Long-Term Survival According to Histology and Radiologic Response to Preoperative Chemotherapy in 126 Patients Undergoing Resection of Non-GIST Sarcoma Liver Metastases

Unraveling the role of local ablative therapies for patients with metastatic soft tissue sarcoma - A retrospective multicenter study of the Bavarian university hospitals

BACKGROUND

Local ablative therapies (LAT) are increasingly used in patients with metastatic soft tissue sarcoma (STS), yet evidence-based standards are lacking. This study aimed to assess the impact of LAT on survival of metastatic STS patients and to identify prognostic factors.

METHODS

In this retrospective multicenter study, 246 STS patients with metastatic disease who underwent LAT on tumor board recommendation between 2017 and 2021 were analyzed. A mixed effects model was applied to evaluate multiple survival events per patient.

RESULTS

Median overall survival (OS) after first metastasis was 5.4 years with 1-, 2- and 5-year survival rates of 93.7, 81.7, and 53.1 %, respectively. A treatment-free interval ≥12 months and treatment of liver metastases were positively correlated with progression-free survival (PFS) after LAT (HR = 0.61, p = 0.00032 and HR = 0.52, p = 0.0081, respectively). A treatment-free interval ≥12 months and treatment of metastatic lesions in a single organ site other than lung and liver were positive prognostic factors for OS after first LAT (HR = 0.50, p = 0.028 and HR = 0.40, p = 0.026, respectively) while rare histotypes and LAT other than surgery and radiotherapy were negatively associated with OS after first LAT (HR = 2.56, p = 0.020 and HR = 3.87, p = 0.025). Additional systemic therapy was independently associated with a PFS benefit in patients ≤60 years with ≥4 metastatic lesions (for max. diameter of treated lesions ≤2 cm: HR = 0.32, p = 0.02 and >2 cm: HR = 0.20, p = 0.0011, respectively).

CONCLUSION

This multicenter study conducted at six German university hospitals underlines the value of LAT in metastatic STS. The exceptionally high survival rates are likely to be associated with patient selection and treatment in specialized sarcoma centers.

The Landmark Series: Multimodal Management of Oligometastatic Sarcoma

The concept of "oligometastatic" disease suggests the presence of intermediate states between localized disease and widespread metastases, which may be potentially treatable with curative therapeutic strategies. Metastases local therapy (MLT) can be accomplished through various techniques such as stereotactic ablative radiotherapy (SABR), radiofrequency ablation (RFA), microwave ablation (MWA), cryoablation, or surgical metastasectomy. The incorporation of MLT in the multidisciplinary treatment of patients with metastatic sarcoma is complex. Retrospective studies support consideration of MLT for selected patients based on factors such as patient condition, disease biology, histologic type, and disease burden. Decisions regarding type and timing of MLT should be made after multidisciplinary discussion including radiation oncologists, surgical and orthopedic oncologists, medical oncologists, and interventional radiology to explore all options before treatment decsions. All MLT techniques have advantages and disadvantages and should be performed in centers specialized in the care of complex oncology patients where various options can be explored concurrently or sequentially for each patient. Future studies evaluating quality of life and patient-reported outcomes are necessary to adequately align patient goals and optimal outcomes. This article reviews the medical scenarios that may benefit the use of MLT, evaluates the distinct advantages and disadvantages associated with these various techniques, and analyzes the findings from pivotal series to provide a comprehensive understanding of its role in clinical practice.

Pleomorphic liposarcoma of the extremity with solitary huge liver metastasis at initial diagnosis treated with conversion surgery combined with adjuvant chemotherapy: a case report

BACKGROUND

Pleomorphic liposarcoma is the rarest subtype of liposarcoma. Pleomorphic liposarcomas are generally unresponsive to chemotherapy and radiotherapy. Moreover, metastasis in the liver, as the first and sole site, from a primary extremity soft tissue sarcoma, including pleomorphic liposarcoma, is extremely rare. Information regarding the appropriate management of these lesions is limited.

CASE PRESENTATION

A 50-year-old Japanese woman presented with a mass in the left thigh. Imaging examination revealed a soft tissue sarcoma on the left posterior thigh. The tumor was histologically diagnosed as pleomorphic liposarcoma. Computed tomography examination for assessment of metastases incidentally detected a huge liver mass. Wide excision of sarcoma was performed prior to chemotherapy. Right trisectionectomy was necessary to achieve hepatic clearance; however, the future liver remnant volume was insufficient. Therefore, we decided to administer anthracycline-based chemotheraphy to shrink the tumor. After seven courses of adriamycin-based chemotherapy, the liver tumor size was reduced from 211 mm × 106 mm × 180 mm to 105 mm × 66 mm × 90 mm. Finally, a right hemihepatectomy was performed. The patient was continuously monitored and was metastasis or local recurrence free within 5 months after liver surgery.

CONCLUSION

Chemotherapy is effective in some cases for the treatment of unresectable liver metastases of pleomorphic liposarcoma, and complete resection is possible with conversion surgery. If the patient's general condition permits, anthracycline-based chemotherapy can be used for the treatment of stage 4 pleomorphic liposarcoma.

A Phase II Trial of Rivoceranib, an Oral Vascular Endothelial Growth Factor Receptor 2 Inhibitor, for Recurrent or Metastatic Adenoid Cystic Carcinoma

PURPOSE

This open-label, single-arm, phase II study evaluated the vascular endothelial growth factor receptor 2 (VEGFR2) tyrosine kinase inhibitor (TKI) rivoceranib in patients with recurrent or metastatic (R/M) adenoid cystic carcinoma (ACC).

PATIENTS AND METHODS

Eligible patients had confirmed disease progression per Response Evaluation Criteria in Solid Tumors (RECIST) with ≥20% increase in radiologically or clinically measurable lesions or appearance of new lesions within the preceding 6 months. Patients received oral rivoceranib 700 mg once daily. Primary outcomes were objective response rate (ORR) by investigator review and by blinded independent review committee (BIRC).

RESULTS

Eighty patients were enrolled and 72 were efficacy evaluable. Seventy-four patients had distant metastases and 49 received prior systemic treatment (14 received VEGFR TKIs). Per investigator and BIRC, respectively, ORR was 15.3% [95% confidence interval (95% CI), 7.9-25.7] and 9.7% (95% CI, 4.0-19.0); median duration of response was 14.9 months (95% CI, 4.9-17.3) and 7.2 months (95% CI, 3.5-8.4); and median progression-free survival was 9.0 months (95% CI, 7.3-11.5) and 9.0 months (95% CI, 7.7-11.5). Grade ≥3 treatment-related adverse events occurred in 56 patients (70.0%); the most common were hypertension (34, 42.5%) and stomatitis (6, 7.5%). Four grade 5 events occurred with one attributed to rivoceranib (epistaxis). Sixty-eight patients (85.0%) had ≥1 dose modifications and 16 patients (20.0%) discontinued rivoceranib for toxicity.

CONCLUSIONS

In patients with progressing R/M ACC, rivoceranib demonstrated antitumor activity and a manageable safety profile consistent with other VEGFR TKIs.

Local Therapies for Metastatic Sarcoma: Why, When, and How?

Management of patients with advanced sarcoma has been evolving in recent decades, from a one-fit-all perspective to a more refined, personalized, and multidisciplinary approach. In parallel, the evolution of local therapies (radiotherapy, surgical and interventional radiology techniques) has contributed to the improvement of survival of patients with advanced sarcoma. In this article, we review the evidence regarding local treatments in advanced sarcoma, as well as its integration with systemic therapies, to provide the reader a wider and deeper perspective on the management of patients with metastatic sarcoma.

Surgical and oncological results after surgical treatment of patients diagnosed with sarcoma liver metastases

INTRODUCTION

The presence of liver metastases in sarcomatous tumors is associated with poor prognosis. However, in selected patients, surgical resection has been suggested as a tool to improve survival rates. The aim of our study is to describe postoperative and oncological outcomes after liver resection.

METHODS

A retrospective unicentric study was conducted including patients diagnosed with hepatic metastases from soft tissue sarcoma who underwent hepatic resection between 2003-2019. The inclusion criteria were the presence of resectable disease, including synchronic and metachronic lesions. The presence of extra-hepatic controlled disease was not considered unresectable.

RESULTS

Nineteen patients underwent liver resection for liver metastasis of 7 different sarcomatous subtypes. Median age was 58-years. Liver metastases were diagnosed a median 25 months after primary tumor diagnosis. Six patients (32%) suffered of synchronic metastases and 12 (63%) were affected of extrahepatic disease. Major hepatectomy was done in 5 (26 %) patients, 8 (42%) minor complications were described. Median follow-up was 33 months. Survival analysis was performed independently for, GIST tumors and non-GIST sarcomas. One, three and five-year survival rate was 100%, 85.7% and 42.9% in non-GIST sarcomas, while Five and ten-year survival rate was 100% and 40% in GIST, respectively.

CONCLUSION

Surgical approach of liver metastases of sarcomatous tumors seems to be useful in order to improve survival in selected patients, while been associated to low complications rate. In our cohort, extrahepatic disease rate is high in comparison with series published before, nevertheless survival is comparable. These results support performing surgical resection in selected patients with stable extrahepatic disease.

Metastasectomy in Leiomyosarcoma: A Systematic Review and Pooled Survival Analysis

Simple Summary

Leiomyosarcoma (LMS) is an aggressive soft tissue sarcoma with a poor prognosis. Approximately 40% of patients will develop metastatic disease. The optimal treatment for patients with metastatic LMS is not well established, and there are no randomized controlled trials regarding metastasectomy. This systematic review and pooled survival analysis aims to assess the survival in patients undergoing a metastasectomy for LMS and compare the outcomes based on the site of metastasectomy. We identified that patients with LMS metastases in the lungs, liver, spine, and brain can undergo metastasectomy with acceptable survival. Two studies have compared survival outcomes between patients treated and not treated with metastasectomy; despite their low quality, these studies support a survival benefit associated with metastasectomy.

Abstract

This study assesses the survival in patients undergoing metastasectomy for leiomyosarcoma (LMS) and compares the outcomes by the site of metastasectomy. We conducted a systematic review and pooled survival analysis of patients undergoing metastasectomy for LMS. Survival was compared between sites of metastasectomy. We identified 23 studies including 573 patients undergoing metastasectomy for LMS. The pooled median survival was 59.6 months (95% CI 33.3 to 66.0). The pooled median survival was longest for lung metastasectomy (72.8 months 95% CI 63.0 to 82.5), followed by liver (34.8 months 95% CI 22.3 to 47.2), spine (14.1 months 95% CI 8.6 to 19.7), and brain (14 months 95% CI 6.7 to 21.3). Two studies compared the survival outcomes between patients who did, versus who did not undergo metastasectomy; both demonstrated a significantly improved survival with metastasectomy. We conclude that surgery is currently being utilized for LMS metastases to the lung, liver, spine, and brain with acceptable survival. Although low quality, comparative studies support a survival benefit with metastasectomy. In the absence of randomized studies, it is impossible to determine whether the survival benefit associated with metastasectomy is due to careful patient selection rather than a surgical advantage; limited data were included about patient selection.

Is hepatic resection justified for non-colorectal non-neuroendocrine liver metastases? A systematic review and meta-analysis

BACKGROUND

Hepatic resection (HR) is effective for colorectal or neuroendocrine liver metastases. However, the role of HR for non-colorectal non-neuroendocrine liver metastases (NCNNLM) is unknown. This study aims to perform a systematic review and meta-analysis on long-term clinical outcomes after HR for NCNNLM.

METHODS

electronic search was performed to identify relevant publications using PRISMA and MOOSE guidelines. Primary outcomes were 3- and 5-year overall survival (OS) and disease-free survival (DFS). Secondary outcomes were post-operative morbidity and 30-day mortality.

RESULTS

There were 40 selected studies involving 5696 patients with NCNNLM undergone HR. Pooled data analyses showed that the 3- and 5-year OS were 40% (95% CI 0.35-0.46) and 32% (95% CI 0.29-0.36), whereas the 3- and 5-year DFS were 28% (95% CI 0.21-0.36) and 24% (95% CI 0.20-0.30), respectively. The postoperative morbidity rate was 28%, while the 30-day mortality was 2%. Subgroup analysis on HR for gastric cancer liver metastasis revealed the 3-year and 5-year OS of 39% and 25%, respectively.

CONCLUSIONS

HR for NCNNLM may achieve satisfactory survival outcome in selected patients with low morbidities and mortalities. However, more concrete evidence from prospective study is warrant in future.

Exploratory analysis of tumor imaging in a Phase 2 trial with cabozantinib in gastrointestinal stromal tumor: lessons learned from study EORTC STBSG 1317 'CaboGIST'

BACKGROUND

Gastrointestinal stromal tumors (GISTs) are malignant mesenchymal tumors arising in the gastrointestinal tract. Their systemic treatment is based on the use of tyrosine kinase inhibitors (TKIs) with imatinib, sunitinib, and regorafenib being the preferred agents. Assessment of tumor response to TKI treatment in GISTs is traditionally done according the Response Evaluation Criteria in Solid Tumors (RECIST), while Choi criteria have also been proposed as alternative tool assessing both volumetric and density changes on computer tomography (CT) scans. EORTC STBSG 1317 'CaboGIST' was a single-arm prospective Phase 2 trial which met its primary endpoint, as 60% of patients previously treated with imatinib and sunitinib were progression-free at 12 weeks (95% CI 45-74%) based on local RECIST assessment.

MATERIALS AND METHODS

We report here an exploratory analysis of local versus central RECIST version 1.1 assessment and a comparison of RECIST version 1.1 versus Choi criteria.

RESULTS

Comparisons between local and central RECIST version 1.1 at week 12 revealed discrepancies in 17/43 evaluable cases (39.5%). When comparing Choi with local and central RECIST version 1.1, discrepancies were observed in 27/43 (62.8%) and 21/43 (48.8%) cases, respectively. A total of 68% of evaluable patients were progression-free and alive at week 12 based on local RECIST, 84% according to central RECIST analysis and 81% when applying Choi criteria. Central assessment upgraded the treatment response both with RECIST version 1.1 and Choi.

CONCLUSIONS

The results of this exploratory analysis support the conclusion that cabozantinib is active in patients with metastatic or recurrent GIST after treatment with imatinib and sunitinib and confirm once again the limitations of RECIST to capture response to TKI in GIST, and the importance to include density changes in the response evaluation in this setting. Clinical trial number: EORTC 1317, NCT02216578.

Laparoscopic liver resection for liver metastasis of leiomyosarcoma of the thigh: a case report

Background

Although there is no established treatment strategy for liver metastasis of leiomyosarcoma, liver resection has been reported to be effective in some cases. However, almost all liver resections performed for liver metastasis of primary leiomyosarcoma are reported to be open resections, and there are few reports of liver resection performed by laparoscopy. Here, we report a case of laparoscopic liver resection for liver metastasis of a leiomyosarcoma in the right thigh.

Case presentation

An 80-year-old man was diagnosed with leiomyosarcoma of the right thigh with liver metastasis. The primary tumor was first resected, and he was discharged on the 25th postoperative day. Four months after primary tumor resection, a laparoscopic right posterior sectionectomy was performed. There were no postoperative complications, and the patient was discharged on the 11th postoperative day with a histopathological diagnosis of liver metastasis of leiomyosarcoma and negative resection margins. Currently, 9 months have passed since the resection of the primary tumor, and 5 months have passed since the laparoscopic liver resection; there is no recurrence.

Conclusions

The liver metastasis of leiomyosarcoma was successfully removed, with good short-term outcomes after the laparoscopic liver resection. Laparoscopic liver resection seems to be effective for liver metastasis of leiomyosarcoma, which is characterized by a high recurrence rate after surgery. However, more case studies may be necessary to examine the effectiveness and long-term results of laparoscopic liver resection for the treatment of liver metastasis of leiomyosarcoma.

Surgical Management of Large Liver Metastases from Urinary Bladder Leiomyosarcoma

Leiomyosarcoma is a malignant tumor developed from the smooth muscle. It can arise in different sites especiallyin gastrointestinal tract (stomach, small bowel and colon), genitourinary tract (uterus, bladder and kidney) and the retroperitoneum (inferior vena cava) (1,2). It’s localization in the bladder is rare, representing 0.5% of all urinary bladder malignancies. There are over 210 cases reported in literature(3).Ten to 30% of the patients willpossibly develop metastases and the most common sites are lungs, liver and bone(4,5). There is no concensus on a standard treatment due to its very low incidence.

We report here a rare case of a surgical management of large liver metastases from urinary bladder leiomyosarcoma.

Metastases of soft tissue sarcoma to the liver: A Historical Cohort Study from a Hospital-based Cancer Registry

BACKGROUND

Hepatic metastasis of soft tissue sarcoma is rare compared to lung metastasis, and the literature is scarce. We examined the risk of hepatic metastasis according to the site of occurrence and histological type.

METHODS

From a Hospital-based Cancer Registry, 658 patients registered between 2007 and 2017 with soft tissue sarcomas were evaluated. The exclusion criteria were gastrointestinal stromal tumors, tumors of unknown origin, and follow-up periods of less than 1 month. SPSS 25 was used for statistical analysis.

RESULTS

The risk of hepatic metastasis was significantly higher in the retroperitoneum (HR, 5.981; 95% CI, 2.793-12.808) and leiomyosarcoma (HR, 4.303; 95% CI, 1.782-10.390). Multivariate analysis showed that the risk of hepatic metastasis as first distant metastasis was high in leiomyosarcoma (HR, 4.546; 95% CI, 2.275-9.086) and retroperitoneal onset (HR, 4.588; 95% CI, 2.280-9.231). The 2-year survival rate after hepatic metastasis was 21.7%.

CONCLUSIONS

The onset of hepatic metastasis indicates a poor prognosis. However, hepatic metastasis from retroperitoneal sarcoma and leiomyosarcoma may be the first distant metastasis in some cases. For retroperitoneal sarcoma and leiomyosarcoma, additional screening for hepatic metastasis such as contrast CT should be considered during staging and follow-up after treatment.

Liver-directed treatments of liver-dominant metastatic leiomyosarcoma

PURPOSE

The purpose of this study was to determine the safety and efficacy of liver-directed therapies in patients with unresectable metastatic leiomyosarcoma to the liver. Liver-directed therapies included in this study were transarterial chemoembolization with doxorubicin eluting beads (DEB-TACE), yttrium-90 (Y90) radioembolization, and percutaneous microwave ablation.

METHODS

This is a single institution retrospective study of unresectable metastatic leiomyosarcoma to the liver treated with DEB-TACE, radioembolization, or microwave ablation. DEB-TACE was performed using 70-150 or 100-300 µ doxorubicin-loaded drug-eluting LC beads. Radioembolization was performed using Y90 glass microspheres. Electronic medical records were retrospectively reviewed to evaluate clinical and biochemical toxicities, tumor response on imaging, overall survival (OS), and liver progression-free survival (PFS).

RESULTS

A total of 24 patients with metastatic leiomyosarcoma to the liver who underwent liver-directed treatment were identified (8 males, 16 females; average age, 62.8±11.4 years). Of these patients, 13 underwent DEB-TACE, 6 underwent Y90, and 5 underwent ablation. Three patients received a combination of treatments: one received Y90 followed by DEB-TACE, one received ablation followed by DEB-TACE, and one received ablation followed by Y90. Of the 24 patients, 19 received prior chemotherapy. At 3-month follow-up, grade 1 or 2 lab toxicities were found in 20 patients; 3 patients had grade 3 toxicities. A grade 3 clinical toxicity was reported in one patient. MELD score was 7.5±1.89 at baseline and 8.8±4.2 at 3 months. Median OS was 59 months (95% CI, 39.8-78.2) from diagnosis, 27 months (95% CI, 22.9-31.0) from development of liver metastasis, and 9 months (95% CI, 0-21.4) from first liver-directed treatment. Median liver PFS was 9 months (95% CI, 1.4-16.6).

CONCLUSION

Treatment with liver-directed therapies for patients with unresectable metastatic leiomyosarcoma to the liver is safe and can improve overall survival, with OS after liver-directed therapy being similar to patients who underwent surgical resection.

Liver resection for sarcoma metastases: A systematic review and experience from two European centres

INTRODUCTION

Studies reporting outcomes of liver resection for sarcoma metastases (LRSM) typically include gastrointestinal stromal tumours (GIST), or pooled analyses of "non-colorectal liver metastases", which do not reflect the subgroup of patients with sarcomatous liver metastases. This study aimed to perform a systematic review to evaluate oncological and surgical outcomes in patients undergoing LRSM, and to report new data from two tertiary institutions.

METHODS

MEDLINE and the Cochrane Library were searched for studies reporting oncological and surgical outcomes after LRSM, following PRISMA guidelines. Studies reporting liver resection for GIST were excluded. The resulting studies were pooled, with data from two European centres.

RESULTS

Six studies of LSRM were included, comprising 212 patients from previously reported series and 24 patients from ours, with median follow-up times of 18-53 months. Postoperative mortality rates ranged from 0 to 9%, and the pooled overall survival (OS) was 89% (95% CI: 83-96%), and 31% (95% CI: 14-47%) at one and five years, respectively (median: 36 months). The presence of synchronous extra-hepatic metastases was found to be a significant risk factor for shorter OS in two cohorts, with hazard ratios of 3.7 (p < 0.001) and 9.1 (p = 0.016), respectively. The largest reported series also found larger metastases (≥100 mm), lack of response to chemotherapy and a shorter disease-free interval to be associated with significantly shorter OS after LSRM.

CONCLUSIONS

Patients undergoing LRSM with negative prognostic factors such as the presence of extra-hepatic metastases are unlikely to benefit from surgery. Acceptable medium- and long-term survival may be achievable in highly selected patients.

Colonic malignant peripheral nerve sheath tumour in a cat

Case summary

A 14-year-old male neutered domestic mediumhair cat presented with a 4 month history of inappetence and weight loss. Pertinent abnormalities on haematology and biochemistry included a mild microcytic regenerative anaemia (packed cell volume [PCV] 24% [reference interval (RI) 30–45%], mean cell volume 30.8 fl [RI 40–45 fl], absolute reticulocyte count 326.8 × 10¹²) and increased alkaline phosphatase activity (76 IU/l; RI <50 IU/l). Abdominal ultrasound and CT scan revealed masses in the transverse colon (2.0 cm × 1.2 cm) and right medial liver lobe (5.0 cm diameter). Thoracic radiographs were unremarkable. Right medial liver lobe resection and colectomy were performed. Immunohistochemistry was positive for S-100 protein, vimentin and glial fibrillary acidic protein, very weakly positive for c-kit and negative for muscle-specific actin and CD18, consistent with a colonic malignant peripheral nerve sheath tumour (MPNST) with a hepatic metastasis. Postoperative treatment with metronomic cyclophosphamide was well tolerated. Eighteen months postoperatively the cat re-presented after 3 days of progressive lethargy and inappetence. Haematology revealed a marked non- or pre-regenerative anaemia (PCV 10%). Coagulation times were prolonged (prothrombin time 39 s [RI 15–22 s] and activated partial thromboplastin time >300 s [RI 65–119 s]). Abdominal ultrasound identified multiple renal and hepatic nodules. Euthanasia was performed and post-mortem examination confirmed metastasis of the MPNST.

Relevance and novel information

This report describes the treatment of a metastatic colonic peripheral nerve sheath tumour in a cat. Feline visceral MPNSTs are rare and little is known about prognosis or optimal treatment.