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Hayes AJ, Nixon IF, Strauss DC, Seddon BM, Desai A, Benson C, Judson IR, Dangoor A. UK guidelines for the management of soft tissue sarcomas. Br J Cancer 2024:10.1038/s41416-024-02674-y. [PMID: 38734790 DOI: 10.1038/s41416-024-02674-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 03/24/2024] [Accepted: 03/27/2024] [Indexed: 05/13/2024] Open
Abstract
Soft tissue sarcomas (STS) are rare tumours arising in mesenchymal tissues and can occur almost anywhere in the body. Their rarity, and the heterogeneity of subtype and location, means that developing evidence-based guidelines is complicated by the limitations of the data available. This makes it more important that STS are managed by expert multidisciplinary teams, to ensure consistent and optimal treatment, recruitment to clinical trials, and the ongoing accumulation of further data and knowledge. The development of appropriate guidance, by an experienced panel referring to the evidence available, is therefore a useful foundation on which to build progress in the field. These guidelines are an update of the previous versions published in 2010 and 2016 [1, 2]. The original guidelines were drawn up by a panel of UK sarcoma specialists convened under the auspices of the British Sarcoma Group (BSG) and were intended to provide a framework for the multidisciplinary care of patients with soft tissue sarcomas. This iteration of the guidance, as well as updating the general multidisciplinary management of soft tissue sarcoma, includes specific sections relating to the management of sarcomas at defined anatomical sites: gynaecological sarcomas, retroperitoneal sarcomas, breast sarcomas, and skin sarcomas. These are generally managed collaboratively by site specific multidisciplinary teams linked to the regional sarcoma specialist team, as stipulated in the recently published sarcoma service specification [3]. In the UK, any patient with a suspected soft tissue sarcoma should be referred to a specialist regional soft tissues sarcoma service, to be managed by a specialist sarcoma multidisciplinary team. Once the diagnosis has been confirmed using appropriate imaging and a tissue biopsy, the main modality of management is usually surgical excision performed by a specialist surgeon, combined with pre- or post-operative radiotherapy for tumours at higher risk for local recurrence. Systemic anti-cancer therapy (SACT) may be utilised in cases where the histological subtype is considered more sensitive to systemic treatment. Regular follow-up is recommended to assess local control, development of metastatic disease, and any late effects of treatment.
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Affiliation(s)
- Andrew J Hayes
- The Sarcoma Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK.
- The Institute of Cancer Research, London, SM2 5NG, UK.
| | - Ioanna F Nixon
- Department of Clinical Oncology, The Beatson West of Scotland Cancer Center, Glasgow, G12 0YN, UK
| | - Dirk C Strauss
- The Sarcoma Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Beatrice M Seddon
- Department of Medical Oncology, University College London Hospital NHS Foundation Trust, London, NW1 2BU, UK
| | - Anant Desai
- The Midlands Abdominal and Retroperitoneal Sarcoma Unit, Queen Elizabeth Hospital, Birmingham, B15 2WB, UK
| | - Charlotte Benson
- The Sarcoma Unit, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Ian R Judson
- The Institute of Cancer Research, London, SM2 5NG, UK
| | - Adam Dangoor
- Department of Medical Oncology, University Hospitals Bristol & Weston NHS Foundation Trust, Bristol, BS1 3NU, UK
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Rastrelli M, Russano F, Cavallin F, Del Fiore P, Pacilli C, Di Prata C, Rossi CR, Vecchiato A, Dall’Olmo L, Mocellin S. Isolated Limb Perfusion and Immunotherapy in the Treatment of In-Transit Melanoma Metastases: Is It a Real Synergy? J Pers Med 2024; 14:442. [PMID: 38793023 PMCID: PMC11122383 DOI: 10.3390/jpm14050442] [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: 03/19/2024] [Revised: 04/11/2024] [Accepted: 04/17/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND Isolated limb hyperthermic-antiblastic perfusion (ILP) was the most effective local treatment for advanced in-transit melanoma, but the advent of modern effective immunotherapy (IT), such as immune checkpoint inhibitors, has changed the treatment landscape. METHODS This study evaluated the role of the association between ILP and IT in the treatment of locally advanced unresectable melanoma, particularly in relation to modern systemic therapies. We analyzed 187 consecutive patients who were treated with ILP (melphalan or melphalan associated with TNF-alpha) for advanced melanoma at the Veneto Institute of Oncology of Padua (Italy) and the Padua University Hospital (Italy) between June 1989 and September 2021. Overall survival (OS), disease-specific survival (DSS), local disease-free survival (local DFS) and distant disease-free survival (distant DFS) were evaluated. Local toxicity was classified according to the Wieberdink scale and surgical complications according to the Clavien-Dindo classification. Response to locoregional therapy was evaluated during follow-up according to the RECIST 1.1 criteria (Response Evaluation Criteria in Solid Tumor). RESULTS A total of 99 patients were treated with ILP and 88 with IT + ILP. The overall response rate was 67% in both groups. At 36 months, OS was 43% in the ILP group and 61% in the ILP + IT group (p = 0.02); DSS was 43% in the ILP group and 64% in the ILP + IT group (p = 0.02); local DFS was the 37% in ILP group and 53% in the ILP + IT group (p = 0.04); and distant DFS was 33% in the ILP group and 35% in the ILP + IT group (p = 0.40). Adjusting for age and lymph node involvement, receiving ILP + IT was associated with improved OS (p = 0.01) and DSS (p = 0.007) but not local DFS (p = 0.13) and distant DFS (p = 0.21). CONCLUSIONS Our findings confirm the synergy between ILP and IT. ILP remains a valuable loco-regional treatment option in the era of effective systemic treatments. Further studies are needed to establish the optimal combination of loco-regional and systemic treatments and address the best timing of this combination to obtain the highest local response rate.
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Affiliation(s)
- Marco Rastrelli
- Soft-Tissue, Peritoneum and Melanoma Surgical Oncology Unit, Veneto Institute of Oncology IOV-IRCCS, 35128 Padova, Italy; (M.R.); (F.R.); (A.V.); (L.D.); (S.M.)
- Department of Surgical, Oncological and Gastroenterological Sciences (DISCOG), University of Padua, 35128 Padova, Italy;
| | - Francesco Russano
- Soft-Tissue, Peritoneum and Melanoma Surgical Oncology Unit, Veneto Institute of Oncology IOV-IRCCS, 35128 Padova, Italy; (M.R.); (F.R.); (A.V.); (L.D.); (S.M.)
| | | | - Paolo Del Fiore
- Soft-Tissue, Peritoneum and Melanoma Surgical Oncology Unit, Veneto Institute of Oncology IOV-IRCCS, 35128 Padova, Italy; (M.R.); (F.R.); (A.V.); (L.D.); (S.M.)
| | - Claudia Pacilli
- Department of Medicine (DIMED), School of Medicine, University of Padova, 35128 Padova, Italy;
| | | | - Carlo Riccardo Rossi
- Department of Surgical, Oncological and Gastroenterological Sciences (DISCOG), University of Padua, 35128 Padova, Italy;
| | - Antonella Vecchiato
- Soft-Tissue, Peritoneum and Melanoma Surgical Oncology Unit, Veneto Institute of Oncology IOV-IRCCS, 35128 Padova, Italy; (M.R.); (F.R.); (A.V.); (L.D.); (S.M.)
| | - Luigi Dall’Olmo
- Soft-Tissue, Peritoneum and Melanoma Surgical Oncology Unit, Veneto Institute of Oncology IOV-IRCCS, 35128 Padova, Italy; (M.R.); (F.R.); (A.V.); (L.D.); (S.M.)
- Department of Surgical, Oncological and Gastroenterological Sciences (DISCOG), University of Padua, 35128 Padova, Italy;
| | - Simone Mocellin
- Soft-Tissue, Peritoneum and Melanoma Surgical Oncology Unit, Veneto Institute of Oncology IOV-IRCCS, 35128 Padova, Italy; (M.R.); (F.R.); (A.V.); (L.D.); (S.M.)
- Department of Surgical, Oncological and Gastroenterological Sciences (DISCOG), University of Padua, 35128 Padova, Italy;
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Mirbahari SN, Da Silva M, Zúñiga AIM, Kooshki Zamani N, St-Laurent G, Totonchi M, Azad T. Recent progress in combination therapy of oncolytic vaccinia virus. Front Immunol 2024; 15:1272351. [PMID: 38558795 PMCID: PMC10979700 DOI: 10.3389/fimmu.2024.1272351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 02/29/2024] [Indexed: 04/04/2024] Open
Abstract
In recent years, oncolytic viruses have emerged as promising agents for treating various cancers. An oncolytic virus is a non-pathogenic virus that, due to genetic manipulation, tends to replicate in and cause lysis of cancerous cells while leaving healthy cells unaffected. Among these viruses, vaccinia virus is an attractive platform for use as an oncolytic platform due to its 190 Kb genome with a high capacity for encoding therapeutic payloads. Combining oncolytic VV therapy with other conventional cancer treatments has been shown to be synergistic and more effective than monotherapies. Additionally, OVV can be used as a vector to deliver therapeutic payloads, alone or in combination with other treatments, to increase overall efficacy. Here, we present a comprehensive analysis of preclinical and clinical studies that have evaluated the efficacy of oncolytic vaccinia viruses in cancer immunotherapy. We discuss the outcomes of these studies, including tumor regression rates, overall survival benefits, and long-term responses. Moreover, we provide insights into the challenges and limitations associated with oncolytic vaccinia virus- based therapies, including immune evasion mechanisms, potential toxicities, and the development of resistance.
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Affiliation(s)
- Seyedeh Nasim Mirbahari
- Faculty of Sciences and Advanced Technologies in Biology, University of Science and Culture, Academic Center for Education, Culture and Research (ACECR), Tehran, Iran
- Department of Genetics, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, Academic Center for Education, Culture and Research (ACECR), Tehran, Iran
| | - Miles Da Silva
- Department of Microbiology and Immunology, University of British Colombia, Vancouver, BC, Canada
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Abril Ixchel Muñoz Zúñiga
- Department of Microbiology and Infectious Diseases, Université de Sherbrooke, Sherbrooke, QC, Canada
- Centre de Recherche du CHUS, Sherbrooke, QC, Canada
| | - Nika Kooshki Zamani
- Department of Microbiology and Infectious Diseases, Université de Sherbrooke, Sherbrooke, QC, Canada
- Centre de Recherche du CHUS, Sherbrooke, QC, Canada
| | - Gabriel St-Laurent
- Department of Microbiology and Infectious Diseases, Université de Sherbrooke, Sherbrooke, QC, Canada
- Centre de Recherche du CHUS, Sherbrooke, QC, Canada
| | - Mehdi Totonchi
- Department of Genetics, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, Academic Center for Education, Culture and Research (ACECR), Tehran, Iran
| | - Taha Azad
- Department of Microbiology and Infectious Diseases, Université de Sherbrooke, Sherbrooke, QC, Canada
- Centre de Recherche du CHUS, Sherbrooke, QC, Canada
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Reijers SJM, Davies E, Grünhagen DJ, Fiore M, Honore C, Rastrelli M, Vassos N, Podleska LE, Niethard M, Jakob J, Perhavec A, Duarte C, González F, Deroose JP, Stas M, Boecxstaens V, Schrage Y, Snow H, Algarra SM, Said HM, Ortega DYG, Martin K, Mattsson J, Djafarrian R, Di Lorenzo G, Colombo C, Gronchi A, Matter M, Verhoef C, Bagge RO, Hohenberger P, Hayes AJ, van Houdt WJ. Variation in response rates to isolated limb perfusion in different soft-tissue tumour subtypes: an international multi-centre study. Eur J Cancer 2023; 190:112949. [PMID: 37453241 DOI: 10.1016/j.ejca.2023.112949] [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: 03/29/2023] [Revised: 05/11/2023] [Accepted: 06/13/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE The aim of this study was to investigate the response rates of different extremity soft-tissue sarcoma subtypes (eSTS) after isolated limb perfusion (ILP), based on an international multi-centre study. MATERIALS AND METHODS The retrospective cohort comprised eSTS patients from 17 specialised ILP centres that underwent melphalan-based ILP, with or without recombinant human tumour necrosis factor (rhTNFα) (TM-ILP and M-ILP, respectively). Response was measured on imaging (magnetic resonance imaging) and/or clinical response, for which M-ILPs were excluded. RESULTS A total of 1109 eSTS patients were included. The three most common histological subtypes were undifferentiated pleomorphic sarcoma (17%, n = 184), synovial sarcoma (16%, n = 175) and myxofibrosarcoma (8%, n = 87). rhTNFα was used in 93% (TM-ILP) and resulted in a significantly better overall response rate (ORR, p = 0.031) and complete responses (CR, p < 0.001) in comparison to M-ILP, without significant differences among histological subgroups. The ORR of TM-ILP was 68%, including 17% CR. Also, 80% showed progressive disease. Significantly higher response rates were shown for Kaposi sarcoma (KS) with 42% CR and 96% ORR (both p < 0.001), and significantly higher CR rates for angiosarcoma (AS, 45%, p < 0.001) and clear cell sarcoma (CCS, 31%, p = 0.049). ILP was followed by resection ≤ 6 months in 80% of the patients. The overall limb salvage rate was 88%, without significant differences among histological subgroups, but was significantly higher for ILP responders compared to non-responders (93% versus 76%, p < 0.001). CONCLUSION ILP resulted in high response and LRS among all eSTS subtypes, however, with significant differences between subtypes with most promising results for KS, AS and CCS.
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Affiliation(s)
- Sophie J M Reijers
- Department of Surgical Oncology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands.
| | - Emma Davies
- Department of Surgical Oncology, Royal Marsden Hospital, 203 Fulham Rd., SW3 6JJ London, UK.
| | - Dirk J Grünhagen
- Department of Surgical Oncology, Erasmus Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.
| | - Marco Fiore
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Giacomo Venezian, 1, 20133 Milan, Italy.
| | - Charles Honore
- Department of Surgical Oncology, Gustave Roussy Cancer Campus, 114 Rue Edouard Vaillant, 94805 Villejuif, France.
| | - Marco Rastrelli
- Department of Surgery Oncology and Gastroenterology, University of Padova, Via VIII Febbraio, 2, 35122 Padua, Italy; Department of Surgical Oncology, Istituto Oncologico Veneto (IOV), Via Gattamelata, 64, 35128 Padua, Italy.
| | - Nikolaos Vassos
- Division of Surgical Oncology, Mannheim University Medical Center, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
| | - Lars E Podleska
- Department of Orthopaedic Oncology and Soft Tissue Sarcoma, Essen University Hospital, Hufelandstraße 55, 45147 Essen, Germany.
| | - Maya Niethard
- Department of Surgical Oncology, Helios Klinikum Berlin-Buch, Schwanebecker Ch 50, 13125 Berlin, Germany; Department of Orthopedic Surgery, University Medicine Greifswald, Fleischmannstraße 6, 17489 Greifswald, Germany.
| | - Jens Jakob
- Department of Orthopaedic Oncology and Soft Tissue Sarcoma, Essen University Hospital, Hufelandstraße 55, 45147 Essen, Germany.
| | - Andraz Perhavec
- Department of Surgical Oncology, Institute of Oncology Ljubljana, Zaloška cesta 2, 1000 Ljubljana, Slovenia.
| | - Carlos Duarte
- Department of Surgical Oncology, Instituto Nacional de Cancerología, Cl. 1 #9-85, Bogota, Colombia.
| | - Felipe González
- Department of Surgical Oncology, Instituto Nacional de Cancerología, Cl. 1 #9-85, Bogota, Colombia.
| | - Jan P Deroose
- Department of Surgical Oncology, Martini Ziekenhuis, Van Swietenplein 1, 9728 NT Groningen, the Netherlands.
| | - Marguerite Stas
- Department of Surgical Oncology, Universitair Ziekenhuis Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Veerle Boecxstaens
- Department of Surgical Oncology, Universitair Ziekenhuis Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Yvonne Schrage
- Department of Surgical Oncology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands.
| | - Hayden Snow
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC 3000. Australia.
| | - Salvador Martín Algarra
- Department of Medical Oncology, Clínica Universidad de Navarra, Av. de Pío XII, 36, 31008 Pamplona, Spain.
| | - Hector Martinez Said
- Department of Surgical Oncology, National Cancer Institute Mexico, Av. San Fernando 22, Belisario Domínguez Secc 16, Tlalpan, 14080 Mexico City, Mexico.
| | - Dorian Yarih Garcia Ortega
- Department of Surgical Oncology, National Cancer Institute Mexico, Av. San Fernando 22, Belisario Domínguez Secc 16, Tlalpan, 14080 Mexico City, Mexico.
| | - Karla Martin
- Department of Surgical Oncology, National Cancer Institute Mexico, Av. San Fernando 22, Belisario Domínguez Secc 16, Tlalpan, 14080 Mexico City, Mexico.
| | - Jan Mattsson
- Department of Surgery, Sahlgrenska University Hospital, Blå stråket 5, 413 45 Gothenburg, Sweden; Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Medicinaregatan 3, 413 90 Gothenburg, Sweden.
| | - Reza Djafarrian
- Department of Visceral Surgery, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland.
| | - Giorgia Di Lorenzo
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Giacomo Venezian, 1, 20133 Milan, Italy.
| | - Chiara Colombo
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Giacomo Venezian, 1, 20133 Milan, Italy.
| | - Alessandro Gronchi
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Giacomo Venezian, 1, 20133 Milan, Italy.
| | - Maurice Matter
- Department of Visceral Surgery, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland.
| | - Cornelis Verhoef
- Department of Surgical Oncology, Erasmus Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.
| | - Roger Olofsson Bagge
- Department of Surgery, Sahlgrenska University Hospital, Blå stråket 5, 413 45 Gothenburg, Sweden; Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Medicinaregatan 3, 413 90 Gothenburg, Sweden.
| | - Peter Hohenberger
- Division of Surgical Oncology, Mannheim University Medical Center, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
| | - Andrew J Hayes
- Department of Surgical Oncology, Royal Marsden Hospital, 203 Fulham Rd., SW3 6JJ London, UK.
| | - Winan J van Houdt
- Department of Surgical Oncology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands.
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Davies E, Reijers S, Van Akkooi A, Van Houdt W, Hayes A. Isolated limb perfusion for locally advanced melanoma in the immunotherapy era. Eur J Surg Oncol 2022; 48:1288-1292. [DOI: 10.1016/j.ejso.2022.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/16/2022] [Accepted: 01/28/2022] [Indexed: 11/24/2022] Open
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Tirotta F, Sayyed R, Jones RL, Hayes AJ. Risk factors for the development of local recurrence in extremity soft-tissue sarcoma. Expert Rev Anticancer Ther 2021; 22:83-95. [PMID: 34822313 DOI: 10.1080/14737140.2022.2011723] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
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.
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Affiliation(s)
- Fabio Tirotta
- Sarcoma Unit, The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Raza Sayyed
- Sarcoma Unit, The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Robin L Jones
- Sarcoma Unit, The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Andrew J Hayes
- Sarcoma Unit, The Royal Marsden Hospital NHS Foundation Trust, London, UK
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Reijers SJM, Husson O, Soomers VLMN, Been LB, Bonenkamp JJ, van de Sande MAJ, Verhoef C, van der Graaf WTA, van Houdt WJ. Health-related quality of life after isolated limb perfusion compared to extended resection, or amputation for locally advanced extremity sarcoma: Is a limb salvage strategy worth the effort? Eur J Surg Oncol 2021; 48:500-507. [PMID: 34389213 DOI: 10.1016/j.ejso.2021.08.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 07/12/2021] [Accepted: 08/06/2021] [Indexed: 01/29/2023] Open
Abstract
INTRODUCTION The aim of this study was to compare long-term patient reported outcomes (PROs) in patients with locally advanced extremity soft tissue sarcoma (eSTS) after isolated limb perfusion followed by resection (IR), compared to extended resection (ER), primary amputation (A) or secondary amputation after IR (IR-A). METHODS Patients were selected from the respondents of a multi-institutional cross-sectional cohort survivorship study (SURVSARC) conducted among sarcoma survivors registered in the Netherlands Cancer Registry (NCR), 2-10 years after diagnosis. Used PROs were the EORTC QLQ-C30, the Cancer worry scale (CWS), the Hospital Anxiety and Depression Scale (HADS), and the Toronto Extremity Salvage Score (TESS). RESULTS We identified 97 eSTS survivors: IR = 20, ER = 49, A = 20, IR-A = 8. While there were no differences in PROs between IR and ER, results showed better functioning and functionality in both groups versus the amputation groups. The amputation groups scored significantly lower on physical functioning (A = 62.7, IR-A = 65.7 versus IR = 78.0, ER = 82.7, p = 0.001) and role functioning (A = 67.5, IR-A = 52.8 versus IR = 79.2, ER = 80.6, p = 0.039), both EORTC QLQ-C30 scales. Also for the TESS, the scores were significantly lower for the amputation groups compared to the limb sparing groups (upper extremity p = 0.007 with A = 68.9, IR-A = 71.6 versus IR = 93.3, ER = 91.1; lower extremity p < 0.001 with A = 72.2, IR-A50.9 versus IR = 84.5 and ER = 85.5). There were no significant differences between the groups on cancer worry, anxiety and depression. CONCLUSION HRQoL in eSTS survivors treated with IR or ER is equal; for maintenance of physical functioning and functionality IR and ER outperform an amputation.
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Affiliation(s)
- Sophie J M Reijers
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Olga Husson
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands; Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, the Netherlands; Division of Clinical Studies, Institute of Cancer Research, London, United Kingdom
| | - Vicky L M N Soomers
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Lukas B Been
- Department of Surgical Oncology, University Medical Center Groningen, Groningen, the Netherlands
| | - Johannes J Bonenkamp
- Department of Surgical Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Cornelis Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Winette T A van der Graaf
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands; Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Winan J van Houdt
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands.
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Abstract
For over three decades, a mainstay and goal of clinical oncology has been the development of therapies promoting the effective elimination of cancer cells by apoptosis. This programmed cell death process is mediated by several signalling pathways (referred to as intrinsic and extrinsic) triggered by multiple factors, including cellular stress, DNA damage and immune surveillance. The interaction of apoptosis pathways with other signalling mechanisms can also affect cell death. The clinical translation of effective pro-apoptotic agents involves drug discovery studies (addressing the bioavailability, stability, tumour penetration, toxicity profile in non-malignant tissues, drug interactions and off-target effects) as well as an understanding of tumour biology (including heterogeneity and evolution of resistant clones). While tumour cell death can result in response to therapy, the selection, growth and dissemination of resistant cells can ultimately be fatal. In this Review, we present the main apoptosis pathways and other signalling pathways that interact with them, and discuss actionable molecular targets, therapeutic agents in clinical translation and known mechanisms of resistance to these agents.
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Affiliation(s)
| | - Wafik S El-Deiry
- The Warren Alpert Medical School, Brown University, Providence, RI, USA.
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Smith HG, Jamal K, Dayal JHS, Tenev T, Kyula‐Currie J, Guppy N, Gazinska P, Roulstone V, Liccardi G, Davies E, Roxanis I, Melcher AA, Hayes AJ, Inman GJ, Harrington KJ, Meier P. RIPK1-mediated immunogenic cell death promotes anti-tumour immunity against soft-tissue sarcoma. EMBO Mol Med 2020; 12:e10979. [PMID: 32419365 PMCID: PMC7278545 DOI: 10.15252/emmm.201910979] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 04/15/2020] [Accepted: 04/20/2020] [Indexed: 11/09/2022] Open
Abstract
Drugs that mobilise the immune system against cancer are dramatically improving care for many people. Dying cancer cells play an active role in inducing anti-tumour immunity but not every form of death can elicit an immune response. Moreover, resistance to apoptosis is a major problem in cancer treatment and disease control. While the term "immunogenic cell death" is not fully defined, activation of receptor-interacting serine/threonine-protein kinase 1 (RIPK1) can induce a type of death that mobilises the immune system against cancer. However, no clinical treatment protocols have yet been established that would harness the immunogenic potential of RIPK1. Here, we report the first pre-clinical application of an in vivo treatment protocol for soft-tissue sarcoma that directly engages RIPK1-mediated immunogenic cell death. We find that RIPK1-mediated cell death significantly improves local disease control, increases activation of CD8+ T cells as well as NK cells, and enhances the survival benefit of immune checkpoint blockade. Our findings warrant a clinical trial to assess the survival benefit of RIPK1-induced cell death in patients with advanced disease at limb extremities.
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Affiliation(s)
- Henry G Smith
- Targeted Therapy TeamThe Institute of Cancer ResearchLondonUK
| | - Kunzah Jamal
- The Breast Cancer Now Toby Robins Research CentreThe Institute of Cancer ResearchLondonUK
| | | | - Tencho Tenev
- The Breast Cancer Now Toby Robins Research CentreThe Institute of Cancer ResearchLondonUK
| | | | - Naomi Guppy
- The Breast Cancer Now Toby Robins Research CentreThe Institute of Cancer ResearchLondonUK
| | - Patrycja Gazinska
- The Breast Cancer Now Toby Robins Research CentreThe Institute of Cancer ResearchLondonUK
| | | | - Gianmaria Liccardi
- The Breast Cancer Now Toby Robins Research CentreThe Institute of Cancer ResearchLondonUK
| | - Emma Davies
- Targeted Therapy TeamThe Institute of Cancer ResearchLondonUK
| | - Ioannis Roxanis
- The Breast Cancer Now Toby Robins Research CentreThe Institute of Cancer ResearchLondonUK
- Cancer Research UK Beatson InstituteGlasgowUK
- Division of Molecular PathologyThe Institute of Cancer ResearchLondonUK
- Royal Free London NHS Foundation TrustLondonUK
| | - Alan A Melcher
- The Translational Immunology TeamThe Institute of Cancer ResearchLondonUK
| | - Andrew J Hayes
- The Sarcoma and Melanoma UnitThe Royal Marsden HospitalLondonUK
| | - Gareth J Inman
- Cancer Research UK Beatson InstituteGlasgowUK
- Institute of Cancer SciencesUniversity of GlasgowGlasgowUK
| | | | - Pascal Meier
- The Breast Cancer Now Toby Robins Research CentreThe Institute of Cancer ResearchLondonUK
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10
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Dilday JC, Nelson DW, Fischer TD, Goldfarb M. Disparities in Amputation Rates for Non-metastatic Extremity Soft Tissue Sarcomas and the Impact on Survival. Ann Surg Oncol 2020; 28:576-584. [PMID: 32409968 DOI: 10.1245/s10434-020-08586-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND There are no definitive recommendations guiding amputation use in extremity soft tissue sarcomas (STSs). This study explores disparities in amputation rates and survival in patients with non-metastatic adult-type extremity STSs. METHODS Patients with non-metastatic adult-type extremity STSs were identified from the 1998-2012 National Cancer Database. Factors affecting amputation were examined across all ages and separately in adults (> 40 years), adolescent/young adults (AYA: ages 15-39), and children (age < 15). Impact on 10-year overall survival (OS) was explored. RESULTS Of 15,886 patients, 4.65% had an amputation. AYAs had the most amputations (6.4%) compared to children (5.9%) and adults (4.2%) (p < 0.001). Patients with public insurance (OR 1.3, CI 1.08-1.58) and from central states (OR 1.5, CI 1.2-1.86) were more likely to undergo amputation, whereas those from high income brackets (OR 0.8, CI 0.62-0.94) and treated at community cancer centers were less likely (OR 0.7, CI 0.62-0.90). Amputation was an independent risk factor for death at 10 years, with the greatest impact in AYAs compared to older adults (HR 1.7, p < 0.001). Treatment in eastern or central states, lower income, lack of private insurance, and comorbidities were all associated with decreased OS (all p < 0.05). Female gender (HR 0.8, CI 0.78-0.89) and high-volume centers (HR 0.8, CI 0.74-0.94) were associated with improved OS. CONCLUSIONS Although amputations for extremity STSs are rare, disparities exist across age groups, insurance and geography when it comes to the use of amputation in patients with extremity STSs. Moreover, having an amputation is an independent risk factor for death, with the greatest impact in AYAs.
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Affiliation(s)
- Joshua C Dilday
- Department of Surgery, William Beaumont Army Medical Center, El Paso, TX, USA
| | - Daniel W Nelson
- Department of Surgery, William Beaumont Army Medical Center, El Paso, TX, USA
| | - Trevan D Fischer
- Division of Surgical Oncology, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Melanie Goldfarb
- Division of Surgical Oncology, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, USA. .,Center for Endocrine Tumors and Disorders, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, USA.
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11
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Boere T, Huis In 't Veld EA, Deroose JP, van Ginhoven TM, Wouters MWJM, Grünhagen DJ, Verhoef C, van Houdt WJ. Isolated limb perfusion is an effective treatment modality for locally advanced Kaposi sarcoma of the extremities. Eur J Surg Oncol 2020; 46:1315-1319. [PMID: 32359920 DOI: 10.1016/j.ejso.2020.04.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 04/03/2020] [Accepted: 04/09/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Kaposi sarcoma (KS) is a rare soft tissue sarcoma. In case of locally advanced disease, mutilating surgery such as amputations or major reconstructive procedures are sometimes inevitable. The aim of this study was to evaluate the effectiveness of isolated limb perfusion (ILP) in patients with locally advanced KS of the extremities. MATERIAL AND METHODS All patients who underwent ILP for KS between 1996 and 2018 at Erasmus MC, Rotterdam were identified. Clinical data was obtained from either a prospectively maintained database or retrospective assessment of patient files. RESULTS A total of 14 primary ILP's were performed in 11 patients. Median follow-up from primary ILP was 30 months (range, 5-98). The overall response rate of primary ILP was 100%, with a complete response (CR) rate of 50%. Only minimal local toxicity (Wieberdink I-III) was observed. Local progressive disease occurred after eight primary ILP's (57%) with a median local progression free survival (PFS) of 18 months (95% confidence interval [CI]: 7.0-28.9). Subsequently, four (46%) patients received a total of 5 recurrent ILP's. After the recurrent ILP on the same leg, the overall response rate was 75% and a CR-rate of 50%. One patient needed amputation post-operatively resulting in a limb salvage rate of 91%. One (9%) patient developed metastases four months after ILP. CONCLUSIONS ILP is a highly effective treatment modality with very limited morbidity rates for patients with locally advanced KS of the extremity. ILP should be considered as a treatment modality for locally advanced KS of the extremities.
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Affiliation(s)
- T Boere
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, the Netherlands.
| | - E A Huis In 't Veld
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, the Netherlands; Department of Surgical Oncology, Erasmus MC - Cancer Institute, Rotterdam, the Netherlands
| | - J P Deroose
- Department of Surgical Oncology, Erasmus MC - Cancer Institute, Rotterdam, the Netherlands; Department of Surgical Oncology, Martini Hospital, Groningen, the Netherlands
| | - T M van Ginhoven
- Department of Surgical Oncology, Erasmus MC - Cancer Institute, Rotterdam, the Netherlands
| | - M W J M Wouters
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - D J Grünhagen
- Department of Surgical Oncology, Erasmus MC - Cancer Institute, Rotterdam, the Netherlands
| | - C Verhoef
- Department of Surgical Oncology, Erasmus MC - Cancer Institute, Rotterdam, the Netherlands
| | - W J van Houdt
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, the Netherlands
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12
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Weishaupt C, Steinert M, Brunner G, Schulze HJ, Fuhlbrigge RC, Goerge T, Loser K. Activation of human vascular endothelium in melanoma metastases induces ICAM-1 and E-selectin expression and results in increased infiltration with effector lymphocytes. Exp Dermatol 2019; 28:1258-1269. [PMID: 31444891 DOI: 10.1111/exd.14023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 07/18/2019] [Accepted: 08/15/2019] [Indexed: 12/12/2022]
Abstract
Lymphocytic infiltration into melanoma tissue is an important prerequisite for effective antitumoral immunity. However, analysis of human metastatic melanoma has shown that leucocyte adhesion receptor expression on melanoma blood vessels is very low or absent, thereby impairing the entry of cytotoxic lymphocytes into tumor tissue. We hypothesized that adhesion molecules can be induced on melanoma vasculature allowing better infiltration of cytotoxic lymphocytes. Quantitative real-time PCR and immunofluorescence staining indicated that the adhesion molecules ICAM-1 (CD54) and E-selectin (CD62E) can be significantly induced by intralesional application of TNF alpha in tissue from human melanoma metastases either in vitro or in vivo when grafted onto immunodeficient NSG (NOD.Cg-PrkdcscidIl2rgtm1Wjl/SzJ) mice that preserved human vessels. Furthermore, activated human autologous CD3+ lymphocytes were injected intravenously into mice bearing melanoma xenografts treated with TNF-α or PBS in addition to the leucocyte chemoattractant TARC (CCL17). Significantly increased numbers of CD8+ cells were detected in TNF-α-treated melanoma metastases compared with PBS-treated controls. In addition, tumor cell apoptosis was enhanced and melanoma cell proliferation reduced as shown by TUNEL assay and KI-67 staining. We conclude that adhesion molecules can be induced on human melanoma vasculature resulting in significantly improved homing of activated autologous cytotoxic T cells to melanoma tissue and inhibition of melanoma cell proliferation. These observations should be considered when designing protocols for immunotherapy of malignant melanoma.
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Affiliation(s)
- Carsten Weishaupt
- Department of Dermatology, University Hospital of Muenster, Muenster, Germany
| | - Meike Steinert
- Department of Dermatology, University Hospital of Muenster, Muenster, Germany
| | - Georg Brunner
- Department of Cancer Research, Fachklinik Hornheide, Münster, Germany
| | | | - Robert C Fuhlbrigge
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Tobias Goerge
- Department of Dermatology, University Hospital of Muenster, Muenster, Germany
| | - Karin Loser
- Department of Dermatology, University Hospital of Muenster, Muenster, Germany.,CRC1009, CRC-TR128 and Interdisciplinary Center of Clinical Research (IZKF), University of Münster, Münster, Germany
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13
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Smith HG, Mansfield D, Roulstone V, Kyula-Currie JN, McLaughlin M, Patel RR, Bergerhoff KF, Paget JT, Dillon MT, Khan A, Melcher A, Thway K, Harrington KJ, Hayes AJ. PD-1 Blockade Following Isolated Limb Perfusion with Vaccinia Virus Prevents Local and Distant Relapse of Soft-tissue Sarcoma. Clin Cancer Res 2019; 25:3443-3454. [PMID: 30885937 DOI: 10.1158/1078-0432.ccr-18-3767] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/16/2019] [Accepted: 03/08/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE The prevention and treatment of metastatic sarcoma are areas of significant unmet need. Immune checkpoint inhibitor monotherapy has shown little activity in sarcoma and there is great interest in identifying novel treatment combinations that may augment responses. In vitro and in vivo, we investigated the potential for an oncolytic vaccinia virus (GLV-1h68) delivered using isolated limb perfusion (ILP) to promote antitumor immune responses and augment response to PD-1 blockade in sarcoma.Experimental Design: In an established animal model of extremity sarcoma, we evaluated the potential of locoregional delivery of a vaccinia virus (GLV-1h68) alongside biochemotherapy (melphalan/TNFα) in ILP. Complementary in vitro assays for markers of immunogenic cell death were performed in sarcoma cell lines. RESULTS PD-1 monotherapy had minimal efficacy in vivo, mimicking the clinical scenario. Pretreatment with GLV-1h68 delivered by ILP (viral ILP) significantly improved responses. Furthermore, when performed prior to surgery and radiotherapy, viral ILP and PD-1 blockade prevented both local and distant relapse, curing a previously treatment-refractory model. Enhanced therapy was associated with marked modulation of the tumor microenvironment, with an increase in the number and penetrance of intratumoral CD8+ T cells and expansion and activation of dendritic cells. GLV-1h68 was capable of inducing markers of immunogenic cell death in human sarcoma cell lines. CONCLUSIONS Viral ILP augments the response to PD-1 blockade, transforming this locoregional therapy into a potentially effective systemic treatment for sarcoma and warrants translational evaluation.
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Affiliation(s)
- Henry G Smith
- Targeted Therapy Team, The Institute of Cancer Research, London, United Kingdom
- The Sarcoma Unit, Department of Academic Surgery, The Royal Marsden Hospital NHS Foundation Trust, London, United Kingdom
| | - David Mansfield
- Targeted Therapy Team, The Institute of Cancer Research, London, United Kingdom
| | - Victoria Roulstone
- Targeted Therapy Team, The Institute of Cancer Research, London, United Kingdom
| | - Joan N Kyula-Currie
- Targeted Therapy Team, The Institute of Cancer Research, London, United Kingdom
| | - Martin McLaughlin
- Targeted Therapy Team, The Institute of Cancer Research, London, United Kingdom
| | - Radhika R Patel
- Flow Cytometry and Light Microscopy Facility, The Institute of Cancer Research, London, United Kingdom
| | | | - James T Paget
- Targeted Therapy Team, The Institute of Cancer Research, London, United Kingdom
| | - Magnus T Dillon
- Targeted Therapy Team, The Institute of Cancer Research, London, United Kingdom
| | - Aadil Khan
- Targeted Therapy Team, The Institute of Cancer Research, London, United Kingdom
| | - Alan Melcher
- Translational Immunotherapy Team, The Institute of Cancer Research, London, United Kingdom
| | - Khin Thway
- The Sarcoma Unit, Department of Academic Surgery, The Royal Marsden Hospital NHS Foundation Trust, London, United Kingdom
| | - Kevin J Harrington
- Targeted Therapy Team, The Institute of Cancer Research, London, United Kingdom.
| | - Andrew J Hayes
- The Sarcoma Unit, Department of Academic Surgery, The Royal Marsden Hospital NHS Foundation Trust, London, United Kingdom
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14
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Smith H, Wilkinson M, Smith M, Strauss D, Hayes A. The effect of age on outcomes after isolated limb perfusion for advanced extremity malignancies. Eur J Cancer 2018; 100:46-54. [DOI: 10.1016/j.ejca.2018.04.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 04/05/2018] [Accepted: 04/11/2018] [Indexed: 12/14/2022]
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15
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Isolated limb perfusion for unresectable extremity cutaneous squamous cell carcinoma; an effective limb saving strategy. Br J Cancer 2018; 119:429-434. [PMID: 29961756 PMCID: PMC6133945 DOI: 10.1038/s41416-018-0149-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 05/04/2018] [Accepted: 05/22/2018] [Indexed: 12/13/2022] Open
Abstract
Background A small minority of patients present with locally advanced cutaneous Squamous Cell Carcinoma (cSCC). The aim of this study was to evaluate the effectiveness of Tumour necrosis factor α (TNF) and melphalan based isolated limb perfusion (TM-ILP) as a limb saving strategy for locally advanced extremity cSCC. Methods A retrospective search from prospectively maintained databases, at two tertiary referral centers, was performed to identify patients treated with TM-ILP for locally advanced cSSC of an extremity between 2000 and 2015. Results A total of 30 patients treated with TM-ILP for cSCC were identified, with a median age of 71 years (36–92) and 50% female. Response could not be evaluated in 3 patients. After a median follow up of 25 months, the overall response rate was 81% (n = 22), with 16 patients having a complete response (CR, 59%). A total of 7 patients developed local recurrence, with a median time to recurrence of 9 months (Interquartile Range 7–10). Progressive disease was observed in 5 patients (19%). Limb salvage rate was 80%. The overall 2-year survival was 67%. Conclusions TM-ILP should be considered as an option in patients with locally advanced cSCC in specialised centers, resulting in a high limb salvage rate.
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16
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Sardi A, Muñoz‐Zuluaga CA, Sittig M, Diaz‐Montes T. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in seven patients with peritoneal sarcomatosis from uterine sarcoma. Clin Case Rep 2018; 6:1142-1152. [PMID: 29881584 PMCID: PMC5986004 DOI: 10.1002/ccr3.1491] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 02/06/2018] [Accepted: 02/17/2018] [Indexed: 12/14/2022] Open
Abstract
Peritoneal sarcomatosis from uterine sarcoma is a rare disease with no effective treatment and poor prognosis. Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) has successful results in peritoneal carcinomatosis from gastrointestinal/gynecological origins. We show that CRS/HIPEC is safe, feasible, and may benefit selected patients with peritoneal sarcomatosis from uterine sarcoma.
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Affiliation(s)
- Armando Sardi
- The Institute for Cancer CareMercy Medical Center227 St. Paul PlaceBaltimore21202‐2001Maryland
| | - Carlos A. Muñoz‐Zuluaga
- The Institute for Cancer CareMercy Medical Center227 St. Paul PlaceBaltimore21202‐2001Maryland
| | - Michelle Sittig
- The Institute for Cancer CareMercy Medical Center227 St. Paul PlaceBaltimore21202‐2001Maryland
| | - Teresa Diaz‐Montes
- The Institute for Cancer CareMercy Medical Center227 St. Paul PlaceBaltimore21202‐2001Maryland
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17
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Oncolytic vaccinia virus combined with radiotherapy induces apoptotic cell death in sarcoma cells by down-regulating the inhibitors of apoptosis. Oncotarget 2018; 7:81208-81222. [PMID: 27783991 PMCID: PMC5348387 DOI: 10.18632/oncotarget.12820] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 10/11/2016] [Indexed: 12/13/2022] Open
Abstract
Advanced extremity melanoma and sarcoma present a significant therapeutic challenge, requiring multimodality therapy to treat or even palliate disease. These aggressive tumours are relatively chemo-resistant, therefore new treatment approaches are urgently required. We have previously reported on the efficacy of oncolytic virotherapy (OV) delivered by isolated limb perfusion. In this report, we have improved therapeutic outcomes by combining OV with radiotherapy. In vitro, the combination of oncolytic vaccinia virus (GLV-1h68) and radiotherapy demonstrated synergistic cytotoxicity. This effect was not due to increased viral replication, but mediated through induction of intrinsic apoptosis. GLV-1h68 therapy downregulated the anti-apoptotic BCL-2 proteins (MCL-1 and BCL-XL) and the downstream inhibitors of apoptosis, resulting in cleavage of effector caspases 3 and 7. In an in vivo ILP model, the combination of OV and radiotherapy significantly delayed tumour growth and prolonged survival compared to single agent therapy. These data suggest that the virally-mediated down-regulation of anti-apoptotic proteins may increase the sensitivity of tumour cells to the cytotoxic effects of ionizing radiation. Oncolytic virotherapy represents an exciting candidate for clinical development when delivered by ILP. Its ability to overcome anti-apoptotic signals within tumour cells points the way to further development in combination with conventional anti-cancer therapies.
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18
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Neuwirth MG, Song Y, Sinnamon AJ, Fraker DL, Zager JS, Karakousis GC. Isolated Limb Perfusion and Infusion for Extremity Soft Tissue Sarcoma: A Contemporary Systematic Review and Meta-Analysis. Ann Surg Oncol 2017; 24:3803-3810. [PMID: 29022281 DOI: 10.1245/s10434-017-6109-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Isolated limb perfusion (ILP) and isolated limb infusion (ILI) have been variably used in recent years for the treatment of locally advanced or marginally resectable extremity soft tissue sarcomas (STSs). We performed a systematic review and meta-analysis of contemporary studies to further characterize treatment patterns and outcomes. METHODS PubMed was queried for articles published in or after the year 2000, in the English language, with > 10 patients, and with adequate outcome data following ILP/ILI. Descriptive aggregate statistics were performed. RESULTS Nineteen studies that met the inclusion criteria were identified, with a total of 1288 patients. Weighted mean patient age was 55.9 years and 52% were male. The majority underwent ILP (88%) versus 12% for ILI, and chemotherapeutic regimens used were as follows: (1) melphalan with tumor necrosis factor (TNF)-α (78%), (2) melphalan ± actinomycin (10%), and (3) other regimens (12%). Most common histologies treated were malignant fibrous histiocytoma (21%), liposarcoma (16%), synovial (11%) and leiomyosarcoma (7%). Aggregate overall response rate (ORR) post-procedure was 73.3%, with 25.8% demonstrating a complete response (CR). Similar unadjusted ORRs were noted in the melphalan treatment groups with and without TNFα (72.0 and 67.0%, respectively; p = 0.27). Grade III toxicity was observed in 15.4% of patients, and grade IV/V toxicity was observed in 6.0% of patients. Overall limb salvage rate was 73.8% and median time to local (in-field) progression ranged from 4 to 28 months (weighted median 22.1 months). CONCLUSION ILP and ILI for extremity STS can be safely performed with appreciable response rates and significant limb salvage rates. Further study is needed to identify optimal treatment regimens by histology.
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Affiliation(s)
- Madalyn G Neuwirth
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Yun Song
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew J Sinnamon
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Douglas L Fraker
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Jonathan S Zager
- Departments of Cutaneous Oncology and Sarcoma, Moffitt Cancer Center, Tampa, FL, USA
| | - Giorgos C Karakousis
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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19
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Huis In 't Veld EA, Grünhagen DJ, Verhoef C, Smith HG, van Akkooi ACJ, Jones R, van Coevorden F, Hayes AJ, van Houdt WJ. Isolated limb perfusion for locally advanced angiosarcoma in extremities: A multi-centre study. Eur J Cancer 2017; 85:114-121. [PMID: 28918185 DOI: 10.1016/j.ejca.2017.07.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 07/18/2017] [Indexed: 01/16/2023]
Abstract
BACKGROUND Angiosarcomas are rare and aggressive soft-tissue sarcomas. The only potential curative treatment is complete surgical excision. This study reports the outcome of isolated limb perfusion (ILP) with high-dose melphalan and tumour necrosis factor α for locally advanced angiosarcoma. MATERIAL AND METHODS All patients who underwent an ILP for angiosarcomas between 1991 and 2016 in three tertiary referral centres were identified from prospectively maintained databases. RESULTS A total of 39 patients were included, with a median follow-up of 18 months (interquartile range 6.1-60.8). Of these patients, 23 (58.9%) patients had a complete response (CR) after ILP, 10 (25.6%) had a partial response, 4 (10.3%) had stable disease and 2 (5.1%) patients had progressive disease immediately after ILP. A total of 22 patients developed local progression (56.4%), whereas nine (23.1%) developed distant metastases. The patients with CR had a significantly prolonged median local progression-free survival (PFS) (15.4 versus 7.3 months, p = 0.015) when compared with non-CR patients, and a trend towards better median overall survival (81.2 versus 14.5 months, p = 0.054). Six patients underwent multiple ILPs, whereby the CR rate of the first, second and third ILPs were 60%, 80% and 67%, respectively. Thirteen (33.3%) patients needed further surgical intervention, consisting of resection in eight patients (20.5%) and amputation in five patients (12.8%). CONCLUSION ILP is an effective treatment option for patients with locally advanced angiosarcoma in the extremities, resulting in a high number of CRs, a high limb salvage rate and prolonged local PFS.
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Affiliation(s)
- E A Huis In 't Veld
- Sarcoma Unit, Department of Surgery, Royal Marsden Hospital, London, United Kingdom; Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - D J Grünhagen
- Department of Surgical Oncology, Erasmus MC - Cancer Institute, Rotterdam, The Netherlands
| | - C Verhoef
- Department of Surgical Oncology, Erasmus MC - Cancer Institute, Rotterdam, The Netherlands
| | - H G Smith
- Sarcoma Unit, Department of Surgery, Royal Marsden Hospital, London, United Kingdom
| | - A C J van Akkooi
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - R Jones
- Sarcoma Unit, Royal Marsden Hospital and Institute of Cancer Research, London, United Kingdom
| | - F van Coevorden
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - A J Hayes
- Sarcoma Unit, Department of Surgery, Royal Marsden Hospital, London, United Kingdom
| | - W J van Houdt
- Sarcoma Unit, Department of Surgery, Royal Marsden Hospital, London, United Kingdom; Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands.
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20
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Ñamendys-Silva SA, Ruiz-Beltran AM, Barragán-Dessavre M, Bautista-Ocampo AR, Meneses-García A, González-Chon O, Herrera-Gómez A. Clinical characteristics of critically ill cancer patients who are undergoing isolated limb perfusion. Mol Clin Oncol 2017; 7:747-750. [PMID: 29142747 PMCID: PMC5666660 DOI: 10.3892/mco.2017.1401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 05/22/2017] [Indexed: 11/13/2022] Open
Abstract
The aim of the present study was to investigate the incidence of organ dysfunction, and to describe the clinical characteristics and intensive care unit (ICU) outcomes of critically ill cancer patients who were admitted to an oncological ICU during the isolated limb perfusion post-operative period. The present study was an observational investigation of 42 critically ill cancer patients who were admitted to the ICU of the Instituto Nacional de Cancerología, during the isolated limb perfusion post-operative period, between July 2010 and February 2016. The mean age of the patients was 45.7±16.9 years, and 45.2% (19 cases) were female. Soft tissue sarcoma was the most common pre-operative diagnosis (38.1%), and the mean duration of surgery was 267.6±50.1 min. Furthermore, a mean blood loss volume of 732.3±526.1 ml during the procedure was recorded, and the patients received a mean volume of 3.88±1.28 l crystalloid fluid during the surgical procedure, subsequently requiring an additional 2.95±6.28 l on the first post-operative day. The incidence of organ dysfunction was 90.5% and was most frequently noted in the respiratory (81%), hepatic (33%), hematologic (31%) and renal (11.9%) systems. No patients succumbed to the disease during the ICU and hospital stay. Nevertheless, <10% of the patients required vasopressors. Additionally, <5% of the patients required invasive mechanical ventilation. Therefore, ICU admission directly following isolated limb perfusion should not be standardized.
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Affiliation(s)
- Silvio A Ñamendys-Silva
- Department of Critical Care Medicine, Instituto Nacional de Cancerología, Mexico City 14080, Mexico.,Department of Critical Care Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico.,Department of Critical Care Medicine, Fundación Clínica Médica Sur, Mexico City 14050, Mexico
| | - Arturo M Ruiz-Beltran
- Department of Critical Care Medicine, Instituto Nacional de Cancerología, Mexico City 14080, Mexico
| | - Mireya Barragán-Dessavre
- Department of Critical Care Medicine, Instituto Nacional de Cancerología, Mexico City 14080, Mexico.,Department of Critical Care Medicine, Fundación Clínica Médica Sur, Mexico City 14050, Mexico
| | | | - Abelardo Meneses-García
- Department of Critical Care Medicine, Instituto Nacional de Cancerología, Mexico City 14080, Mexico
| | - Octavio González-Chon
- Department of Critical Care Medicine, Fundación Clínica Médica Sur, Mexico City 14050, Mexico
| | - Angel Herrera-Gómez
- Department of Critical Care Medicine, Instituto Nacional de Cancerología, Mexico City 14080, Mexico
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21
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Hatcher H, Benson C, Ajithkumar T. Systemic Treatments in Soft Tissue Sarcomas. Clin Oncol (R Coll Radiol) 2017; 29:507-515. [PMID: 28552518 DOI: 10.1016/j.clon.2017.05.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 05/08/2017] [Indexed: 12/15/2022]
Abstract
Systematic treatment of adult-type soft tissue sarcoma is evolving. Its role in the neoadjuvant setting is currently experimental, whereas the data on adjuvant chemotherapy are inconclusive. Nevertheless, in clinical practice, neoadjuvant and adjuvant chemotherapy may be considered on an individual basis after multidisciplinary discussion. Systemic therapy has a well-established role in the management of locally advanced and metastatic disease and histology-based treatment approaches are being studied.
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Affiliation(s)
- H Hatcher
- Cambridge University Hospitals, Cambridge, UK.
| | - C Benson
- Royal Marsden Hospital, London, UK
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Smith HG, Thomas JM, Smith MJ, Hayes AJ, Strauss DC. Major Amputations for Extremity Soft-Tissue Sarcoma. Ann Surg Oncol 2017; 25:387-393. [DOI: 10.1245/s10434-017-5895-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Indexed: 12/31/2022]
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Madu MF, Deken MM, van der Hage JA, Jóźwiak K, Wouters MWJM, van Akkooi ACJ. Isolated Limb Perfusion for Melanoma is Safe and Effective in Elderly Patients. Ann Surg Oncol 2017; 24:1997-2005. [DOI: 10.1245/s10434-017-5803-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Indexed: 11/18/2022]
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Dangoor A, Seddon B, Gerrand C, Grimer R, Whelan J, Judson I. UK guidelines for the management of soft tissue sarcomas. Clin Sarcoma Res 2016; 6:20. [PMID: 27891213 PMCID: PMC5109663 DOI: 10.1186/s13569-016-0060-4] [Citation(s) in RCA: 276] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 11/01/2016] [Indexed: 01/18/2023] Open
Abstract
Soft tissue sarcomas (STS) are rare tumours arising in mesenchymal tissues, and can occur almost anywhere in the body. Their rarity, and the heterogeneity of subtype and location means that developing evidence-based guidelines is complicated by the limitations of the data available. However, this makes it more important that STS are managed by teams, expert in such cases, to ensure consistent and optimal treatment, as well as recruitment to clinical trials, and the ongoing accumulation of further data and knowledge. The development of appropriate guidance, by an experienced panel referring to the evidence available, is therefore a useful foundation on which to build progress in the field. These guidelines are an update of the previous version published in 2010 (Grimer et al. in Sarcoma 2010:506182, 2010). The original guidelines were drawn up following a consensus meeting of UK sarcoma specialists convened under the auspices of the British Sarcoma Group (BSG) and were intended to provide a framework for the multidisciplinary care of patients with soft tissue sarcomas. This current version has been updated and amended with reference to other European and US guidance. There are specific recommendations for the management of selected subtypes of disease including retroperitoneal and uterine sarcomas, as well as aggressive fibromatosis (desmoid tumours) and other borderline tumours commonly managed by sarcoma services. An important aim in sarcoma management is early diagnosis and prompt referral. In the UK, any patient with a suspected soft tissue sarcoma should be referred to one of the specialist regional soft tissues sarcoma services, to be managed by a specialist sarcoma multidisciplinary team. Once the diagnosis has been confirmed using appropriate imaging, plus a biopsy, the main modality of management is usually surgical excision performed by a specialist surgeon. In tumours at higher risk of recurrence or metastasis pre- or post-operative radiotherapy should be considered. Systemic anti-cancer therapy (SACT) may be utilized in some cases where the histological subtype is considered more sensitive to systemic treatment. Regular follow-up is recommended to assess local control, development of metastatic disease, and any late-effects of treatment. For local recurrence, and more rarely in selected cases of metastatic disease, surgical resection would be considered. Treatment for metastases may include radiotherapy, or systemic therapy guided by the sarcoma subtype. In some cases, symptom control and palliative care support alone will be appropriate.
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Affiliation(s)
- Adam Dangoor
- Bristol Cancer Institute, Bristol Haematology & Oncology Centre, University Hospitals Bristol NHS Trust, Bristol, BS2 8ED UK
| | - Beatrice Seddon
- Department of Oncology, University College London Hospital NHS Trust, London, NW1 2PG UK
| | - Craig Gerrand
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Newcastle-upon-Tyne, NE7 7DN UK
| | - Robert Grimer
- Royal Orthopaedic Hospital NHS Trust, Birmingham, B31 2AP UK
| | - Jeremy Whelan
- Department of Oncology, University College London Hospital NHS Trust, London, NW1 2PG UK
| | - Ian Judson
- Royal Marsden NHS Foundation Trust, London, SW3 6JJ UK
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Wilkinson MJ, Smith HG, Pencavel TD, Mansfield DC, Kyula‐Currie J, Khan AA, McEntee G, Roulstone V, Hayes AJ, Harrington KJ. Isolated limb perfusion with biochemotherapy and oncolytic virotherapy combines with radiotherapy and surgery to overcome treatment resistance in an animal model of extremity soft tissue sarcoma. Int J Cancer 2016; 139:1414-22. [PMID: 27116656 PMCID: PMC5082541 DOI: 10.1002/ijc.30162] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 04/15/2016] [Indexed: 11/18/2022]
Abstract
The management of locally advanced or recurrent extremity sarcoma often necessitates multimodal therapy to preserve a limb, of which isolated limb perfusion (ILP) is a key component. However, with standard chemotherapeutic agents used in ILP, the duration of response is limited. Novel agents or treatment combinations are urgently needed to improve outcomes. Previous work in an animal model has demonstrated the efficacy of oncolytic virotherapy when delivered by ILP and, in this study, we report further improvements from combining ILP‐delivered oncolytic virotherapy with radiation and surgical resection. In vitro, the combination of radiation with an oncolytic vaccinia virus (GLV‐1h68) and melphalan demonstrated increased cytotoxicity in a panel of sarcoma cell lines. The effects were mediated through activation of the intrinsic apoptotic pathway. In vivo, combinations of radiation, oncolytic virotherapy and standard ILP resulted in delayed tumour growth and prolonged survival when compared with standard ILP alone. However, local disease control could only be secured when such treatment was combined with surgical resection, the timing of which was crucial in determining outcome. Combinations of oncolytic virotherapy with surgical resection and radiation have direct clinical relevance in extremity sarcoma and represent an exciting prospect for improving outcomes in this pathology. What's new? The management of locally advanced or recurrent extremity sarcoma often necessitates multimodal therapy to preserve a limb, of which isolated limb perfusion (ILP) is a key component. But the response to standard ILP is short‐lived in the majority of cases, making novel agents or treatment combinations urgently needed. Previous work in an animal model has demonstrated the effectiveness of combining oncolytic virotherapy with ILP. However, local disease progression was delayed rather than prevented. This paper demonstrates that durable local disease control can be achieved when ILP‐delivered oncolytic virotherapy is utilised as an induction therapy prior to surgical resection and radiotherapy.
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Affiliation(s)
- Michelle J. Wilkinson
- Targeted Therapy TeamThe Institute of Cancer ResearchLondonUnited Kingdom
- Sarcoma/Melanoma Unit, Department Of Academic SurgeryThe Royal Marsden Hospital NHS Foundation TrustLondonUnited Kingdom
| | - Henry G. Smith
- Targeted Therapy TeamThe Institute of Cancer ResearchLondonUnited Kingdom
- Sarcoma/Melanoma Unit, Department Of Academic SurgeryThe Royal Marsden Hospital NHS Foundation TrustLondonUnited Kingdom
| | - Timothy D. Pencavel
- Targeted Therapy TeamThe Institute of Cancer ResearchLondonUnited Kingdom
- Sarcoma/Melanoma Unit, Department Of Academic SurgeryThe Royal Marsden Hospital NHS Foundation TrustLondonUnited Kingdom
| | - David C. Mansfield
- Targeted Therapy TeamThe Institute of Cancer ResearchLondonUnited Kingdom
| | - Joan Kyula‐Currie
- Targeted Therapy TeamThe Institute of Cancer ResearchLondonUnited Kingdom
| | - Aadil A. Khan
- Targeted Therapy TeamThe Institute of Cancer ResearchLondonUnited Kingdom
| | - Gráinne McEntee
- Targeted Therapy TeamThe Institute of Cancer ResearchLondonUnited Kingdom
| | - Victoria Roulstone
- Targeted Therapy TeamThe Institute of Cancer ResearchLondonUnited Kingdom
| | - Andrew J. Hayes
- Sarcoma/Melanoma Unit, Department Of Academic SurgeryThe Royal Marsden Hospital NHS Foundation TrustLondonUnited Kingdom
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