Modern Management of High-risk Soft Tissue Sarcoma With Neoadjuvant Chemoradiation: A Single-center Experience

Failure Modes in Orthopedic Oncologic Reconstructive Surgery: A Review of Imaging Findings and Failure Rates

Limb salvage surgeries utilizing endoprostheses and allografts are performed for a variety of oncologic conditions. These reconstructions can fail and require revision for many reasons, which are outlined and classified into mechanical failures (soft tissue failures, aseptic loosening, structural failure), non-mechanical failures (infection, tumor progression), and pediatric failures (physeal arrest, growth dysplasia). Distinct radiologic and clinical findings define specific failure subtypes but are sparsely illustrated in the radiology literature. Specifically, an understanding of the organizational structure of the failure modes can direct radiologists' search for post-reconstruction complications, enhance an appreciation of their prognostic significance, and facilitate research by standardizing the language and conceptual framework around outcomes. The purpose of this review is to highlight the key radiologic findings and imaging studies of each failure mode in orthopedic oncologic reconstructive surgery in the context of risk factors, failure rates, prognosis and survival statistics, and clinical decision-making regarding chemotherapy, radiation, and revision surgery.

The role of neoadjuvant radiochemotherapy in the management of localized high-grade soft tissue sarcoma

BACKGROUND

Standard treatment of soft tissue sarcoma (STS) of the extremities includes limb-sparing surgery combined with pre- or postoperative radiotherapy (RT). The role of perioperative chemotherapy (CTX) remains uncertain. STS patients with high-risk features for local recurrence, distant metastases, and increased mortality may require additional systemic therapy. The objective of this study was to evaluate predictors of outcome regarding local control (LC), overall survival (OS), and freedom from distant metastases (FFDM) in a large single-center cohort of patients suffering from localized high-grade STS (grade 2/3, G2/G3). Special emphasis was put on a subgroup of patients who received combined neoadjuvant radiochemotherapy (RCT).

METHODS

Overall, 115 adult STS patients were included in this retrospective study. The median follow-up was 34 months. Twenty-three patients (20.0%) were treated with neoadjuvant RCT, 92 (80.0%) received other therapies (adjuvant RT alone (n = 58); neoadjuvant CTX + adjuvant RT (n = 17); adjuvant RCT (n = 10), neoadjuvant RT alone (n = 7)). To assess potential prognostic factors on LC, OS, and FFDM, univariate (UVA) and multivariable (MVA) Cox proportional hazards models were applied.

RESULTS

UVA showed significantly better LC rates in the neoadjuvant RCT group (p = 0.025), with trends in MVA (p = 0.057). The 3-year LC rate was 89.7% in the neoadjuvant RCT group vs. 75.6% in the "other therapies" group. UVA also showed significantly better OS rates in the neoadjuvant RCT group (p = 0.049), however, this was not confirmed in MVA (p = 0.205), the 3-year OS rate was 85.8% for patients treated with neoadjuvant RCT compared to 73.5% in the "other therapies" group. UVA showed significantly better FFDM rates in (p = 0.018) and a trend towards better FFDM rates in MVA (p = 0.059). The 3-year FFDM rate was 89.7% for patients treated with neoadjuvant RCT compared to 65.9% in the "other therapies" group. In the subgroup of patients with G3 STS, neoadjuvant RCT was a significant positive predictor of LC and FFDM in MVA (p = 0.047, p = 0.027) but not for OS. Overall grade 3 and 4 toxicities were significantly higher (p = 0.019) in the neoadjuvant RCT group and occurred in 73.9% vs. 38.0% in patients receiving other therapies.

CONCLUSIONS

The results suggest that neoadjuvant RCT might improve LC and FFDM in patients with localized G3 STS while also being associated with increased acute complication rates. Further prospective research is warranted to confirm these findings.