Extremity soft tissue sarcoma: adding to the prognostic meaning of local failure

What is the Optimal Treatment Strategy after Sarcoma R2 Surgery?

OPINION STATEMENT

Soft tissue sarcomas (STS) are rare tumours of mesenchymal origin, most commonly occurring in the extremity but also in the retroperitoneum. The curative treatment for STS is radical surgery with wide margins, in some cases in combination with perioperative radiotherapy and chemotherapy. Nonradical resection (R2) of STS has been an emerging issue in recent decades, as optimal subsequent management remains debatable. Similarly, there is still no consensus on optimal surgical margins. Combining multiple treatment modalities in adjuvant therapy can achieve local and distant control in patients following surgery with positive margins. Patients who have undergone nonradical resection therefore require additional surgical interventions, and adjuvant radiotherapy resulting in a better prognosis but a higher number of complications. Following non-radical treatment, patients with limb and trunk wall sarcomas and retroperitoneal sarcomas should also undergo increased oncological surveillance. Given the potential issues that may emerge in such clinical situations, it is crucial to up-date the current guidelines to enhance the long-term prognosis of these patients.

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.

[Predictive factors assessment of pathological response to neoadjuvant radiotherapy of soft tissue sarcomas]

PURPOSE

Conserving surgery combined with radiotherapy in presence of local recurrence risk factors is standard treatment of soft tissue sarcomas, a group of rare and heterogeneous tumours. Radiotherapy is performed before or after surgery. In neoadjuvant setting, late radiation-induced toxicity is reduced and pathological response to radiotherapy could be achieved. A complete pathological response to radiotherapy has recently been shown to predict better survival. Our study aims at identifying predictive factors of pathological response to neoadjuvant radiotherapy (clinical, radiological or histological) of soft tissue sarcomas.

PATIENTS AND METHODS

Clinical, imaging (MRI: perilesional oedema, necrosis, tumour heterogeneity, vasculonervous relationships) and pathological (pathological subtype, tumour grade, anticipated/obtained resection quality) data were retrospectively collected. Tumour response (imaging and pathological), patient outcome, acute and late radiation-induced toxicity, predictive factors of pathological response to neoadjuvant radiotherapy were studied. The 2-test or exact-Fisher test (qualitative variables) and by Student's t-test or Kruskal-Wallis test (quantitative variables) were used for statistical analysis.

RESULTS

From April 2017 to April 2021, neoadjuvant radiotherapy (50Gy in 25 fractions) followed by surgical excision was performed to 36 consecutive patients with liposarcomas (n=17/36), or undifferentiated sarcomas (n=8/36). MRI response was complete in 1 patient, partial in 9 patients (n=9/36, 25%), stable in 21 patients (n=21/36, 58%) or in progression in 5 patients (n=5/36, 14%). Pathological response was observed in 22 patients (61%). No grade 3-4 acute radiation-induced toxicity was observed. Regarding late toxicity, 28% of patients had grade 1-2 oedema (n=10/36), 39% had a grade 1 fibrosis (n=14/36), and 30% grade 1 pain (n=11/36). No predictive factors of response to radiotherapy was statistically significant.

CONCLUSIONS

Neoadjuvant radiotherapy is well-tolerated. No clinical, radiological or pathological predictive factors was identified for radiotherapy tumour response.

System describing surgical field extension associated with flap reconstruction after resection of a superficial malignant soft tissue tumor

BACKGROUND

Flap reconstruction after resection of a superficial malignant soft tissue tumor extends the surgical field and is an indicator for potential recurrence sites.

AIM

To describe a grading system for surgical field extension of soft tissue sarcomas.

METHODS

Grading system: CD-grading is a description system consisting of C and D values in the surgical field extension, which are related to the compartmental position of the flap beyond the nearby large joint and deeper extension for the pedicle, respectively. C1/D1 are positive values and C0/D0 are negative. With a known location, 1/0 values can be "p" (proximal), "d" (distal), and "b" (in the tumor bed), and the description method is as follows: flap type, CxDx [x = 0, 1, p, d or b].

RESULTS

Four representative patients with subcutaneous sarcomas who underwent reconstruction using fasciocutaneous flaps are presented. The cases involved a distal upper arm (elbow) synovial sarcoma reconstructed using a pedicled latissimus dorsi (pedicled flap: CpDp); a distal upper arm (elbow) pleomorphic rhabdomyosarcoma reconstructed using a transpositional flap from the forearm (transpositional flap: CdD0); an undifferentiated pleomorphic sarcoma in the buttocks reconstructed using a transpositional flap (transpositional flap: C0D0); and a myxofibrosarcoma in the buttocks reconstructed using a propeller flap from the thigh (pedicled flap: CdDd).

CONCLUSION

The reconstruction method is chosen by the surgeon based on size, location, and other tumor characteristics; however, the final surgical field cannot be determined based on preoperative images alone. CD-grading is a description system consisting of C and D values in the surgical field extension that are related to the compartmental position of the flap beyond the nearby large joint and deeper extension for the pedicle, respectively. The CD-grading system gives a new perspective to the flap reconstruction classification. The CD-grading system also provides important information for follow-up imaging of a possible recurrence.

Tumor size and surgical margins are important prognostic factors of synovial sarcoma - A retrospective study

Background

Synovial Sarcoma (SS) is a rare soft tissue sarcoma. Mean time to get a SS diagnosis from the onset of symptoms is 10 years, furthermore, SS is associated with late metastasis. Surgery is the main treatment option, whose quality deeply affects SS outcomes, and it can be associated to preoperative or post-operative radiotherapy. Chemotherapy is considered very effective in Children, while in adults its efficacy is still under debate. The aim of this study was to investigate the oncologic results in SS treatment and to identify the risk factors for local and systemic control of the disease.

Methods

From 1994 to 2018, 211 patients affected by SS were treated in 3 Referral Centres of Orthopaedic Oncology. One hundred seventy-seven patients were included in the study, the median follow-up length was 96 months (5-374).

Results

Overall Survival on the Kaplan Meier Analyses was 80%, 70% and 56% at 5, 10 and 20 years. In multivariate analyses, OS correlated with tumour size and negative surgical margins. Chemotherapy use wasn't associated with better survival although patients who underwent CT had bigger and more aggressive tumours.

Conclusions

Our findings suggests that surgery with negative margins is the most important factor in Synovial Sarcoma. Adjuvant treatments as chemotherapy and radiation therapy didn't change the disease's course.

Outcome After Surgical Treatment of Dermatofibrosarcoma Protuberans (DFSP): Does it Require Extensive Follow-up and What is an Adequate Resection Margin?

INTRODUCTION

Dermatofibrosarcoma protuberans (DFSP) is a rare cutaneous tumour of indeterminate malignant potential. The mainstay treatment for DFSP is surgical resection. Given the reported high local recurrence rate, the ideal resection margin for DFSP is unclear. The purpose of this study was to ascertain the local recurrence and metastatic rate of DFSP and DFSP with fibrosarcomatous degeneration (FS-DFSP), with specific attention to margin status in an attempt to address the issue of margin adequacy.

METHODS

Patients treated for DFSP at a single sarcoma centre were identified from a prospective database. DFSP and FS-DFSP patients with and without prior surgery were included. Patients were followed after surgery to monitor complications, local recurrence and metastasis.

RESULTS

The study included 200 patients: 166 patients with DFSP and 34 patients with FS-DFSP. In the DFSP group, nine patients (5.4%) had positive margins, one case (0.6%) developed local recurrence (LR) and no patients developed distant metastases. In the FS-DFSP group, seven patients (20.6%) had positive margins, six patients (17.6%) developed local recurrence (LR) and eight patients (23.5%) developed distant metastases, of which three (37.5%) were in the lungs, one (12.5%) in bone and four (50%) in other soft tissue sites.

DISCUSSION AND CONCLUSION

Local recurrence and metastases are extremely rare in patients with DFSP. Achieving a negative as opposed to a wide surgical margin may be sufficient to avoid local recurrence of most DFSP. We suggest that no ongoing surveillance for local or systemic relapse is required for DFSP patients after negative margin resection. For FS-DFSP, we recommend the same surveillance schedule, based on tumour grade, as other soft tissue sarcoma.

Low rate of function-limiting side effects with high-dose adjuvant radiotherapy in high-grade soft tissue extremity sarcomas: a retrospective single-center analysis over 10 years

Background

Over the years, radiotherapy has been established as a tool to improve local control for high-grade sarcomas. Although the European Society for Medical Oncology guidelines has taken notice of a shift toward a neoadjuvant radiotherapy approach, the American Society for Radiation Oncology guidelines clearly favor a neoadjuvant approach, citing debilitating long-term adverse effects when radiotherapy is applied postoperatively. In this study, we examined these irradiation-associated adverse events for adjuvant radiotherapy and focused on the prognostic factors for disease outcome, including local control.

Methods

In this retrospective study, data for 106 patients with extremity soft-tissue sarcomas diagnosed between 1997 and 2021, of which 40 received adjuvant radiotherapy, were collected from the clinical and radiological information systems of a high-volume sarcoma treatment center. These data were then analyzed for radiation-associated side effects as well as predictive factors for overall survival, disease-free survival, local control, and surgical complications.

Results

Radiotherapy was beneficial to patients improving local control, especially for high-grade sarcomas, even when those were resected with negative margins. Side effects due to radiotherapy occurred in 87.5% of the patients, and these effects primarily included radiation dermatitis in 67.5%; however, only 40.0% had any adverse event of ≥ grade 2 according to Common Terminology Criteria for Adverse Events. Long-term function-limiting side effects occurred in 45.0% of the patients; 10% exhibited ≥ grade 2 function-limiting adverse events. Greater time between surgery and adjuvant radiotherapy was beneficial for the patients, whereas joint infiltrating sarcomas were associated with more severe long term, function-limiting adverse events. 28.3% of the patients experienced a recurrence at any location (median time 18.35 months) and in 16% the recurrence was local (median time 16.11 months), resulting in 1, 3, and 5 year disease-free survival rates of 74.1, 58.9, and 38.5% and local control rates of 78.7, 61.6, and 42.8% were observed, respectively.

Conclusion

Recurrences may be avoided with high-dose radiation, especially for high-grade G2 and G3 sarcomas, even after complete R0 resection. This resulted in a low rate of severe long-term function-limiting adverse events. Thus, adjuvant radiotherapy should be seriously considered when planning patient treatment, especially when treating patients that present with high-grade sarcomas.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00432-022-04423-1.

Risk factors for the development of local recurrence in extremity soft-tissue sarcoma

INTRODUCTION

Local recurrence (LR) is one of the main pitfalls in surgery for extremities soft tissue sarcoma (eSTS). Achieving clear histopathological margins is the most important factor to reduce the risk of LR, but the ability to do so depends on not only surgical technique but also the interplay between tumor biology, anatomical location and surgical approach. The balance between postoperative morbidity and oncological benefits in reducing the risk of LR needs to be considered.

AREAS COVERED

This review will cover which etiological factors for the development of eSTS lead to an increased risk of LR and discuss histological subtypes that have a high risk of LR and which surgical and neoadjuvant therapeutic strategies can minimize the risk of LR.

EXPERT OPINION

The traditional view that surgical radicality always results in low rates of LR, while marginality alone always leads to high rates of relapse, is outdated. In the modern era of surgical oncology, limb salvage and high-level function after resectional surgery are the key surgical goals. The best results are achieved by combining effective neoadjuvant treatments with planned bespoke oncological operations that consider the biological and anatomical factors of each individual sarcoma.

Is local recurrence in bone and soft tissue sarcomas just a local recurrence or does it impact the overall survival, retrospective cohort from a sarcoma referral center

BACKGROUND AND OBJECTIVES

Sarcoma local recurrence (LR) is often associated with metastasis, but it is unclear if LR can be a causal event leading to metastasis. We question if LR is best viewed as an independent oncologic event or as a worrisome harbinger threatening a patient's overall survival.

METHODS

We identified patients with LR and/or metastasis from an ongoing cohort of 629 patients with primary sarcoma and performed a detailed review to assess the timing of metastasis resulting in the following groups: (1) Isolated LR, (2) LR before metastasis, (3) LR within 6 months of metastasis, (4) LR 6-12 months after metastasis, (5) LR >12 months after metastasis, and (6) metastasis at diagnosis.

RESULTS

Overall, 43 patients met the inclusion criteria with an LR rate of 7%. Ten patients (2% of the entire cohort, 23% of LR) developed an LR before or within 6 months of metastasis. For patients without systemic disease preceding LR, 3 of 23 soft tissue sarcoma STS (13%) and 7 of 10 bone sarcoma (70%) subsequently developed metastasis (p < 0.01).

CONCLUSION

LR with subsequent metastasis is a rare event. LR appears to be best viewed as a marker of tumor aggressiveness rather than the cause of metastasis and poor survival. LR in bone sarcoma patients should warn providers of a high risk of imminent metastasis.

Histologic Subtype Defines the Risk and Kinetics of Recurrence and Death for Primary Extremity/Truncal Liposarcoma

OBJECTIVE

We sought to define the prognostic significance of histologic subtype for extremity/truncal liposarcoma (LPS).

BACKGROUND

LPS, the most common sarcoma, is comprised of 5 histologic subtypes. Despite their distinct behaviors, LPS outcomes are frequently reported as a single entity.

METHODS

We analyzed data on all patients from a single-institution prospective database treated from July 1982 to September 2017 for primary, nonmetastatic, extremity or truncal LPS of known subtype. Clinicopathologic variables were tested using competing risk analyses for association with disease-specific death (DSD), distant recurrence (DR), and local recurrence (LR).

RESULTS

Among 1001 patients, median follow-up in survivors was 5.4 years. Tumor size and subtype were independently associated with DSD and DR. Size, subtype, and R1 resection were independently associated with LR. DR was most frequent among pleomorphic and round cell LPS; the former recurred early (43% by 3 years), and the latter over a longer period (23%, 3 years; 37%, 10 years). LR was most common in dedifferentiated LPS, in which it occurred early (24%, 3 years; 33%, 5 years), followed by pleomorphic LPS (18%, 3 years; 25%, 10 years).

CONCLUSIONS

Histologic subtype is the factor most strongly associated with DSD, DR, and LR in extremity/truncal LPS. Both risk and timing of adverse outcomes vary by subtype. These data may guide selective use of systemic therapy for patients with round cell and pleomorphic LPS, which carry a high risk of DR, and radiotherapy for LPS subtypes at high risk of LR when treated with surgery alone.

Re-excision after unplanned excision of soft tissue sarcoma: A systematic review and metanalysis. The rationale of systematic re-excision

In Soft Tissue Sarcomas (STS) referral centre many patients have already had an incomplete tumour resection. In the majority of specimen, tumoral residual is detected and linked to a worsen prognosis. Systematic surgical re-resection of the scar tissue area is often performed. Some authors suggested to postpone re-resections until a clinically evident local recurrence is detected. A searching strategy was applied to Pubmed-Central and Ovid Medline. Odds ratio (OR) for local recurrence (LR), distant metastasis (MTS) or overall survival (OS) were calculated comparing patients who had tumour residual to people who hadn't. OR of local recurrences, distant metastasis and OS were calculated in planned vs unplanned-excisions groups. OR to develop a metastasis and OS after a local recurrences were calculated. Residual tumour led to an OR for LR of 3,56, OR of MTS was 3,42; OR of decreased OS was 3,42. Having a LR lead to a OR of 1,55 for MTS and to a OR of decreased OS of 2,32. Patients who underwent a re-excision compared to planned surgery did not have an increased OR of LR and had an OR to develop a MTS of 0,56. Our data confirm that there is a strong correlation between local recurrences, distant relapses and overall survival. Although there is a selection bias; this analysis highlights the optimal oncological outcome in patients who underwent re-resection. The rationale for systematic re-resection after unplanned excision of soft tissue sarcomas is very strong and this treatment remains the gold standard of care in these patients.

Margin Assessment in Soft Tissue Sarcomas: Review of the Literature

Simple Summary

Many classifications to assess margins status for soft tissue sarcomas are reported in the literature. Most of the series are heterogeneous and variable in size, making it difficult to compare results from study to study. Thus, which is the best way to assess margins in order to predict the risk of local recurrence is still debated. The aim of this narrative review is to provide a comprehensive assessment of the literature on margins, and to highlight the need for a uniform description of the margin status for patients with soft tissue sarcomas (STS).

Abstract

Adequacy of margins must take into consideration both the resection margin width (quantity) and anatomic barrier (quality). There are several classification schemes for reporting surgical resection margin status for soft tissue sarcomas (STS). Most of the studies regarding treatment outcomes in STS included all histologic grades and histological subtypes, which include infiltrative and non-infiltrative subtypes and are very heterogeneous in terms of both histologic characteristics and treatment modalities (adjuvant treatments or not). This lack of consistency makes it difficult to compare results from study to study. Therefore, there is a great need for evidence-based standardization concerning the width of resection margins. The aim of this narrative review is to provide a comprehensive assessment of the literature on margins, and to highlight the need for a uniform description of the margin status for patients with STS. Patient cases should be discussed at multidisciplinary tumor boards and treatments should be individualized to clinical and demographic characteristics, which must include also a deep knowledge of specific histotypes behaviors, particularly infiltrative ones.

The Effect of Resection Margin on Local Recurrence and Survival in High Grade Soft Tissue Sarcoma of the Extremities: How Far Is Far Enough?

Simple Summary

In soft tissue sarcomas the width of surgical margins after resection determines the extent of surgery and the function after resection. But how far is really necessary? 305 patients with deep-seated, G2/3 soft tissue sarcomas of the extremity, the trunk wall, or the pelvis were reviewed. The 5-year local recurrence-free survival (LRFS) was 82%. Overall survival (OS) at 5 years was 66%. Positive (contaminated) margins worsened LRFS and OS. A margin of >10 mm did not improve LRFS and OS as compared to one of >5 mm. A resection margin of <1 mm showed a trend but not significantly better LRFS or OS compared to a contaminated margin. In conclusion the margin should at least be free of tumor, in sound tissue. A margin of >5 mm sound tissue seems to be sufficient. Resecting more tissue does not benefit the patient.

Abstract

Background: The significance of surgical margins after resection of soft tissue sarcomas in respect to local-recurrence-free survival and overall survival is evaluated. Methods: A total of 305 patients with deep-seated, G2/3 soft tissue sarcomas (STS) of the extremity, the trunk wall, or the pelvis were reviewed. The margin was defined according to the Fédération Nationale des Centres de Lutte Contre le Cancer (FNCLCC) classification system (R0-2), the Union Internationale Contre le Cancer (UICC) classification (R + 1 mm) for which a margin <1 mm is included into the R1 group, and in groups of <1 mm, 1–5 mm, >5 mm, or >10 mm. Results: Of these patients, 31 (10.2%) had a contaminated margin, 64 (21%) a margin of <1 mm, 123 (40.3%) a margin of 1–5 mm, 47 (15.4%) a margin of >5 mm, and 40 (13.1%) a margin of >10 mm. The 5-year local recurrence-free survival (LRFS) was 81.6%. Overall survival (OS) at 5 years was 65.9%. Positive margins worsened LRFS and OS. A margin of >10 mm did not improve LRFS and OS as compared to one of >5 mm. Conclusions: A resection margin of <1 mm showed a trend but not significantly better LRFS or OS compared to a contaminated margin. This finding supports use of the UICC classification. A margin of more than 10 mm did not improve LRFS or OS.

A multidisciplinary approach to soft-tissue sarcoma of the extremities

INTRODUCTION

Soft-tissue sarcoma (STS) denotes a group of rare and highly heterogeneous malignant tumors of mesenchymal origin. Accurate histological diagnosis is critical for selecting appropriate treatment. Complete tumor resection is the primary treatment for STS, and the efficacies of radiotherapy and chemotherapy have been tested in the adjuvant setting to improve oncological outcomes. Because most STS lesions arise in the extremities, preserving limb function and managing limb impairment after radical local treatment represent significant challenges.

AREAS COVERED

This article reviews the current front-line treatments for patients with extremity STS and discusses the multidisciplinary team-based efforts needed to improve oncological outcomes and survivorship.

EXPERT OPINION

Given the rarity, variety, and complexity of STS, a multidisciplinary approach involving experts in various disciplines is vital for improving outcomes in patients ranging from diagnosis to survivorship. A major challenge is building a sustainable system in each region permitting all patients with extremity STS to be treated at high-volume centers with multidisciplinary teams dedicated to this rare and complex disease.

The adequacy of resection margin for non-infiltrative soft-tissue sarcomas

OBJECTIVES

There remains no consensus on what constitutes an adequate margin of resection for non-infiltrative soft-tissue sarcomas (STSs). We aimed to investigate the role of resection margins in millimetres for non-infiltrative STSs.

METHODS

502 patients who underwent surgical resection for a localized, non-infiltrative, high-grade STSs were studied. The prognostic significance of margin width was analysed and compared with the conventional R- and R+1-classification of surgical margins.

RESULTS

The overall local recurrence (LR) rate was 13%; 9% and 27% with negative and positive margins, respectively (p < 0.001). In patients with negative margins, the LR rates were greater than 10% in patients with margins ≤5.0 mm but reduced to less than 4% with margins >5.0 mm. When classified by the R- (or R+1)-classification, the 5-year cumulative LR incidence was 8%, 23% (16%), and 31% for R0, R1, and R2, respectively, which did not stratify the LR risk with negative margins. On the other hand, an accurate risk stratification was possible by metric distance; the 5-year cumulative incidence of LR was 29%, 10%, and 1% with 0 mm, 0.1-5.0 mm, and >5.0 mm, respectively (p < 0.001). This classification also stratified the LR risk in patients with or without adjuvant radiotherapy.

CONCLUSION

While a negative margin is essential to optimize local control in patients with non-infiltrative STSs, surgical margin width greater than 5 mm minimises the risk of local failure regardless of the use of adjuvant radiotherapy.

Neoadjuvant radiation improves margin-negative resection rates in extremity sarcoma but not survival

BACKGROUND AND OBJECTIVES

Radiation improves limb salvage in extremity sarcomas. Timing of radiation therapy remains under investigation. We sought to evaluate the effects of neoadjuvant radiation (NAR) on surgery and survival of patients with extremity sarcomas.

MATERIALS AND METHODS

A multi-institutional database was used to identify patients with extremity sarcomas undergoing surgical resection from 2000-2016. Patients were categorized by treatment strategy: surgery alone, adjuvant radiation (AR), or NAR. Survival, recurrence, limb salvage, and surgical margin status was analyzed.

RESULTS

A total of 1483 patients were identified. Most patients receiving radiotherapy had high-grade tumors (82% NAR vs 81% AR vs 60% surgery; P < .001). The radiotherapy groups had more limb-sparing operations (98% AR vs 94% NAR vs 87% surgery; P < .001). NAR resulted in negative margin resections (90% NAR vs 79% surgery vs 75% AR; P < .0001). There were fewer local recurrences in the radiation groups (14% NAR vs 17% AR vs 27% surgery; P = .001). There was no difference in overall or recurrence-free survival between the three groups (OS, P = .132; RFS, P = .227).

CONCLUSION

In this large study, radiotherapy improved limb salvage rates and decreased local recurrences. Receipt of NAR achieves more margin-negative resections however this did not improve local recurrence or survival rates over.

Ifosfamide, Carboplatin, and Etoposide (ICE) in Combination with Regional Hyperthermia as Salvage Therapy in Patients with Locally Advanced Nonmetastatic and Metastatic Soft-Tissue Sarcoma

Patients with localized relapse of soft-tissue sarcoma (STS) after anthracycline-based chemotherapy have a dismal prognosis, particularly when surgery is not possible. To facilitate resection and improve long-term tumor control, we applied an intensified perioperative treatment consisting of ICE (ifosfamide 6 g/m², carboplatin 400 mg/m², and etoposide 600 mg/m²) in combination with regional hyperthermia (RHT) to maximize local control. Here, we retrospectively evaluate the safety and efficacy of this strategy. Patients aged ≥18 years with locally advanced high-risk STS, either with or without metastasis, treated with ICE + RHT after the failure of first-line anthracycline-based chemotherapy were included in this analysis. Radiographic response, toxicity, progression-free survival (PFS), and overall survival (OS) were assessed. Between 1996 and 2018, 213 sarcoma patients received ICE at our centre. Of these, 110 patients met the selection criteria (progressive disease, suitable high-grade STS histology, anthracycline pretreatment, RHT treatment) for this analysis. Fifty-four patients had locally advanced disease without metastases (LA-STS), and 56 patients had additional metastatic disease (M-STS). Disease control was achieved in 59% of LA-STS patients and in 47% of M-STS patients. For LA-STS, 21% of the patients achieved radiographic response, facilitating resection in 4 patients (7%), compared with 11% of the M-STS patients, facilitating resection in 5 patients (9%). PFS was significantly longer in LA-STS than in M-STS (10 vs. 4 months, p < 0.0001). Median OS was 26 months in LA-STS and 12 months in M-STS. Disease control was the only independent prognostic factor for improved OS in multivariate analysis. Toxicity was high with neutropenic fever occurring in 25% of the patients and three therapy-related deaths (3%). ICE + RHT demonstrated activity in high-risk STS and facilitated resection in selected patients after anthracycline failure. Disease control was associated with improved OS. Based on the observed toxicities, the dose should be reduced to 75%.

Surgical Resection Margin Classifications for High-grade Pleomorphic Soft Tissue Sarcomas of the Extremity or Trunk After Neoadjuvant Cytotoxic Therapy

Soft tissue sarcomas of the extremities or trunk are often resected after treatment with neoadjuvant radiotherapy. Adequate surgical resection margins for sarcomas after neoadjuvant cytotoxic therapy are not well characterized. Minimum surgical resection margins required for local control of primary, high-grade, pleomorphic soft tissue sarcomas treated with neoadjuvant therapy was assessed by competing risk regression in a series of 166 cases. Optimal tumor clearance was determined to be ≥1 mm. Predictive accuracy of three commonly used resection margin classification schemes (American Joint Committee on Cancer, Musculoskeletal Tumor Society, and the margin distance method) were comparable. However, diagnostic performance of a binary system (positive vs. negative) was more specific than margin distance classification (positive or <1 vs. ≥1 mm from tumor), but less sensitive in predicting local recurrence. The American Joint Committee on Cancer R classification (R0 vs. R1/R2) seems to adequately stratify patients by risk for local recurrence after neoadjuvant therapy and subsequent surgical resection. Furthermore, close but negative resection margins (<1 mm from tumor) appear sufficient for local control of high-grade pleomorphic soft tissue sarcomas of the extremity or trunk in this clinical setting, with minimal reduction in the risk of local recurrence with increasing margin width or surgical clearance.

Extremity Soft Tissue Sarcoma: Role of Local Control

OPINION STATEMENT

For localized extremity soft tissue sarcoma (eSTS), treatment is individualized and each patient needs to be evaluated by a multidisciplinary team at a referral sarcoma center specialized in the care of sarcoma. For a majority of patients, treatment for eSTS involves limb-salvage surgery, with or without the addition of radiation therapy. Surgery should only be performed by surgeons specifically fellowship trained in the resection of eSTS. Surgery alone may be considered for small, low-grade, and superficial tumors as long a wide (≥ 2 cm) margin can be achieved. In cases where a less than wide negative margin can be achieved, radiation therapy should be utilized to facilitate a planned close margin resection to preserve critical structures (such as nerves, blood vessels, and bone) without a significant impact on oncologic outcomes. Soft tissue sarcomas are rare, and as such patients often present following an inadvertent excision. In these situations, we recommend preoperative radiation and wide tumor bed re-excision, as rates of residual tumor can be high in this scenario. While there is large amount of evidence to support the use of radiotherapy to enhance local tumor control, the evidence to support the use of chemotherapy to enhance local tumor control is lacking, and as such cannot be recommended for all patients.

[Resection margins in soft tissue sarcomas]

BACKGROUND

Soft tissue sarcomas (STS) are a rare and heterogeneous group of malignant tumors that arise from the mesenchymal tissue. STS can form anywhere in the human body, with the extremities being preferred sites of predilection.

TREATMENT

A fundamental pillar of treatment is the surgical resection of soft tissue sarcomas. The goal is always an R0 resection with a safety margin. There is no consensus in the literature about the desired tumor-free resection margin. The decisive factors for these resection margins are histopathology, presence of anatomical barriers (capsule, tendon, fascia, cartilage, periosteum) and possibilities of (neo-) adjuvant therapy.

DISCUSSION

References in the literature support the role of resection margins as a predictor of local recurrence. Regarding the role of resection margins in overall survival, available data is divergent. There are known prognostic factors that influence overall survival, such as histological subtype, tumor size, tumor grading, and presence of metastases. So far, several studies have attempted to quantify the margins of resection, but no consensus has been reached, and debates are ongoing. When analyzing all the results of the data in the literature, it seems appropriate to aim for a negative resection margin >1 mm including an anatomical border structure, if possible.

Significance of HIFU in local unresectable recurrence of soft tissue sarcoma, a single-center, respective, case series in China

PURPOSE

Multimodality treatment of soft tissue sarcoma(STS) by expert teams reportedly affords a tremendous improvement in outcome of patients. Despite advances, treatment of local unresectable recurrence remains difficult and is not standardized. We performed this retrospective study in order to assess the efficacy and safety of high-intensity focused ultrasound (HIFU) ablation in treating STS patients with local unresectable recurrence.

METHODS

Thirty-six STS patients with local unresectable recurrence from January 2015 to December 2016 were recruited according to the inclusion criteria. Pain rating, response rate, disease control rate, local disease progression-free survival(LPFS), progression-free survival (PFS) and overall survival(OS) were used to evaluate efficacy of HIFU treatment.

RESULTS

HIFU resulted in a significant relief in pain rating, without severe side effects. According to magnetic resonance imaging(MRI), three months after HIFU treatment, response rate was 47.3% and the local disease control rate was 80.6%. Twelve months post HIFU treatment, response rate was 38.9% and the local disease control rate was 55.6%. The median LPFS, PFS and OS time for 36 patients was 13 months, 10 months and 20 months respectively.

CONCLUSION

HIFU is a tolerated treatment modality with promising activity and safety in STS patients with local unresectable recurrence.

Diagnosis and Management of Subcutaneous Soft Tissue Sarcoma

OPINION STATEMENT

The proper diagnosis and treatment planning for subcutaneous soft tissue sarcoma is very important. Soft tissue tumors can occur anywhere in the body, but if they occur subcutaneously, patients can easily notice a subcutaneous soft tissue mass. Therefore, it is possible to determine through recording, the growth speed of the mass, which is often difficult to obtain with deep-situated soft tissue masses. Palpation can also provide information about the firmness and mobility of the mass. Thus, history taking and physical examinations are informative for subcutaneous soft tissue tumors, compared to tumors that occur deeply. Because subcutaneous soft tissue tumors are easily recognized, they are often resected, without sufficient imaging analyses or thorough treatment planning. An operation performed based on such an inadequate preoperative plan is called a "whoops surgery." In the case of "whoops surgeries," subsequent radical surgery is required to remove additional areas, including hematomas that result from the initial surgery, that require a wider range of resection and soft tissue reconstruction. Therefore, as with deep-seated soft tissue tumors, it is important to conduct careful imaging examinations and make appropriate preoperative plans for subcutaneous soft tissue tumors. Subcutaneous soft tissue sarcomas often show an invasive pattern, and such tumors require a more careful assessment to prevent local recurrence after surgery. During surgery, it is necessary to remove the entire infiltration area along the fascia. Sometimes, an adequately wide excision is necessary, which is considered the minimum necessary procedure to eradicate the lesion. As noted above, clinicians who see patients with subcutaneous soft tissue tumors are encouraged to have sufficient knowledge and experience regarding the diagnosis and treatment. This article is intended for all doctors who deal with subcutaneous soft tissue tumors and focuses on essential points regarding their diagnosis and management.

What Is the Success of Repeat Surgical Treatment of a Local Recurrence After Initial Wide Resection of Soft Tissue Sarcomas?

BACKGROUND

Treatment for patients with locally recurrent soft tissue sarcomas after wide resection is challenging, and few studies have examined the results of treating these patients. In treatment of recurrent tumors, it has been reported that positive margins are correlated to local rerecurrence, but the relationship between surgical margin and survival remains controversial and risk factors for local recurrences after wide resection of soft tissue sarcomas are not well established. This study examined clinical outcomes and factors associated with survival and local rerecurrence in patients with local recurrence after initial surgical treatment who underwent another resection with a goal of negative margins.

QUESTIONS/PURPOSES

The purpose of this study was to determine (1) oncologic outcomes (survival rates and local rerecurrence-free rates) of surgical treatment for patients with local recurrence after wide resection; (2) whether factors associated with survival and local rerecurrence-free rates can be determined; and (3) the proportion of patients treated by amputation at final followup.

METHODS

Between 1992 and 2013, we treated 530 patients with soft tissue sarcoma without metastasis. Of those, 26 (5%) were lost before 3 years of followup but were not known to have died. Of the remainder, 59 have had a local recurrence. Of those with a local recurrence, 34 (58%) were treated with wide resection, whereas 25 (42%) were treated with nonsurgical treatment including chemotherapy and radiotherapy. During that period, our general indications for wide resection were patients (1) without distant metastasis; or (2) without distant lymph node metastasis, and contraindications were distant organ metastasis and/or distant lymph node metastasis. Of those treated with wide resection, 30 (88%) were available for followup. We conducted a retrospective analysis of these 30 patients with local recurrence (17 men, 13 women) who had previously undergone wide resection. Patient followup ranged from 1 to 12 years (median, 5 years). Survivorship (including overall survival and survival free from repeat recurrence) was ascertained by the Kaplan-Meier method. Factors associated with survival were evaluated by the log-rank test. Amputations were performed when limb-sparing surgery was deemed unsuitable because of extensive involvement of the limb by tumor, including invasion of multiple muscle compartments and neurovascular components. Survivorship free from amputation was ascertained by the Kaplan-Meier method.

RESULTS

Overall 5- and 10-year Kaplan-Meier survival rates after resection were 70% (95% confidence interval [CI], 50%-91%) and 44% (95% CI, 12%-76%), respectively, and 12 patients (40%) developed distant metastases after the second operation. Ten patients (33%) had additional local recurrences, and overall 5- and 10-year local rerecurrence-free rates were 66% (95% CI, 48%-85%) and 50% (95% CI, 18%-81%), respectively. A positive margin was associated with further recurrence (5-year local rerecurrence-free rates of positive margin: 20% [95% CI, 0%-52%], negative margin: 89% [95% CI, 74%-100%], p < 0.01) and with survival (5-year survival rates of positive margin: 36% [95% CI, 0%-75%], negative margin: 91% [95% CI, 74%-100%], p < 0.01). The survival rate was lower in patients with recurrence developing after 2 years (5-year survival rates of within 2 years: 46% [95% CI, 2%-90%], after 2 years: 83% [95% CI, 62%-100%], p = 0.01). The overall 5- and 10-year amputation-free rates were 86% (95% CI, 74%-99%) and 81% (95% CI, 67%-96%), respectively.

CONCLUSIONS

A surgical procedure with negative margins appears to be important for reducing the likelihood of local recurrences and improving survival of patients with rerecurrence after wide resection of soft tissue sarcomas. Although these findings need to be confirmed in larger studies, it appears that when tumor recurrence is evident within 2 years from the primary surgery, it is associated with a poor prognosis. Local recurrence within 2 years after wide resection may also be an indicator of aggressive tumor biology.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Survival and prognostic factors in conventional central chondrosarcoma

BACKGROUND

Chondrosarcoma is the second most frequent primary malignant bone tumor. Treatment is mainly based on surgery. In general, wide resection is advocated at least in G2 and G3 tumors. But which margins should be achieved? Does localization as for example in the pelvis have a higher impact on survival than surgical margins themselves?

METHODS

From 1982 to 2014, 87 consecutive patients were treated by resection. The margin was defined as R0 (wide resection), R1 (marginal resection) or, R2 if the tumor was left intentionally. All patients were followed for evidence of local recurrence or distant metastasis. Overall and recurrence-free survival were calculated, significance analysis was performed.

RESULTS

In 54 (62%) cases a R0 resection, in 31 (36%) a R1 and in 2 (2%) patients a R2-resection was achieved. Histology proved to be G1 in 37 patients (43%), G2 in 41 (47%) and G3 in 9 cases (10%). 5-year local recurrence-free survival (LRFS) was 75%. Local recurrence-free survival showed a significant association with the margin status and the localization of the tumor with pelvic lesions doing worst. Metastatic disease was initially seen in 4 patients (4.6%), 19 others developed metastatic disease during follow-up. Overall survival of the entire group at 5 and 10 years were 79 and 75%, respectively. The quality of surgical margins and the presence of local recurrence did not influence overall survival in a multivariate analysis. Pelvic lesions had a worse prognosis as did higher grades of the tumor, metastatic disease and age.

CONCLUSIONS

The mainstay of therapy in Chondrosarcoma remains surgery. Risk factors as grading, metastatic disease, age and location significantly influence overall survival. Margin status (R0 vs. R1) did influence local recurrence-free survival but not overall survival. Chondrosarcomas of the pelvis have a higher risk of local recurrence and should be treated more aggressively.

Autologous fat grafting after sarcoma surgery: Evaluation of oncological safety

BACKGROUND

The regenerative effectiveness of lipoaspirate procedures relies on the presence of mesenchymal stem cells, but the stromal microenvironment and hormonal secretions of the adipose tissue may be involved in cancer growth. Only few oncological outcome studies of fat grafting at the surgical site of malignant neoplasms of mesenchymal origin are available; none of these studies examined a series of sarcoma cases.

OBJECTIVES

We analyzed outcome in terms of local or distant spread and overall survival to investigate the oncological safety of fat grafting in patients with sarcoma.

PATIENTS AND METHODS

Sixty consecutive patients who had undergone 143 fat grafting procedures after surgical resection of bone and soft tissue sarcomas of the head, trunk, and limbs with clear resection margins were enrolled from 2004 to 2015 in our tertiary care center. A multidisciplinary sarcoma team administered adjuvant therapies. Patients were recurrence free at fat grafting.

RESULTS

The overall median follow-up was 7.5 years. At follow-up after fat grafting (2.4 years), one patient had distant metastasis and two had local relapse. Kaplan-Meier analysis showed disease-free survival rate of 95.4% (CI: 89.1-100.0) at 24 months. The risk of local recurrence (LR) within 24 months was 4.6% (CI: 0.0-20.9). The probability of not having LR after fat grafting was ≥ 89.1%.

CONCLUSION

We found no evidence of an increased cancer risk after fat grafting procedures in patients with sarcoma, but a stimulatory role of fat cannot be excluded for bone sarcomas based on the cases reported here, and further studies are therefore needed.

Adequate Local Control in High-Risk Soft Tissue Sarcoma of the Extremity Treated with Surgery Alone at a Reference Centre: Should Radiotherapy Still be a Standard?

BACKGROUND

Established practice for the management of soft tissue sarcoma (STS) of the extremity and trunk wall combines perioperative radiotherapy (RT) with limb-preserving surgery.

OBJECTIVE

The aim of this study was to explore whether high-quality surgery at high-volume centers may offer equivalent local control in selected cases, when RT needs to be avoided.

METHODS

All consecutive adult cases of primary, high-risk STSs treated in a high-volume reference center over a 12-year timeframe were included, and, on retrospective analysis, were divided into two groups. Group A received RT with surgery, and Group B received surgery alone. The primary endpoint was local recurrence-free survival (LRFS).

RESULTS

Overall, 390 patients were included (318 in Group A and 72 in Group B), with a median follow-up of 53 months. The main reasons for avoiding RT were patient choice and technical considerations (vascular bypass or flap reconstruction). No difference in R0 resection was seen between the groups (79% vs. 70%; p = 0.18), but Group A had more G3 tumors (80.5% vs. 68%; p = 0.021). No difference in 5-year LRFS was evident (84% vs. 81%; p = 0.16).

CONCLUSIONS

LRFS did not differ between patients with high-risk STSs receiving perioperative RT and those treated with surgery alone. The study was retrospective and omission of RT was largely uncontrolled with inherent bias. Nonetheless, data suggest that in experienced centers, the omission of RT did not diminish local disease outcome. Future studies on a selective approach to RT administration are awaited.

Histopathological tumor response following neoadjuvant hyperthermic isolated limb perfusion in extremity soft tissue sarcomas: Evaluation of the EORTC-STBSG response score

INTRODUCTION

This study aims to evaluate the applicability and prognostic value of the European Organization for Research and Treatment of Cancer-Soft Tissue and Bone Sarcoma Group (EORTC-STBSG) histopathological response score in extremity soft tissue sarcoma (ESTS) patients treated with neoadjuvant hyperthermic isolated limb perfusion (HILP) and delayed surgical resection.

METHODS

Patients treated between 1991 and 2016 were included. The histopathological tumor response was established in accordance with the EORTC-STBSG response score. The distribution of patients was assorted according to the 5-tier histopathological response score for tumor grade, histological subtype and HILP regimen. Predictors for local recurrence free survival (LRFS) and overall survival (OS) were identified through Kaplan-Meier and Cox regression analyses.

RESULTS

Ninety-one patients were included and their resection specimens were reanalyzed. Which resulted in 11 Grade A (12.1%), ten Grade B (11.0%), 15 Grade C (16.5%), 22 Grade D (24.2%) and 33 Grade E (36.3%) responses found among the series. The histopathological response was significantly influenced by the HILP regimen used, p = 0.033. Median follow-up was 65.0 (18.0-157.0) months. The histopathological response was not associated with LRFS nor OS. Resection margins, HILP regimen and adjuvant radiotherapy were associated with LRFS. Patients' age, tumor grade, tumor size and histological subtype were predictors for OS.

CONCLUSIONS

The EORTC-STBSG response score is applicable for determining the histopathological response to neoadjuvant ESTS treatment. However, this response does not seem to predict LRFS nor OS in locally advanced ESTS.

Analysis of Margin Classification Systems for Assessing the Risk of Local Recurrence After Soft Tissue Sarcoma Resection

Purpose To compare the ability of margin classification systems to determine local recurrence (LR) risk after soft tissue sarcoma (STS) resection. Methods Two thousand two hundred seventeen patients with nonmetastatic extremity and truncal STS treated with surgical resection and multidisciplinary consideration of perioperative radiotherapy were retrospectively reviewed. Margins were coded by residual tumor (R) classification (in which microscopic tumor at inked margin defines R1), the R+1mm classification (in which microscopic tumor within 1 mm of ink defines R1), and the Toronto Margin Context Classification (TMCC; in which positive margins are separated into planned close but positive at critical structures, positive after whoops re-excision, and inadvertent positive margins). Multivariate competing risk regression models were created. Results By R classification, LR rates at 10-year follow-up were 8%, 21%, and 44% in R0, R1, and R2, respectively. R+1mm classification resulted in increased R1 margins (726 v 278, P < .001), but led to decreased LR for R1 margins without changing R0 LR; for R0, the 10-year LR rate was 8% (range, 7% to 10%); for R1, the 10-year LR rate was 12% (10% to 15%) . The TMCC also showed various LR rates among its tiers ( P < .001). LR rates for positive margins on critical structures were not different from R0 at 10 years (11% v 8%, P = .18), whereas inadvertent positive margins had high LR (5-year, 28% [95% CI, 19% to 37%]; 10-year, 35% [95% CI, 25% to 46%]; P < .001). Conclusion The R classification identified three distinct risk levels for LR in STS. An R+1mm classification reduced LR differences between R1 and R0, suggesting that a negative but < 1-mm margin may be adequate with multidisciplinary treatment. The TMCC provides additional stratification of positive margins that may aid in surgical planning and patient education.

Diagnosis and treatment of soft-tissue sarcomas of the extremities and trunk

The relatively low incidence and often atypical clinical presentation of soft-tissue sarcomas (STS) impedes early and adequate diagnosis. Patients may report on recently enlarged soft-tissue swellings, infrequently complain of painful lesions, or even have no symptoms at all.

A thorough diagnostic work-up is essential in order to distinguish between benign soft-tissue tumours and STSs. Patient history, clinical features and radiological findings all help in assessing the underlying pathology. ‘Worrying’ features such as recent increase in size, deep location relative to the fascia, a tumour exceeding 4 cm in size, and invasive growth patterns seen on imaging should prompt verification by biopsy.

Even though acquisition of biopsy material may be incomplete, one should bear in mind some essential rules. Regardless of the biopsy technique applied, the most direct route to the lump in question should be identified, contamination of adjacent structures should be avoided and a sufficient amount of tissue acquired.

Treatment of STS is best planned by a multidisciplinary team, involving experts from various medical specialities. The benchmark therapy consists of en bloc resection of the tumour, covered by a safety margin of healthy tissue. Depending on tumour histology, grade, local extent and anatomical stage, radiotherapy, chemotherapy and isolated hyperthermic limb perfusion may be employed.

Due to the complexity of treatment, any soft-tissue swelling suspected of malignancy is best referred directly to a sarcoma centre, where therapeutic management is carefully planned by an experienced multidisciplinary team.

Cite this article: EFORT Open Rev 2017;2:421-431. DOI: 10.1302/2058-5241.2.170005

The width of resection margins influences local recurrence in soft tissue sarcoma patients

BACKGROUND

Patients with soft tissue sarcoma (STS) being treated following the standardized guidelines can still not be guaranteed to remain free from local recurrence (LR). A complete tumour resection has been accepted as a major prognostic factor for LR. This retrospective study was designed to analyse the influence of two different classifications of resection margins (R-classification and UICC-classification) on LR in STS patients.

MATERIALS AND METHODS

Of 411 patients treated at our institution for STS, 265 were eligible for statistical analysis. Kaplan-Meier curves and Cox regression models were used to assess the impact of an R0 resection according to the R-classification (resection margin clear but allowing <1 mm) and according to the UICC-classification (minimal resection margin ≥1 mm) on LR.

RESULTS

Survival curves showed a lower LR rate for R0 resections in the UICC-classification, namely 1.3%, 12% and 12% as compared to 2.1%, 9.5% and 16.5% for the R-classification. In multivariate analysis calculated separately for each classification, R1 resection as defined by the R-classification (HR: 11.214; 95%CI: 2.394-52.517; p = 0.002) as well as by UICC-classification (HR: 15.634; 95%CI: 2.493-98.029; p = 0.003) remained significant.

CONCLUSION

In our study, margin status according to both classifications represents an independent prognostic factor for LR in patients with STS following curative surgery. Local control rates were superior after a minimal resection margin of 1 mm (R0 by UICC-classification) compared to R0 resections after the R-classification.

The Use of Radiation Therapy in Well-Differentiated Soft Tissue Sarcoma of the Extremities: An NCDB Review

Objective. This study investigated patterns of utilization of radiation therapy (RT) and correlated this with overall survival by assessing patients with well-differentiated soft tissue sarcoma of the extremity (STS-E) in the National Cancer Database (NCDB). Methods. All patients diagnosed with well-differentiated STS-E between 1998 and 2006 were identified in the NCDB. Patients were stratified by use of surgery alone versus use of adjuvant RT after surgery and analyzed using multivariate analysis, Kaplan-Meier analysis, and propensity matching. Results. 2113 patients with well-differentiated STS-E were identified in the NCDB for inclusion with a mean follow-up time of 74 months. 69% of patients were treated with surgery alone, while 26% were treated with surgery followed by adjuvant RT. Patients undergoing amputation were less likely to receive adjuvant RT. There was no difference in overall survival between patients with well-differentiated STS treated with surgery alone and those patients who received adjuvant RT. Conclusions. In the United States, adjuvant RT is being utilized in a quarter of patients being treated for well-differentiated STS-E. While the use of adjuvant RT may be viewed as a means to facilitate limb salvage, this large national database review confirms no survival benefit, regardless of tumor size or margin status.

Intra-muscular location in soft tissue sarcomas: impact on oncologic outcome

BACKGROUND

Soft tissue sarcoma (STS) of intra-muscular location is confined within well-defined barrier, amenable to easier surgical resection. It is generally assumed that STS of intra-muscular location would have favorable outcomes compared to those of inter-muscular location. However, no clear evidence on this assumption can be found. This study examined if intra-muscular location of STS would have favorable effect on oncologic outcomes.

METHODS

Among the 161 patients treated for previously untreated, non-metastatic and deep-seated STS, extra-compartmental tumors (65) or tumors that spread beyond the muscle of origin (23) were excluded. Remaining 73 patients were classified into two groups according to tumor location; intra-muscular group (confined within muscle of origin, n = 32) and inter-muscular group (located between muscles, n = 41).

RESULTS

Two patients (6.3%) in intra-muscular group developed local recurrence whereas 10 patients (24.3%) developed local recurrence in inter-muscular group (p = 0.056). Patients in intra-muscular group showed significantly better local recurrence-free survival than those in inter-muscular group (p = 0.029). However, there was no significant difference in development of metastasis (p = 0.143) nor disease-specific survival (p = 0.106).

CONCLUSIONS

Our study indicates that STS of intra-muscular location is associated with better local control. Whether this advantage is due to its biological property or surgical resectability remains to be elucidated.

Impact of margin status and local recurrence on soft-tissue sarcoma outcomes

BACKGROUND

The impact of local recurrence and surgical resection margin status on survival in extremity soft-tissue sarcomas remains to be clearly defined. Our aim was to conduct a retrospective analysis of prospectively collected data to determine the prognostic relevance of positive resection margins and local recurrence for extremity soft-tissue sarcomas for survival.

METHODS

Three hundred and sixty-three patients who underwent resection of localized primary extremity soft-tissue sarcomas with curative intent were selected from the United States Department of Defense Automated Central Tumor Registry. Outcomes for local recurrence, distant recurrence, disease-specific survival, and overall survival were analyzed according to clinical, pathological, and treatment variables with use of the Kaplan-Meier method (log-rank test) and the multivariate Cox regression model.

RESULTS

Positive margins (hazard ratio, 1.99 [95% confidence interval, 1.15 to 3.45]), local recurrence (hazard ratio, 2.93 [95% confidence interval, 1.38 to 6.23]), and distant recurrence (hazard ratio, 12.13 [95% confidence interval, 5.97 to 24.65]) were significantly associated with overall survival on multivariate Cox regression analysis. However, for disease-specific survival, local recurrence was not significant and tumor size of >10 cm (hazard ratio, 2.83 [95% confidence interval, 1.15 to 6.95]), positive margins (hazard ratio, 1.95 [95% confidence interval, 1.05 to 3.63]), and distant recurrence (hazard ratio, 9.46 [95% confidence interval, 4.37 to 20.47]) were independent adverse prognostic factors. The disease-specific survival rate for patients with localized soft-tissue sarcomas was 89% (95% confidence interval, 85% to 92%) for five years and 75% (95% confidence interval, 70% to 81%) for ten years.

CONCLUSIONS

Positive surgical margins are consistently associated with adverse survival-related outcomes in localized soft-tissue sarcomas of the extremity. Local recurrence had a significant impact on overall survival, but not on disease-specific survival.

Surgical margins and handling of soft-tissue sarcoma in extremities: a clinical practice guideline

QUESTIONS

In limb salvage surgery for extremity soft-tissue sarcoma (sts), what is an adequate surgical margin?What is the appropriate number of samples to take from the margins of a surgical resection specimen?What is the appropriate handling of surgical resection specimens?

BACKGROUND

Surgery is the primary treatment for extremity sts. The combination of radiotherapy with surgery allows for limb salvage by using radiation to biologically "sterilize" microscopic extensions of tumour and to spare neurovascular and osseous structures. Adjuvant chemotherapy in sts-except for rhabdomyosarcoma and Ewing sarcoma-continues to be controversial.

METHODS

The medline and embase databases (1975 to June 2011) and the Cochrane Library were searched for pertinent studies. The Web sites of the main guideline organizations and the American Society of Clinical Oncology conference proceedings (2007-2010) were also searched.

RESULTS AND CONCLUSIONS

Thirty-three papers, including four guidelines, one protocol, and one abstract, were eligible for inclusion. The data suggest that patients with clear margins have a better prognosis, but no prospective studies have indicated how wide margins should be. In limb-salvage surgery for extremity sts, the procedure should be planned to achieve a clear margin. However, to preserve functionality, surgery may result in a very close (<1 cm) or even microscopically positive margin. In this circumstance, the use of preoperative or postoperative radiation should be considered. No studies described the optimal number of tissue sections required to assess adequacy of excision nor the appropriate handling of surgical resection specimens. The Sarcoma Disease Site Group made its recommendations based on expert opinion and consensus.

Predictors of local recurrence in high-grade soft tissue sarcomas: hydrogen peroxide as a local adjuvant

Soft tissue sarcomas have a mortality rate of 40% to 60%, with local recurrence being a poor prognostic factor for overall survival. Three-percent nondiluted hydrogen peroxide is hypothesized to be an effective local adjuvant. The purpose of this study was to identify risk factors for local recurrence in high-grade soft tissue sarcomas and to determine whether using hydrogen peroxide as a local adjuvant reduced the risks of local recurrence and surgical-site infection. Retrospective data were collected for 106 patients surgically treated for high-grade soft tissue sarcomas between 2002 and 2010. The primary endpoint was local recurrence. Eighteen (16.98%) cases of local recurrence occurred. Predictors of local recurrence were margin status, estimated blood loss, and histology (ie, malignant peripheral nerve sheath tumor), with hazard ratios of 4.44 (95% confidence interval [CI], 1.32-14.95), 1.19 (95% CI, 1.06-1.35), and 9.21 (95% CI, 2.11-40.16), respectively. Hydrogen peroxide yielded a statistically insignificant improvement in local recurrence, with a hazard ratio of 0.81 (95% CI, 0.27-2.48) and a reduced risk of surgical site infection, with a hazard ratio of 0.52 (95% CI, 0.15-1.81). Margin status, increased blood loss, and histologic subtype are associated with increased local recurrence risk. Using hydrogen peroxide improved local control and infection rates, but the difference was not statistically significant.

Survival and prognostic factors in chondrosarcoma: results in 115 patients with long-term follow-up

BACKGROUND AND PURPOSE

There have been few long-term studies on the outcome of chondrosarcoma and the findings regarding prognostic factors are controversial. We examined a homogeneous group of patients with primary central chondrosarcoma of bone who were treated according to a uniform surgical protocol at our institution, in order to determine the factors that influence survival and identify potential improvements to our therapeutic algorithm.

PATIENTS AND METHODS

We performed a retrospective analysis of 115 patients with primary central chondrosarcoma of bone who presented with localized disease and who had a minimum follow-up of 5 years after diagnosis. 68 tumors were localized in the extremities and 47 in the axial skeleton or pelvis. 59 patients had a high-grade (II and III) and 56 a low-grade (I) tumor. 94 patients underwent surgical resection with adequate (wide or radical) margins, while 21 patients had inadequate (marginal or intralesional) margins.

RESULTS

Tumor grade and localization were found to be statistically significant independent predictors of disease-related deaths in multivariate analysis. The quality of surgical margins did not influence survival. The AJCC staging system was able to predict prognosis in patients with chondrosarcoma of the extremities, but not in those with tumors of the axial skeleton and pelvis. Long-term survival after secondary metastatic disease was only observed when metastases were resected with wide margins. Patients with metastases who received further treatment with conventional chemotherapy, radiotherapy, and/or further surgery had significantly better survival compared to those who received best supportive care.

INTERPRETATION

The outcome in patients with primary central chondrosarcoma of bone who present with localized disease is mostly affected by tumor-related parameters.

Does delayed reexcision affect outcome after unplanned excision for soft tissue sarcoma?

BACKGROUND

Unplanned excision of a soft tissue sarcoma generally requires reexcision to achieve an adequate surgical margin. Many surgeons assume delay of definitive surgery adversely affects patient survival and local recurrence. However, no clear evidence of this assumption can be found in the literature.

QUESTIONS/PURPOSES

We asked whether delay in reexcision affects patient survival and local recurrence in reexcision after unplanned excision for soft tissue sarcoma.

PATIENTS AND METHODS

We retrospectively reviewed 104 patients who underwent definitive surgery after unplanned excision of a localized soft tissue sarcoma. The average age of the patients was 44 years (range, 5-81 years). The most common diagnoses were malignant fibrous histiocytoma (36) and synovial sarcoma (22). Locations of the tumors were the lower extremity (62), upper extremity (32), and trunk (10). The median interval to definitive surgery was 32 days (interquartile range, 22-50 days). The minimum followup was 0.2 years (median, 4.7 years; range, 0.2-16.7 years).

RESULTS

The 5-year disease-specific survival was 88% and 5-year local control rate was 74%. We found no difference in disease-specific survival or local recurrence according to the time until definitive surgery. Higher histologic grade and larger tumor size independently predicted disease-specific survival whereas a positive margin at reexcision and larger tumor size independently predicted local control.

CONCLUSIONS

The data suggest any influence of delayed definitive surgery is likely to be of minor clinical importance.

LEVEL OF EVIDENCE

Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Local recurrence after initial multidisciplinary management of soft tissue sarcoma: is there a way out?

BACKGROUND

Multimodality treatment of primary soft tissue sarcoma by expert teams reportedly affords a low incidence of local recurrence. Despite advances, treatment of local recurrence remains difficult and is not standardized.

QUESTIONS/PURPOSES

We (1) determined the incidence of local recurrence from soft tissue sarcoma; (2) compared characteristics of the recurrent tumors with those of the primary ones; (3) evaluated local recurrences, metastases and death according to treatments; and (4) explored the relationship between the diagnosis of local recurrence and the occurrence of metastases.

METHODS

From our prospective database, we identified 618 soft tissue sarcomas. Thirty-seven of the 618 patients (6%) had local recurrence. Leiomyosarcoma was the most frequent diagnosis (eight of 37). The mean delay from original surgery was 22 months (range, 2-75 months). Mean size was 4.8 cm (range, 0.4-28.0 cm). Median followup after local recurrence was 16 months (range, 0-98 months).

RESULTS

Recurrent tumors had a tendency toward becoming deeper seated and higher graded. Nineteen of the 37 patients with recurrence underwent limb salvage (nine free flaps) and six had an amputation. Twenty-two (59%) had metastases, including 10 occurring after the local recurrence event at an average delay of 21 months (range, 1-34 months). Six patients developed additional local recurrences, with no apparent difference in risk between amputation (two of six) and limb salvage (four of 19).

CONCLUSIONS

Patients with a local recurrence of a soft tissue sarcoma have a poor prognosis. Limb salvage and additional radiotherapy remain possible but with substantial complications. Amputation did not prevent additional local recurrence or death.

Do surgical margin and local recurrence influence survival in soft tissue sarcomas?

BACKGROUND

Established prognostic factors influencing survival in soft tissue sarcomas include tumor stage, histopathologic grade, size, depth, and anatomic site. The presence of tumor near or at the margin of resection increases the risk of local recurrence but whether a positive surgical margin or local recurrence affect overall survival is controversial.

QUESTIONS/PURPOSES

We explored the impact of microscopic margin on local recurrence, metastasis, and overall survival in patients with intermediate- to high-grade soft tissue sarcomas of the extremities. We then determined whether local recurrence decreases overall survival.

METHODS

We retrospectively reviewed the medical records of 248 patients who had soft tissue sarcomas of the extremities treated surgically from 1995 to 2008. We estimated survival, local recurrence, and distant metastasis and examined factors potentially influencing these outcomes. The minimum followup was 0.4 years (median, 4.4 years; range, 0.4-13 years).

RESULTS

The 5-year cumulative incidence of local recurrence was 4.1%. Patients who presented with positive margins or a margin of 2 mm or less had a worse survival than patients who had margins of greater than 2 mm and wide margins (5-year survival, 47% versus 70% and 72%). In addition to surgical margin, developing metastasis, tumor response of less than 90% necrosis, high histopathologic grade, high AJCC stage (Stage III), increasing age, and male gender were associated with decreased overall survival. Local recurrence independently predicted decreased overall survival.

CONCLUSIONS

Microscopic surgical margin and local recurrence after surgical treatment should be included as risk factors predicting decreased overall survival for intermediate- to high-grade soft tissue sarcomas of the extremities.

Soft tissue sarcoma of extremities: the prognostic significance of adequate surgical margins in primary operation and reoperation after recurrence

BACKGROUND

Adult soft tissue sarcomas (STS) of extremities are prone to recurrence despite apparently complete resection. This study aimed to explore the impact of clinicopathological factors on outcome and to define an "oncological safe margin" in these patients.

METHODS

A total of 181 patients with extremity STS were enrolled in a retrospective study. The prognostic influence of margin status and other clinicopathological characteristics on local recurrence-free survival (LRFS), distant metastasis-free survival (DMFS), and disease-specific survival (DSS), were examined by univariate and multivariate analyses. The influence of surgical margins on postrecurrence survival (PRS) of patients undergoing reoperation for relapsed lesions during follow-up was analyzed by the Kaplan-Meier method.

RESULTS

Surgical margin width <10 mm and deep tumor depth at primary operation were consistently statistically significant independent adverse factors for LRFS, DMFS, and DSS. Patients with liposarcoma or low grade tumors had significantly higher chances of achieving adequate margins. Of 83 patients who experienced recurrence or metastasis, 53 (63.9%) received reoperation for their relapsed lesions. Patients who achieved microscopically negative margins (R0) at reoperation had significantly better PRS than those who did not (P < 0.007). Overall, patients with no recurrences had the best DSS, while relapsed patients receiving R0 reoperation had better DSS than those receiving either non-R0 reoperation or no reoperation at all.

CONCLUSION

Surgical margins prognostically influence survival in both patients undergoing primary surgery and those undergoing reoperation for relapse of extremity STS. In primary surgery, the chance of achieving adequate margin may reflect the underlying aggressiveness of tumors.