1
|
Evaluation of two modalities of perioperative treatment in the management of extremity and truncal soft tissue sarcomas: neoadjuvant concurrent chemoradiotherapy and sequential treatment. Strahlenther Onkol 2021; 197:1051-1062. [PMID: 34673991 DOI: 10.1007/s00066-021-01847-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 08/17/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Patients with locally advanced grade 2-3 extremity/truncal soft tissue sarcomas (STS) are at high risk of recurrence. The objective of this study was to assess the efficacy and feasibility of neoadjuvant concurrent chemoradiotherapy (cCRT) in selected grade 2-3 patients with limb or trunk wall STS, and to compare this schedule to a sequential approach combining neoadjuvant chemotherapy and adjuvant radiotherapy. METHODS We retrospectively included patients who underwent neoadjuvant cCRT at two comprehensive cancer centers from 1992-2016. We then compared these results to those of patients treated with preoperative chemotherapy and postoperative radiotherapy from a third comprehensive cancer center with a propensity score matched analysis. RESULTS A total of 53 patients were treated by neoadjuvant cCRT; 58 patients could be matched with 29 patients in each treatment group after propensity score matching. Disease-free survival and overall survival at 5 years were 54.9 and 63.5%, respectively with neoadjuvant cCRT, with no significant difference when compared to the sequential treatment group. R0 resection rate was higher (90.9 vs 44.8%, p < 0.01) in the cCRT group than in the sequential treatment group during a shorter therapeutic sequence (118 vs 210.5 days, p < 0.01), with no impact on the surgical procedure or postoperative complications. CONCLUSION cCRT is feasible with acceptable immediate and late toxicities. It could facilitate surgery by increasing the R0 resection rate and improve patient compliance by shortening the therapeutic sequence.
Collapse
|
2
|
Rauch M, Agaimy A, Semrau S, Willner A, Ott O, Fietkau R, Hohenberger W, Croner RS, Grützmann R, Fechner K, Vassos N. Long-Term Follow-Up of Patients Receiving Neoadjuvant Treatment Modalties for Soft Tissue Sarcomas of the Extremities. Cancers (Basel) 2021; 13:cancers13205244. [PMID: 34680391 PMCID: PMC8534061 DOI: 10.3390/cancers13205244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/03/2021] [Accepted: 10/14/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Neoadjuvant treatment modalities in soft tissue sarcoma (STS) of the extremities have become more popular in recent years, but because of the rarity and heterogeneity of STS, there are yet few studies on the long-term impact of neoadjuvant treatment modalities, especially in terms of neoadjuvant radiochemotherapy. METHODS The study enrolled 136 patients with primary STS of the extremities who underwent surgery with curative intent or neoadjuvant therapy, followed by surgery in a 15-year period. Neoadjuvant treatment consisted of radiotherapy (RT) with 60 Gy and in most cases simultaneous chemotherapy (CTx) with ifosfamide (1.5 g/m2/d, d1-5, q28) and doxorubicine (50 mg/m2/d, d3, q28). We investigated the clinical, (post)-operative and histopathological data and the oncological follow-up as well. The median follow-up period was 82 months (range 6-202). RESULTS A total of 136 patients (M:F = 73:63) with a mean age of 62 years (range; 21-93) was observed. Seventy-four patients (54.4%) received neoadjuvant therapy (NT), 62 patients (45.6%) received primary surgery (PS). When receiving NT, patients with high-risk STS had a lower risk to develop distant metastasis (p = 0.025). Age, histological type, tumor size and surgical margins (R0 vs. R1) had no influence on any survival rates. There was an association between NT and the occurrence of postoperative complications (p = 0.001). The 5-year local recurrence free survival (LRFS), metastasis free survival (MFS), disease free survival (DFS) and overall survival (OS) rate of the whole cohort was 89.9%, 77.0%, 70.6% and 72.6%; whereas the 5-year LRFS, MFS, DFS and OS rate was 90.5%, 67.2%, 64.1% and 62.8% for the NT group and 89.5%, 88.3%. 78.4% and 83.8% for the PS group. CONCLUSIONS Multimodal treatment strategies in patients with STS of extremities lead to excellent oncological outcomes. Patients with high-risk STS had a significantly better MFS when receiving NT than patients with low-risk STS. NT was associated with a higher probability of postoperative but well-manageable complications.
Collapse
Affiliation(s)
- Miriam Rauch
- Department of Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (M.R.); (W.H.); (R.G.); (K.F.)
- Faculty of Medicine, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany
| | - Abbas Agaimy
- Department of Pathology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany;
| | - Sabine Semrau
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (S.S.); (A.W.); (O.O.); (R.F.)
| | - Alexander Willner
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (S.S.); (A.W.); (O.O.); (R.F.)
| | - Oliver Ott
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (S.S.); (A.W.); (O.O.); (R.F.)
| | - Rainer Fietkau
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (S.S.); (A.W.); (O.O.); (R.F.)
| | - Werner Hohenberger
- Department of Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (M.R.); (W.H.); (R.G.); (K.F.)
| | - Roland S. Croner
- Department of Surgery, University Hospital Magdeburg, 39106 Magdeburg, Germany;
| | - Robert Grützmann
- Department of Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (M.R.); (W.H.); (R.G.); (K.F.)
| | - Katja Fechner
- Department of Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (M.R.); (W.H.); (R.G.); (K.F.)
| | - Nikolaos Vassos
- Department of Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (M.R.); (W.H.); (R.G.); (K.F.)
- Mannheim University Medical Center, Division of Surgical Oncology, Department of Surgery, University of Heidelberg, 68167 Mannheim, Germany
- Correspondence: ; Tel.: +49-621-383-3921; Fax: +49-621-383-1479
| |
Collapse
|
3
|
Bedi M, Ethun CG, Charlson J, Tran TB, Poultsides G, Grignol V, Howard JH, Tseng J, Roggin KK, Chouliaras K, Votanopoulos K, Cullinan D, Fields RC, Cardona K, King DM. Is a Nomogram Able to Predict Postoperative Wound Complications in Localized Soft-tissue Sarcomas of the Extremity? Clin Orthop Relat Res 2020; 478:550-559. [PMID: 32168066 PMCID: PMC7145071 DOI: 10.1097/corr.0000000000000959] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Postoperative wound complications are challenging in patients with localized extremity soft-tissue sarcomas. Various factors have been associated with wound complications, but there is no individualized predictive model to allow providers to counsel their patients and thus offer methods to mitigate the risk of complications and implement appropriate measures. QUESTIONS/PURPOSES We used data from multiple centers to ask: (1) What risk factors are associated with postoperative wound complications in patients with localized soft-tissue sarcomas of the extremity? (2) Can we create a predictive nomogram that will assess the risk of wound complications in individual patients after resection for soft-tissue sarcoma? METHODS From 2000 to 2016, 1669 patients undergoing limb-salvage resection for a localized primary or recurrent extremity soft-tissue sarcoma with at least 120 days of follow-up at eight participating United States Sarcoma Collaborative institutions were identified. Wound complications included superficial wounds with or without drainage, deep wounds with drainage because of dehiscence, and intentional opening of the wound within 120 days postoperatively. Sixteen variables were selected a priori by clinicians and statisticians as potential risk factors for wound complications. A univariate analysis was performed using Fisher's exact tests for categorical predictors, and Wilcoxon's rank-sum tests were used for continuous predictors. A multiple logistic regression analysis was used to train the prediction model that was used to create the nomogram. The prediction performance of the datasets was evaluated using a receiver operating curve, area under the curve, and calibration plot. RESULTS After controlling for potential confounding factors such as comorbidities, functional status, albumin level, and chemotherapy use, we found that increasing age (odds ratio 1.02; 95% confidence interval, 1.00-1.03; p = 0.008), BMI (OR 1.05; 95% CI, 1.02-1.09; p = 0.004), lower-extremity location (OR 6; 95% CI, 2.87-12.69; p < 0.001), and neoadjuvant radiation (OR 2; 95% CI, 1.47-3.16; p < 0.001) were associated with postoperative wound complications (area under the curve 69.2% [range 62.8%-75.6%]). CONCLUSIONS We found that age, BMI, tumor location, and timing of radiation are associated with the risk of wound complications. Based on these factors, a validated nomogram has been established that can provide an individualized prediction of wound complications in patients with a resected soft-tissue sarcoma of the extremity. This may allow for proactive management with nutrition and surgical techniques, and help determine the delivery of radiation in patients with a high risk of having these complications. LEVEL OF EVIDENCE Level III, therapeutic study.
Collapse
|
4
|
Zaidi MY, Ethun CG, Tran TB, Poultsides G, Grignol VP, Howard JH, Bedi M, Mogal H, Tseng J, Roggin KK, Chouliaras K, Votanopoulos K, Krasnick B, Fields RC, Oskouei S, Reimer N, Monson D, Maithel SK, Cardona K. Assessing the Role of Neoadjuvant Chemotherapy in Primary High-Risk Truncal/Extremity Soft Tissue Sarcomas: An Analysis of the Multi-institutional U.S. Sarcoma Collaborative. Ann Surg Oncol 2019; 26:3542-3549. [PMID: 31342400 DOI: 10.1245/s10434-019-07639-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND The role of neoadjuvant chemotherapy (NCT) for high-risk soft tissue sarcoma (STS) is questioned. This study aimed to define which patients may experience a survival advantage with NCT. METHODS All the patients from the U.S. Sarcoma Collaborative database (2000-2016) who underwent curative-intent resection of high-grade, primary truncal/extremity STS size 5 cm or larger were included in this study. The primary end points were recurrence-free survival (RFS) and overall survival (OS). RESULTS Of the 4153 patients, 770 were included in the study. The median tumor size was 10 cm, and 669 of the patients (87%) had extremity tumors. The most common histology was undifferentiated pleomorphic sarcoma (UPS), found in 42% of the patients. Of the 770 patients, 216 (28%) received NCT. The patients who received NCT had deeper, larger tumors (p < 0.001). Of the patients with tumors 5 cm or larger and 8 cm or larger, NCT was not associated with improved RFS or OS. However for the patients with tumors 10 cm or larger, NCT was associated with improved 5-year RFS (51% vs 40%; p = 0.053) and 5-year OS (58% vs 47%; p = 0.043). By location, the patients with extremity tumors 10 cm or larger but not truncal tumors had improved 5-yearr RFS (54% vs 42%; p = 0.042) and 5-year OS (61% vs 47%; p = 0.015) with NCT. According to histology, no subtype had improved RFS or OS with NCT, although the patients with UPS had a trend toward improved 5-year RFS (56% vs 42%; p = 0.092) and 5-year OS (66% vs 52%; p = 0.103) with NCT. CONCLUSION For the patients with high-grade STS, NCT was associated with improved RFS and OS when tumors were 10 cm or larger and located in the extremity. However, no histiotype-specific advantage was identified. Future studies assessing the efficacy of NCT may consider focusing on these patients, with added focus on histology-specific strategies.
Collapse
Affiliation(s)
- Mohammad Y Zaidi
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Cecilia G Ethun
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Thuy B Tran
- Department of Surgery, Stanford University Medical Center, Palo Alto, CA, USA
| | - George Poultsides
- Department of Surgery, Stanford University Medical Center, Palo Alto, CA, USA
| | - Valerie P Grignol
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - J Harrison Howard
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Meena Bedi
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Harveshp Mogal
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jennifer Tseng
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Kevin K Roggin
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | | | | | - Brad Krasnick
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Shervin Oskouei
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Nickolas Reimer
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - David Monson
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Kenneth Cardona
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA.
| |
Collapse
|
5
|
Gannon NP, King DM, Ethun CG, Charlson J, Tran TB, Poultsides G, Grignol V, Howard JH, Tseng J, Roggin KK, Votanopoulos K, Krasnick B, Fields RC, Cardona K, Bedi M. The role of radiation therapy and margin width in localized soft-tissue sarcoma: Analysis from the US Sarcoma Collaborative. J Surg Oncol 2019; 120:325-331. [PMID: 31172531 DOI: 10.1002/jso.25522] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 05/12/2019] [Accepted: 05/13/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND OBJECTIVES Soft-tissue sarcomas (STSs) are often treated with resection and radiation (RT)±chemotherapy. The role of RT in decreasing resection width to achieve local control is unclear. We evaluated RT on margin width to achieve local control and local recurrence (LR). METHODS From 2000 to 2016, 514 patients with localized STS were identified from the US Sarcoma Collaborative database. Patients were stratified by a margin and local control was compared amongst treatment groups. RESULTS LR was 9% with positive, 4.2% with ≤1 mm, and 9.3% with >1 mm margins (P = .315). In the ≤1 mm group, LR was 5.7% without RT, 0% with preoperative RT, and 0% with postoperative RT (P < .0001). In the >1 mm group, LR was 10.2%, 0%, and 3.7% in the no preoperative and postoperative RT groups, respectively (P = .005). RT did not influence LR in patients with positive margins. In stage I-III and II-III patients, local recurrence-free survival was higher following RT (P = .008 and P = .05, respectively). CONCLUSIONS RT may play a larger role in minimizing LR than margin status. In patients with positive margins, RT may decrease LR to similar rates as a negative margin without RT and may be considered to decrease the risk of LR with anticipated close/positive margins.
Collapse
Affiliation(s)
- Nicholas P Gannon
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David M King
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Cecilia G Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - John Charlson
- Division of Hematology and Oncology, Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Thuy B Tran
- Department of Surgery, Stanford University, Palo Alto, California
| | | | - Valerie Grignol
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, Ohio
| | - J Harrison Howard
- Division of Surgical Oncology, Department of Surgery, University of South Alabama, Mobile, Alabama
| | - Jennifer Tseng
- Department of Surgery, University of Chicago, Chicago, Illinois
| | - Kevin K Roggin
- Department of Surgery, University of Chicago, Chicago, Illinois
| | | | - Bradley Krasnick
- Department of Surgery, Washington University, St. Louis, Missouri
| | - Ryan C Fields
- Department of Surgery, Washington University, St. Louis, Missouri
| | - Kenneth Cardona
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Meena Bedi
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| |
Collapse
|
6
|
Does Vacuum-assisted Closure Reduce the Risk of Wound Complications in Patients With Lower Extremity Sarcomas Treated With Preoperative Radiation? Clin Orthop Relat Res 2019; 477:768-774. [PMID: 30811365 PMCID: PMC6437357 DOI: 10.1097/corr.0000000000000371] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although preoperative radiation followed by wide local excision yields excellent local control in soft tissue sarcomas, the risk of wound complications is reported to be higher compared with the incidence in patients who were administered postoperative radiation therapy. Vacuum (vac)-assisted closure may improve wound healing, but it is unknown whether vac-assisted closure during soft tissue sarcoma resection may reduce the risk of wound complications or impair local disease control. QUESTIONS/PURPOSES (1) Does the use of a wound vac application at the time of soft tissue sarcoma resection reduce the risk of developing wound complications after lower extremity sarcoma resection? (2) Is vac-assisted closure associated with an increased risk of local relapse? METHODS From 2000 to 2016, 312 patients with stage I to III soft tissue sarcomas were treated. Of these, 123 were treated with preoperative radiation ± chemotherapy followed by limb-sparing resection based on tumor location, size, grade, histology, and patient age. There was a minimum followup of 12 months. Radiation was delivered generally based on tumor size, grade, superficial versus deep nature, and proximity to neurovascular structures. Chemotherapy was administered in patients < 70 years old with high-grade tumors and tumors > 5 cm. Patient, demographic, and treatment variables, including incisional vac application and wound outcomes, were retrospectively evaluated. Incisional vac-assisted closure took place at the time of primary resection in 32% (46 of 123) of patients. Vac-assisted closure was considered when there was a concern for risk of external contamination such as instances in which fixation of adhesives would be difficult or regions where there was a high risk of contamination. Vac-assisted closure may have also been used in instances with increased wound tension at closure or with heightened concern for shearing on the wound such as buttock wounds. Ten patients were lost to followup, two in the vac group and eight in the non-vac group. Potential factors associated with wound complications were evaluated using Fisher's exact test for univariate analysis and logistic regression for multivariate analysis. Local recurrence-free survival was evaluated using the Kaplan-Meier estimate. RESULTS After taking into consideration factors such as tumor size, location, age, and patient comorbidities, it was shown that patients who underwent vac-assisted closure were less likely to experience wound complications compared with patients who did not undergo vac-assisted closure (odds ratio, 0.129; 95% confidence interval [CI], 0.041-0.398; p = 0.004). The local control incidence in the entire cohort was 98%. With the numbers available, Kaplan-Meier survivorship free from local recurrence did not differ between patients treated with or without the vac (100% [95% CI, 154.09-154.09] versus 96% [95% CI, 152.21-169.16]; p = 0.211), respectively. CONCLUSIONS Vac-assisted closure at the time of resection of proximal lower extremity soft tissue sarcomas is associated with a lower risk of wound complications, and its use apparently did not compromise local control. We show that the use of vac-assisted closure may be worth considering in surgeons' attempts to reduce the risk of wound complications among patients with soft tissue sarcomas of the proximal lower extremities. LEVEL OF EVIDENCE Level III, therapeutic study.
Collapse
|
7
|
Pathologic necrosis following neoadjuvant radiotherapy or chemoradiotherapy is prognostic of poor survival in soft tissue sarcoma. J Cancer Res Clin Oncol 2019; 145:1321-1330. [DOI: 10.1007/s00432-019-02885-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 03/01/2019] [Indexed: 12/14/2022]
|
8
|
Charlson J. Selection of Patients With Localized Extremity Soft Tissue Sarcoma for Treatment With Perioperative Chemotherapy. Curr Treat Options Oncol 2018; 19:65. [PMID: 30361919 DOI: 10.1007/s11864-018-0586-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OPINION STATEMENT Soft tissue sarcoma (STS) is a heterogeneous disease, in terms of histologic subtype, body site of presentation, and behavior. Localized soft tissue sarcoma may be cured with complete tumor excision, but overall, outcomes are sub-optimal. Metastatic disease is associated with shortened survival. Systemic therapy has been studied for several decades as adjunctive therapy, but the use of adjuvant and neo-adjuvant chemotherapy remains controversial. The heterogeneity of patients included in clinical trials, and of sarcoma in general, has made it difficult to draw conclusions about which patients with localized STS should be treated with chemotherapy. Over time, published outcomes for STS of the extremities have improved, and one of the factors that contributes to this improvement may be selection of patients most likely to benefit from the prescribed treatment. Recent studies of neo-adjuvant and adjuvant chemotherapy have recruited patients with the highest recurrence risk-those with large, high-grade, deep tumors. It is reasonable, in practice, to apply similar criteria in deciding whether to recommend treatment. Looking ahead, it will be important to refine our ability to identify patients at highest risk of recurrence, and to develop tools to predict which patients and tumors will respond to chemotherapy.
Collapse
Affiliation(s)
- John Charlson
- Hematology/Oncology, Medical College of Wisconsin, Froedtert/MCW Cancer Center, 4th Floor, 9200 W. Wisconsin Ave., Milwaukee, WI, 53226, USA.
| |
Collapse
|
9
|
Gannon NP, King DM, Bedi M. Smoking is predictive of poorer distant metastasis-free and progression free-survival in soft tissue sarcoma patients treated with pre-operative radiotherapy or chemoradiotherapy. Clin Sarcoma Res 2018; 8:7. [PMID: 29686838 PMCID: PMC5901866 DOI: 10.1186/s13569-018-0088-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Accepted: 01/31/2018] [Indexed: 01/14/2023] Open
Abstract
Background Soft tissue sarcomas (STS) are often treated with pre-operative radiation (RT), with or without chemotherapy, followed by wide local excision. Prognosis for these patients involves an interplay of tumor and patient characteristics. Known prognostic determinants include tumor size, grade, response to therapy, and patient characteristics such as age. While smoking is negatively correlated with outcomes in various malignancies, the impact on STS is unknown. We aimed to assess if smoking impacts overall (OS), distant metastasis-free (DMFS), and progression-free (PFS) survival in patients with STS treated with pre-operative RT. Methods Between 2000 and 2015, 166 patients with STS were identified from our prospective database. Patient variables were retrospectively reviewed. Smoking was defined as a ≥ 10 pack year history of current and former smokers. Survival was evaluated using the fisher exact test for univariate (UVA) and logistic regression for multivariate (MVA) analysis. Results Fifty-seven (34.3%) patients had smoking histories of ≥ 10 pack years. On UVA, smoking was associated with decreased DMFS (p = 0.0009) and PFS (p = 0.0036), but not OS (p = 0.05). Smoking held significance on MVA for both DMFS and PFS. Current smokers and patients with ≥ 24-month follow-up demonstrated decreased DMFS and PFS on UVA and MVA. Conclusions Current smokers and patients with a significant smoking history demonstrated decreased DMFS and PFS in STS patients treated with pre-operative RT. Smoking may cause immunologic compromise and therefore lead to higher rates of progression and distant metastasis.
Collapse
Affiliation(s)
- Nicholas P Gannon
- 1Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, WI 53226 USA
| | - David M King
- 1Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, WI 53226 USA
| | - Manpreet Bedi
- 2Department of Radiation Oncology, Medical College of Wisconsin, 9200 West Wisconsin Ave, Milwaukee, WI 53226 USA
| |
Collapse
|
10
|
Postoperative Day 1 Glucose May Be Associated With Wound Complications in Sarcomas Treated With Preoperative Radiation. Clin Orthop Relat Res 2018; 476. [PMID: 29529645 PMCID: PMC6260049 DOI: 10.1007/s11999.0000000000000056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Uncontrolled blood glucose impacts key phases of the wound healing process. Various factors have been associated with postoperative wound complications in soft tissue sarcomas; however, the association of postoperative early morning blood glucose with wound complications, if any, remains to be determined. Because blood glucose levels may be modified, understanding whether glucose levels are associated with wound complications has potential therapeutic importance. QUESTIONS/PURPOSES The purposes of this study were (1) to evaluate if postoperative early morning blood glucose is associated with the development of wound complications in soft tissue sarcomas; (2) to determine a blood glucose cutoff that may be associated with an increased risk of wound complications; and (3) to evaluate if patients with diabetes have higher postoperative blood glucose and an associated increased risk of wound complications. METHODS From 2000 to 2015, 298 patients with Stage I to III soft tissue sarcomas of the extremity or chest wall were treated with preoperative radiation ± chemotherapy followed by limb-sparing resection. Of those, 191 (64%) patients had demographic, treatment, and postoperative variables and wound outcomes available; these patients' results were retrospectively evaluated. None of the 191 patients were lost to followup. Early morning blood glucose levels on postoperative day (POD) 1 were available in all patients. Wound complications were defined as those resulting in an operative procedure or prolonged wound care for 6 months postresection. Variables that may be associated with wound complications were evaluated using logistic regression for multivariate analysis. Receiver operative curve (ROC) analysis was used to assess the early morning blood glucose level that best was associated postoperative wound complications. RESULTS After controlling for potentially relevant confounding variables such as patient comorbidities, tumor size, and location, lower extremity soft tissue sarcomas (p = 0.002, odds ratio [OR], 6.4; 95% confidence interval [CI], 1.97-20.84) and elevated POD 1 early morning blood sugars (p < 0.001; OR, 1.1; 95% CI, 1.04-1.11) were associated with increased wound complications postoperatively. ROC analysis revealed that early morning POD 1 blood glucose of > 127 mg/dL was associated with postoperative wound complications with a sensitivity of 89% (area under the curve 0.898, p < 0.001). Median POD 1 early morning blood glucose in patients without diabetes was 118 mg/dL and 153 mg/dL in patients with diabetes (p = 0.023). However, with the numbers available, there was no increase in wound complications in patients with diabetes compared with those without it. CONCLUSIONS Our study provides preliminary information suggesting that POD 1 early morning blood glucose in patients with soft tissue sarcomas may be associated with a slightly increased risk of postoperative wound complications. An early morning blood glucose of > 127 mg/dL may be a threshold associated with this outcome. Although patients with diabetes had higher POD 1 early morning blood glucose levels, diabetes itself was not associated with the development of wound complications. We cannot conclude that better glycemic control will reduce wound complications in patients who receive preoperative radiation, but our data suggest this should be further studied in a larger, prospective study. LEVEL OF EVIDENCE Level III, therapeutic study.
Collapse
|
11
|
Lozano-Calderón SA. CORR Insights®: Postoperative Day 1 Glucose May Be Associated With Wound Complications in Sarcomas Treated With Preoperative Radiation. Clin Orthop Relat Res 2018; 476. [PMID: 29529646 PMCID: PMC6260015 DOI: 10.1007/s11999.0000000000000139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Santiago A Lozano-Calderón
- S. A. Lozano-Calderón, Instructor in Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
12
|
Heaver C, Isaacson A, Gregory JJ, Cribb G, Cool P. Patient factors affecting the Toronto extremity salvage score following limb salvage surgery for bone and soft tissue tumors. J Surg Oncol 2016; 113:804-10. [DOI: 10.1002/jso.24247] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 03/21/2016] [Indexed: 11/07/2022]
Affiliation(s)
- Catriona Heaver
- Robert Jones and; Agnes Hunt Orthopaedic Hospital; Oswestry United Kingdom
| | - Antonia Isaacson
- Robert Jones and; Agnes Hunt Orthopaedic Hospital; Oswestry United Kingdom
| | | | - Gill Cribb
- Robert Jones and; Agnes Hunt Orthopaedic Hospital; Oswestry United Kingdom
| | - Paul Cool
- Robert Jones and; Agnes Hunt Orthopaedic Hospital; Oswestry United Kingdom
| |
Collapse
|
13
|
Stubbe F, Agaimy A, Ott O, Lettmaier S, Vassos N, Croner R, Hohenberger W, Fietkau R, Semrau S. Effective local control of advanced soft tissue sarcoma with neoadjuvant chemoradiotherapy and surgery: A single institutional experience. Cancer Radiother 2016; 20:6-13. [DOI: 10.1016/j.canrad.2015.05.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 04/22/2015] [Accepted: 05/29/2015] [Indexed: 01/25/2023]
|
14
|
|
15
|
Vaynrub M, Taheri N, Ahlmann ER, Yao C, Fedenko AN, Allison DC, Chawla SP, Menendez LR. Prognostic value of necrosis after neoadjuvant therapy for soft tissue sarcoma. J Surg Oncol 2014; 111:152-7. [DOI: 10.1002/jso.23775] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 08/05/2014] [Indexed: 12/21/2022]
Affiliation(s)
- Max Vaynrub
- Department of Orthopaedic Surgery; Los Angeles County - University of Southern California Medical Center; Keck School of Medicine; Los Angeles California
| | - Nima Taheri
- Keck School of Medicine; Los Angeles California
| | - Elke R. Ahlmann
- Department of Orthopaedic Surgery; Los Angeles County - University of Southern California Medical Center; Keck School of Medicine; Los Angeles California
- Department of Orthopaedic Oncology; University of Southern California Keck School of Medicine; Keck Hospital; Los Angeles California
| | - Caroline Yao
- Department of General Surgery; Division of Plastic Surgery; Los Angeles County - University of Southern California Medical Center; Keck School of Medicine; Los Angeles California
| | - Alexander N. Fedenko
- Department of Pathology; University of Southern California Keck School of Medicine; Keck Hospital; Hoffman Medical Research Center 211; Los Angeles California
| | - Daniel C. Allison
- Department of Orthopaedic Surgery; Los Angeles County - University of Southern California Medical Center; Keck School of Medicine; Los Angeles California
- Department of Orthopaedic Oncology; University of Southern California Keck School of Medicine; Keck Hospital; Los Angeles California
| | | | - Lawrence R. Menendez
- Department of Orthopaedic Oncology; University of Southern California Keck School of Medicine; Keck Hospital; Los Angeles California
| |
Collapse
|
16
|
Cai L, Mirimanoff RO, Mouhsine E, Guillou L, Leyvraz PF, Leyvraz S, Gay B, Matzinger O, Ozsahin M, Zouhair A. Prognostic factors in adult soft tissue sarcoma treated with surgery combined with radiotherapy: a retrospective single-center study on 164 patients. Rare Tumors 2013; 5:e55. [PMID: 24416489 PMCID: PMC3882927 DOI: 10.4081/rt.2013.e55] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Revised: 07/05/2013] [Accepted: 07/05/2013] [Indexed: 11/24/2022] Open
Abstract
The aim of the present study is to assess the disease profile, outcome and prognostic factors in patients treated with surgery combined with radiotherapy (RT), with or without chemotherapy (CXT), for soft-tissue sarcoma (STS) in a multidisciplinary setting. One hundred and sixty-four patients with STS treated between 1980 and 2010 at the Centre Hospitalier Universitaire Vaudois were enrolled in this retrospective study. Seventy-six percent of patients underwent postoperative RT with (24%), or without (52%) CXT, 15% preoperative RT with (5%), or without (10%) CXT, surgery alone (7%), or RT alone (2%) with or without CXT. The median follow-up was 60 months (range 6-292). Local failure was observed in 18%, and distant failure in 21% of the patients. Overall survival (OS), diseasefree survival (DFS), local control (LC) and distant metastases-free survival (DMFS) were 88%, 68%, 83%, and 79% at 5 years, and 80%, 56%, 76%, and 69% at 10 years, respectively. In univariate analyses, favorable prognostic factors for OS, DFS, and DMFS were tumor size 6 cm or less, World Health Organization (WHO)/Zubrod score 0, and stage 2 or less. Age and superficial tumors were favorable only for OS and DMFS respectively. STS involving the extremities had a better outcome regarding DFS and LC. Histological grade 2 or less was favorable for DFS, DMFS, and LC. Radical surgery was associated with better LC and DMFS. RT dose more than 60 Gy was favorable for OS, DFS, and LC. In multivariate analyses, independent factors were age for OS; tumor size for OS, DFS and DMFS; WHO/Zubrod score for OS, DFS and LC; hemoglobin level for DFS; site for DFS and LC; tumor depth for DMFS; histological grade for DFS and LC; surgical procedure for LC and DMFS; and RT dose for OS. This study confirms that in a multidisciplinary setting, STS have a fairly good prognosis. A number of prognostic and predictive factors, including the role of surgery combined with RT, were identified. Regarding RT, a dose of more than 60 Gy was associated with a better outcome, at the price of a higher toxicity. We could not demonstrate a superiority of preoperative RT over postoperative RT.
Collapse
Affiliation(s)
- Ling Cai
- Departments of Radiation Oncology, Vaud University Hospital Center, Lausanne, Switzerland
| | | | - Elyazid Mouhsine
- Departments of Orthopedic Surgery, Vaud University Hospital Center, Lausanne, Switzerland
| | - Louis Guillou
- Departments of Pathology, Vaud University Hospital Center, Lausanne, Switzerland
| | | | - Serge Leyvraz
- Departments of Medical Oncology, Vaud University Hospital Center, Lausanne, Switzerland
| | - Beatrice Gay
- Departments of Medical Oncology, Vaud University Hospital Center, Lausanne, Switzerland
| | - Oscar Matzinger
- Departments of Radiation Oncology, Vaud University Hospital Center, Lausanne, Switzerland
| | - Mahmut Ozsahin
- Departments of Radiation Oncology, Vaud University Hospital Center, Lausanne, Switzerland
| | - Abderrahim Zouhair
- Departments of Radiation Oncology, Vaud University Hospital Center, Lausanne, Switzerland
| |
Collapse
|