Soft tissue sarcomas (STS) are rare malignant tumors often associated with poor outcomes and high local recurrence rates. Current tools for intraoperative and definitive margin assessment include intraoperative frozen section and permanent pathology, respectively. Indocyanine green dye (ICG) is a historically safe fluorophore dye that has demonstrated efficacy for intraoperative margin assessment in the surgical management of both breast and gastrointestinal cancers. The utility of ICG in the surgical management of sarcoma surgery has primarily been studied in pre-clinical mouse models and warrants further investigation as a potential adjunct to achieving negative margins. This study is a prospective, non-randomized clinical study conducted on patients with confirmed or suspected STS. Patients younger than 18 years, with a prior adverse reaction to iodine or fluorescein, or with renal disease were excluded from the study. Intravenous ICG was infused approximately three hours prior to surgery at a dosage of 2.0-2.5 mg/kg, and following tumor resection, the excised tumor and tumor bed were imaged for fluorescence intensity. When scanning the tumor bed, a threshold of 77% calibrated to the region of maximum intensity in the resected tumor was defined as a positive ICG margin, according to published protocols from the breast cancer literature. ICG results were then compared with the surgeon's clinical impression of margin status and permanent pathology results. Out of 26 subjects recruited for the original study, 18 soft tissue sarcomas (STS) were included for analysis. Three subjects were excluded for having bone sarcomas, and five subjects were excluded due to final pathology, which was ultimately inconsistent with sarcoma. The average age of patients was 64.1 years old (range: 28-83), with an average ICG dose of 201.8 mg. In 56% (10/18) of patients, ICG margins were consistent with the permanent pathology margins, with 89% specificity. The use of ICG as an intraoperative adjunct to obtaining negative margins in soft tissue sarcoma surgery is promising. However, studies with larger sample sizes are warranted to further delineate the accuracy, optimal dosage, timing, and types of sarcoma in which this diagnostic tool may be most useful.

Trends in Overall Survival among Patients Treated for Sarcoma at a Large Tertiary Cancer Center between 1986 and 2014

Sarcomas are relatively rare malignancies accounting for about 1% of all cancer diagnoses. Studies on sarcomas comprising large cohorts covering extended time periods are lacking. Therefore, this study aimed to evaluate the impact of demographic, behavioral, and clinical characteristics on overall survival (OS) among individuals diagnosed with soft tissue sarcoma (STS) or bone sarcoma at the Moffitt Cancer Center between 1986 and 2014. Unadjusted and multivariable Cox proportional hazard regression (CPHR) models were constructed to generate hazard ratios (HRs) and 95% confidence intervals (CIs) to evaluate associations between a range of demographic, behavioral, and clinical characteristics, and OS. Additionally, Kaplan-Meier survival curves, associated log-rank statistics, and adjusted CPHR models were generated by time periods based on the year of first contact (1986-1994, 1995-1999, 2000-2005, 2006-2010, 2011-2014) to evaluate for temporal differences in OS. Of the 2570 patients, 2037 were diagnosed with STS, whereas 533 were diagnosed with bone sarcoma. At the time of analysis, 50% of the population were alive. In multivariable analyses, we observed poorer survival for patients ≥ 40 years of age (HR = 1.54, 95% CI = 1.34-1.78), current smokers (HR = 1.18, 95% CI = 1.01-1.37), patients with metastasis (HR = 2.19, 95% CI = 1.95-2.47), and patients not receiving first-line surgery treatment (HR = 2.11, 95% CI = 1.82-2.45). We discovered limited improvements in OS over time among individuals diagnosed with STS or bone sarcomas with the exception of gastrointestinal stromal tumors (GIST), which showed a significant improvement in OS across time periods (p = 0.0034). Overall, we identified well-established characteristics associated with OS (e.g., metastasis) in addition to factors (e.g., smoking status) not previously reported to impact OS. Improvements in survival over time have been relatively modest, suggesting the need for improved therapeutic options, especially for those diagnosed with less frequent sarcomas.

Effect of Favorable Pathologic Response After Neoadjuvant Radiation Therapy Alone in Soft-tissue Sarcoma

Purpose

Whether the therapeutic response of soft-tissue sarcoma to neoadjuvant treatment is predictive for clinical outcomes is unclear. Given the rarity of this disease and the confounding effects of chemotherapy, this study analyzes whether a favorable pathologic response (fPR) after neoadjuvant radiation therapy (RT) alone is associated with clinical benefits.

Methods and Materials

An institutional review board-approved retrospective review was conducted on a database of patients with primary soft-tissue sarcoma treated at our institution between 1987 and 2015 with neoadjuvant RT alone followed by surgical resection. Time-to-event outcomes estimated with a Kaplan-Meier analysis included overall survival, progression-free survival (PFS), locoregional control, and distant control (DC). Cox regression analyses were performed to determine prognostic variables associated with clinical outcomes.

Results

Of the overall cohort of 315 patients, 181 patients (57%) were included in the primary analysis with documented pathologic necrosis (PN) rates (mean: 59%) and a median follow up from diagnosis of 48 months (range, 4-170 months). The median neoadjuvant RT dose was 50 Gy (range, 40-60 Gy), and the majority of patients had negative surgical margins (79%). Only 35 patients (19%) achieved a fPR (PN ≥95%), which was associated with a higher R0 resection rate (94% vs. 75%; P = .013), a significant 5-year PFS benefit (74% vs. 43%; P = .014), and a nonsignificant 5-year DC benefit (76% vs. 62%; P = .12) compared with PN <95%. On multivariable analysis, fPR was an independent predictor for PFS (hazard ratio: 0.47; 95% confidence interval, 0.25-0.90; P = .022).

Conclusions

Achieving fPR with neoadjuvant RT alone is associated with a higher R0 resection rate and possible DC benefit, translating into a significant improvement in PFS. Further studies to improve pathologic response rates and prospectively validate this endpoint are warranted.

Overall survival in patients with re-excision of positive microscopic margins of limb and trunk wall soft tissue sarcoma operated outside of a reference center: a nationwide cohort analysis

Background

This French nationwide NETSARC exhaustive prospective cohort aims to explore the impact of systematic re-excision (RE) as adjuvant care on overall survival (OS), local recurrence free survival (LRFS), and local and distant control (RFS) in patients with soft tissue sarcoma (STS) with positive microscopic margins (R1) after initial resection performed outside of a reference center.

Methods

Eligible patients had experienced STS surgery outside a reference center from 2010 to 2017, and had R1 margins after initial surgery. Characteristics and treatment comparisons used chi-square for categorical variables and Kruskall-Wallis test for continuous data. Survival distributions were compared in patients reexcised (RE) or not (No-RE) using a log-rank test. A Cox proportional hazard model was used for subgroup analysis.

Results

A total of 1,284 patients had experienced initial STS surgery outside NETSARC with R1 margins, including 1,029 patients with second operation documented. Among the latter, 698 patients experienced re-excision, and 331 were not re-excised. Characteristics were significantly different regarding patient age, tumor site, tumor size, tumor depth, and histotype in the population of patients re-excised (RE) or not (No-RE). The study identified RE as an independent favorable factor for OS (HR 0.36, 95%CI 0.23–0.56, p<0.0001), for LRFS (HR 0.45, 95%CI 0.36–0.56, p<0.0001), and for RFS (HR 0.35, 95%CI 0.26–0.46, p<0.0001).

Conclusion

This large nationwide series shows that RE improved overall survival in patients with STS of extremities and trunk wall, with prior R1 resection performed outside of a reference center. RE as part of adjuvant care should be systematically considered.

Level of evidence II

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-10121-5.

Five decades of sarcoma care at Memorial Sloan Kettering Cancer Center

Early studies of the management of soft tissue sarcoma at Memorial Sloan Kettering Cancer Center were influenced by development of robust prospective long-term databases. Increasing capacity for molecular diagnostics has identified a myriad of subtypes with definable natural history. Accurate identification of tissue-specific risk of recurrence and disease-specific survival have increasingly allowed selective use of surgery, radiation therapy, and target-specific cytotoxic and immune therapies.

The role of soluble CD80 in patients with soft tissue tumors

BACKGROUND

Immune checkpoint protein (ICP), which is a central factor group of the immune system, has been reported to have a correlation between the degree of its expression and the prognosis of patients with malignant tumors, and many inhibitors have appeared as therapeutic targets. On the other hand, a soluble form of ICP in circulating blood induced systemic immunosuppression. In this study, we investigated the relationship between the soluble form of CD80 (sCD80) which is a ligand for the inhibitory system CTLA-4, in blood, and clinicopathological parameters in patients with soft tissue tumors.

METHODS

A total of 119 patients with primary soft tissue tumors were enrolled in this study. The sCD80 levels were measured by enzyme immunoassay.

RESULTS

There were no significant differences in sCD80 levels between benign (34) and soft tissue sarcoma (STS) patients (85). In STS, the high-sCD80 group had significantly lower metastasis-free survival (MS) and lower overall survival (OS) than the low-sCD80 group at 5 years using the log-rank test (OS: high > 404 pg/mL, low ≤ 404 pg/mL, MS: high > 531 pg/ml, low ≤ 531 pg/ml). On multivariate Cox proportional hazard analysis, the high-sCD80 group had significant differences in 5MS and 5OS compared to the low-sCD80 group.

CONCLUSIONS

In conclusion, sCD80 may negatively affect systemic immune circumstances, in STS, and may have potential as a therapeutic target.

The Therapeutic Role of Plastic and Reconstructive Surgery in the Interdisciplinary Treatment of Soft-Tissue Sarcomas in Germany-Cross-Sectional Results of a Prospective Nationwide Observational Study (PROSa)

Simple Summary

The mainstay of soft-tissue-sarcoma treatment remains ablative surgery with complete tumor resection. In this context, reconstructive plastic surgery has become an important aspect of multidisciplinary sarcoma therapy aiming at limb preservation as an alternative to amputations. In this present study, cross-sectional data collected prospectively at 39 study centers across Germany were analyzed, focusing on both the inhouse availability of plastic surgery and external accessibility to plastic surgery in 621 cases. In summary, unplanned and incomplete primary tumor resections carried out at centers with lower degrees of specialization were associated with a significantly increased need for subsequent flap-based defect coverage. In line with this, a readily available team of plastic surgeons was independently associated with successful defect reconstruction, which in turn was associated with significantly higher chances of limb preservation. We conclude that easily accessible plastic surgery and a high degree of expertise in the field of sarcoma treatment are indispensable for limb preservation following sarcoma resection. Plastic and reconstructive surgery therefore plays a vital role in achieving the best possible outcomes in the interdisciplinary treatment of soft-tissue sarcomas.

Abstract

Although the involvement of plastic surgery has been deemed important in the treatment of sarcoma patients to avoid oncological compromises and ameliorate patient outcomes, it is not ubiquitously available. The accessibility of defect reconstruction and its therapeutic impact on sarcoma care is the subject of this analysis. Cross-sectional data from 1309 sarcoma patients were collected electronically at 39 German study centers from 2017 to 2019. A total of 621 patients with surgical treatment for non-visceral soft-tissue sarcomas were included. The associated factors were analyzed exploratively using multifactorial logistic regression to identify independent predictors of successful defect reconstruction, as well Chi-squared and Cochran–Mantel–Haenszel tests to evaluate subgroups, including limb-salvage rates in extremity cases. A total of 76 patients received reconstructive surgery, including 52 local/pedicled versus 24 free flaps. Sarcomas with positive margins upon first resection (OR = 2.3, 95%CI = 1.2–4.4) that were excised at centers with lower degrees of specialization (OR = 2.2, 95%CI = 1.2–4.2) were independently associated with the need for post-oncological defect coverage. In this context, the inhouse availability of plastic surgery (OR = 3.0, 95%CI = 1.6–5.5) was the strongest independent predictor for successful flap-based reconstruction, which in turn was associated with significantly higher limb-salvage rates (OR = 1.4, 95%CI = 1.0–2.1) in cases of extremity sarcomas (n = 366, 59%). In conclusion, consistent referral to specialized interdisciplinary sarcoma centers significantly ameliorates patient outcomes by achieving higher rates of complete resections and offering unrestricted access to plastic surgery. The latter in particular proved indispensable for limb salvage through flap-based defect reconstruction after sarcoma resection. In fact, although there remains a scarcity of readily available reconstructive surgery services within the current sarcoma treatment system in Germany, plastic and reconstructive flap transfer was associated with significantly increased limb-salvage rates in our cohort.

Canady Cold Helios Plasma Reduces Soft Tissue Sarcoma Viability by Inhibiting Proliferation, Disrupting Cell Cycle, and Inducing Apoptosis: A Preliminary Report

Soft tissue sarcomas (STS) are a rare and highly heterogeneous group of solid tumors, originating from various types of connective tissue. Complete removal of STS by surgery is challenging due to the anatomical location of the tumor, which results in tumor recurrence. Additionally, current polychemotherapeutic regimens are highly toxic with no rational survival benefit. Cold atmospheric plasma (CAP) is a novel technology that has demonstrated immense cancer therapeutic potential. Canady Cold Helios Plasma (CHCP) is a device that sprays CAP along the surgical margins to eradicate residual cancer cells after tumor resection. This preliminary study was conducted in vitro prior to in vivo testing in a humanitarian compassionate use case study and an FDA-approved phase 1 clinical trial (IDE G190165). In this study, the authors evaluate the efficacy of CHCP across multiple STS cell lines. CHCP treatment reduced the viability of four different STS cell lines (i.e., fibrosarcoma, synovial sarcoma, rhabdomyosarcoma, and liposarcoma) in a dose-dependent manner by inhibiting proliferation, disrupting cell cycle, and inducing apoptosis-like cell death.

The Outcome of Extremity Soft Tissue Sarcomas in Terms of Resection Margins: A Study From a Cancer Dedicated Center

Introduction

Extremity soft-tissue sarcomas are uncommon malignancies of mesenchymal tissue, it accounts for <1 % of cancers and has a high recurrence rate with positive resection margins and unplanned excision. This study aims to determine the influence of unplanned excision and resection margins on local recurrence, metastasis, and overall survival in soft tissue sarcoma of the extremities.

Methods

A retrospective review was conducted from January 2005 to December 2015 on all the patients with soft tissue sarcoma of the extremities. Age, sex, histopathology, site, tumor grade, biopsy type, recurrence, metastasis, and end outcome were analyzed. Kaplan-Meir curves were used for Survival analysis, and log-rank or the Cox proportional-hazards regression model was used for Significance analysis. The data were entered into SPSS version 20, and Statistical significance was set at a p-value ≤0.05.

Results

One hundred forty-five patients with soft tissue sarcoma of extremities were managed with a mean follow-up of 76.3+/-6.7 months. Undifferentiated pleomorphic sarcoma 47 (32.4%) was the most common pathology found in this cohort, followed by Synovial sarcoma 34 (23.4%) and Liposarcoma 19 (13.1%). The most common site of occurrence was lower extremity 102 (70.3%). All the patients had residual disease after unplanned excisions; 107 underwent R0 resection, while 38 underwent R1 resection. Five-year overall survival was 70.2 & 71.1 % for R1 & R0 resections, respectively, and 71.3% for excisional and 74.2% for incisional biopsy. The tumor grade significantly influences overall survival, while other variables were not found to affect Recurrence-free survival and metastasis-free survival.

Conclusion

The data indicates that the high-grade tumor has a negative influence on overall survival, while resection margins width and unplanned excision have no significant effect on local recurrence, Metastasis free survival, and overall survival; however, before excision, adequate planning and awareness among general surgeons is necessary to improve the surgical morbidity and financial burden over the health care facilities.