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Russell M, Wilkinson M, Hayes A. Isolated Limb Perfusion for Extremity Soft Tissue Sarcoma and Malignant Melanoma. Indian J Surg Oncol 2024; 15:499-508. [PMID: 39239444 PMCID: PMC11371996 DOI: 10.1007/s13193-024-01920-2] [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: 09/27/2023] [Accepted: 03/03/2024] [Indexed: 09/07/2024] Open
Abstract
Isolated limb perfusion (ILP) is a regional chemotherapy technique used in the treatment of locally advanced or unresectable extremity soft tissue sarcoma (ESTS) or malignant melanoma (MM) of the limbs. It allows for high concentrations of chemotherapeutic agents to be perfused in the limb while minimising the risk of systemic side-effects. While the technique has been utilized for decades, the role of ILP has evolved as other treatment strategies have become available. Current indications for ILP in sarcoma include induction in unresectable ESTS to allow for future definitive limb preservation procedures as well as definitive treatment of unresectable, multifocal ESTS. In MM, ILP is typically used in unresectable in-transit melanoma, and rarely as an alternative to amputation in bulky, symptomatic extremity disease. This review seeks to summarise the current evidence base and indications for ILP as well as present some technical insights from a high-volume United Kingdom (UK) unit.
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Affiliation(s)
- Michael Russell
- Sarcoma and Melanoma Unit, The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Michelle Wilkinson
- Sarcoma and Melanoma Unit, The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Andrew Hayes
- Sarcoma and Melanoma Unit, The Royal Marsden Hospital NHS Foundation Trust, London, UK
- Institute of Cancer Research, 237 Fulham Road, London, SW3 6JJ UK
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Chowdhury A, Thway K, Pasquali S, Callegaro D, Gronchi A, Jones RL, Huang PH. Opportunities and Challenges in Soft Tissue Sarcoma Risk Stratification in the Era of Personalised Medicine. Curr Treat Options Oncol 2024; 25:1124-1135. [PMID: 39080193 DOI: 10.1007/s11864-024-01244-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2024] [Indexed: 08/17/2024]
Abstract
OPINION STATEMENT Soft tissue sarcomas (STS) are a rare and heterogeneous group of cancers. Treatment options have changed little in the past thirty years, and the role of neoadjuvant chemotherapy is controversial. Accurate risk stratification is crucial in STS in order to facilitate clinical discussions around peri-operative treatment. Current risk stratification tools used in clinic, such as Sarculator, use clinicopathological characteristics and may be specific to anatomical site or to histology. More recently, risk stratification tools have been developed using molecular or immunological data. Combining Sarculator with other risk stratification tools may identify novel patient groups with differential clinical outcomes. There are several considerations when translating risk stratification tools into widespread clinical use, including establishing clinical utility, health economic value, being applicable to existing clinical pathways, having strong real-world performance, and being supported by investment into infrastructure. Future work may include incorporation of novel modalities and data integration techniques.
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Affiliation(s)
- Avirup Chowdhury
- Division of Molecular Pathology, The Institute of Cancer Research, 15 Cotswold Road Sutton, London, SM2 5NG, UK
| | - Khin Thway
- Division of Molecular Pathology, The Institute of Cancer Research, 15 Cotswold Road Sutton, London, SM2 5NG, UK
- The Royal Marsden NHS Foundation Trust, London, UK
| | - Sandro Pasquali
- Molecular Pharmacology, Department of Experimental Oncology, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
- Department of Surgery, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Dario Callegaro
- Department of Surgery, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Alessandro Gronchi
- Department of Surgery, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Robin L Jones
- The Royal Marsden NHS Foundation Trust, London, UK
- Division of Clinical Studies, The Institute of Cancer Research, London, UK
| | - Paul H Huang
- Division of Molecular Pathology, The Institute of Cancer Research, 15 Cotswold Road Sutton, London, SM2 5NG, UK.
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Weadick CS, Goggin C, Keogh RJ, Murphy JF, Feeley L, Bennett MW, O’Reilly S, Redmond HP, Kelly J, O’Mahony D, Noonan S, Clover AJP, Bambury RM. Risk Stratification Tools to Aid Decisions on Adjuvant Chemotherapy Usage in Resected Soft Tissue Sarcomas: A Ten-Year Review of an Irish Sarcoma Center Experience. World J Oncol 2024; 15:640-647. [PMID: 38993253 PMCID: PMC11236376 DOI: 10.14740/wjon1863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 05/01/2024] [Indexed: 07/13/2024] Open
Abstract
Background Soft tissue sarcoma (STS) is comprised of approximately 80 subtypes, with an incidence of 4 - 5 per 100,000 annually in Europe. The National Comprehensive Cancer Network (NCCN) guidelines recommend consideration of neoadjuvant/adjuvant chemotherapy in tumors at high risk of recurrence based on the American Joint Committee on Cancer (AJCC) staging. Alternatively, the Sarculator is a risk prediction tool that has identified a threshold of risk, above which chemotherapy may provide an overall survival (OS) benefit. Using this nomogram, patients with a 10-year predicted OS < 60% are classified as high risk and should be considered for chemotherapy. The aim of this study was to assess the prognostic accuracy of these two risk prediction methods in an Irish population. Methods All newly diagnosed patients with resected STS discussed in the STS tumor board in Cork University Hospital between January 2012 and December 2021 were identified. Clinicopathological data were collected. Risk assessment using AJCC and Sarculator nomogram was performed on all patients with an extremity/trunk sarcoma. The OS was calculated including Kaplan-Meier method for time to event analysis. Results In total, 200 STS patients were reviewed, of whom 134 had truncal or extremity tumors. Sarculator score was calculated for 60 of these (well differentiated liposarcomas, desmoid tumors and dermatofibrosarcoma protuberans were excluded). Using the Sarculator nomogram to calculate 10-year predicted OS, 19 patients were categorized as high risk and 41 were categorized as low risk. Using AJCC staging, 25 patients were categorized as high risk and 35 as low risk. The 5-year OS rate in the Sarculator high-risk group was 60.2%, compared with 87.1% in the low-risk group (P = 0.009). The 5-year OS rate in the AJCC high-risk group was 67.6%, compared with 86.3% in the low-risk group (P = 0.083). Conclusions Our cohort is representative of the broad histological subtypes expected. In our population, Sarculator score results correlate with international outcomes and higher scores were associated with increased mortality. The Sarculator was more predictive of clinical outcome than AJCC staging, and its use would lower the proportion of patients being considered for adjuvant chemotherapy thereby sparing toxicity, which is important in the setting of uncertain clinical benefit.
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Affiliation(s)
| | - Caitriona Goggin
- Department of Medical Oncology, Cork University Hospital, Wilton, Cork, Ireland
| | - Rachel J. Keogh
- Department of Medical Oncology, Cork University Hospital, Wilton, Cork, Ireland
| | - Jake F. Murphy
- Department of Radiation Oncology, Cork University Hospital, Wilton, Cork, Ireland
| | - Linda Feeley
- Department of Histopathology, Cork University Hospital, Wilton, Cork, Ireland
| | - Michael W. Bennett
- Department of Histopathology, Cork University Hospital, Wilton, Cork, Ireland
| | - Seamus O’Reilly
- Department of Medical Oncology, Cork University Hospital, Wilton, Cork, Ireland
- Cancer Research @UCC, University College Cork, Cork, Ireland
| | - H. Paul Redmond
- Department of Surgery, Cork University Hospital, Wilton, Cork, Ireland
| | - Jason Kelly
- Department of Surgery, Cork University Hospital, Wilton, Cork, Ireland
| | - Deirdre O’Mahony
- Department of Medical Oncology, Cork University Hospital, Wilton, Cork, Ireland
| | - Sinead Noonan
- Department of Medical Oncology, Cork University Hospital, Wilton, Cork, Ireland
- Cancer Research @UCC, University College Cork, Cork, Ireland
| | - A. James P Clover
- Department of Plastic Surgery, Cork University Hospital, Wilton, Cork, Ireland
| | - Richard M. Bambury
- Department of Medical Oncology, Cork University Hospital, Wilton, Cork, Ireland
- Cancer Research @UCC, University College Cork, Cork, Ireland
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Borghi A, Gronchi A. Sarculator: how to improve further prognostication of all sarcomas. Curr Opin Oncol 2024; 36:253-262. [PMID: 38726834 DOI: 10.1097/cco.0000000000001051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
PURPOSE OF REVIEW Prognostication of soft tissue sarcomas is challenging due to the diversity of prognostic factors, compounded by the rarity of these tumors. Nomograms are useful predictive tools that assess multiple variables simultaneously, providing estimates of individual likelihoods of specific outcomes at defined time points. Although these models show promising predictive ability, their use underscores the need for further methodological refinement to address gaps in prognosis accuracy. RECENT FINDINGS Ongoing efforts focus on improving prognostic tools by either enhancing existing models based on established parameters or integrating novel prognostic markers, such as radiomics, genomic, proteomic, and immunologic factors. Artificial intelligence is a new field that is starting to be explored, as it has the capacity to combine and analyze vast and intricate amounts of relevant data, ranging from multiomics information to real-time patient outcomes. SUMMARY The integration of these innovative markers and methods could enhance the prognostic ability of nomograms such as Sarculator and ultimately enable more accurate and individualized healthcare. Currently, clinical variables continue to be the most significant and effective factors in terms of predicting outcomes in patients with STS. This review firstly introduces the rationale for developing and employing nomograms such as Sarculator, secondly, reflects on some of the latest and ongoing methodological refinements, and provides future perspectives in the field of prognostication of sarcomas.
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Affiliation(s)
- Alessandra Borghi
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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Borghi A, Gronchi A. Extremity and Truncal Soft Tissue Sarcoma: Risk Assessment and Multidisciplinary Management. Semin Radiat Oncol 2024; 34:147-163. [PMID: 38508780 DOI: 10.1016/j.semradonc.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
Extremity and truncal soft tissue sarcomas are a heterogeneous group of rare cancers that arise from mesenchymal tissues. Hence, the adoption of tailored risk assessment and prognostication tools plays a crucial role in optimizing the decision-making for which of the many possible treatment strategies to select. Management of these tumors requires a multidisciplinary strategy, which has seen significant development in recent decades. Surgery has emerged as the primary treatment approach, with the main goal of achieving microscopic negative tumor margins. To reduce the likelihood of local recurrence, loco-regional treatments such as radiation therapy and isolated limb perfusion are often added to the treatment regimen in combination with surgery. This approach also enables surgeons to perform limb-sparing surgery, particularly in cases where a positive tumor margin is expected. Chemotherapy may also provide a further benefit in decreasing the probability of local recurrence or reducing distant metastasis in selected patients. Selecting the optimal treatment strategy for these rare tumors is best accomplished by an experienced multi-disciplinary team.
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Affiliation(s)
- Alessandra Borghi
- Department of Surgery, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Alessandro Gronchi
- Department of Surgery, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy..
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Danieli M, Gronchi A. Staging Systems and Nomograms for Soft Tissue Sarcoma. Curr Oncol 2023; 30:3648-3671. [PMID: 37185391 PMCID: PMC10137294 DOI: 10.3390/curroncol30040278] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 03/17/2023] [Accepted: 03/23/2023] [Indexed: 03/29/2023] Open
Abstract
Reliable tools for prognosis prediction are crucially needed by oncologists so they can tailor individual treatments. However, the wide spectrum of histologies and prognostic behaviors of sarcomas challenges their development. In this field, nomograms could definitely better account for their granularity compared to the more widely used AJCC/UICC TNM staging system. Nomograms are predictive tools that incorporate multiple risk factors and return a numerical probability of a clinical event. Since the development of the first nomogram in 2002, several other nomograms have been built, either general, site-specific, histology-specific, or both. Recently, some new “dynamic” nomograms and prognostic tools have been developed, allowing doctors to “recalculate” a patient’s prognosis by taking into account the time since primary surgery, the event history, and the potential time-dependent effect of covariates. Due to these new tools, prognosis prediction is no longer limited to the time of the first computation but can be adapted and recalculated based on the occurrence (or not) of any event as time passes from the first computation. In this review, we aimed to give an overview of the available nomograms for STS and to help clinicians in the process of selecting the best tool for each patient.
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Acem I, van de Sande MAJ. Prediction tools for the personalized management of soft-tissue sarcomas of the extremity. Bone Joint J 2022; 104-B:1011-1016. [PMID: 36047022 PMCID: PMC9987162 DOI: 10.1302/0301-620x.104b9.bjj-2022-0647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Prediction tools are instruments which are commonly used to estimate the prognosis in oncology and facilitate clinical decision-making in a more personalized manner. Their popularity is shown by the increasing numbers of prediction tools, which have been described in the medical literature. Many of these tools have been shown to be useful in the field of soft-tissue sarcoma of the extremities (eSTS). In this annotation, we aim to provide an overview of the available prediction tools for eSTS, provide an approach for clinicians to evaluate the performance and usefulness of the available tools for their own patients, and discuss their possible applications in the management of patients with an eSTS.Cite this article: Bone Joint J 2022;104-B(9):1011-1016.
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Affiliation(s)
- Ibtissam Acem
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands.,Department of Orthopaedic Oncology, Leiden University Medical Centre, Leiden, the Netherlands
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Patel A, Kane JM. Wide Resection of Extremity/Truncal Soft Tissue Sarcomas. Surg Clin North Am 2022; 102:551-565. [DOI: 10.1016/j.suc.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Squires MH, Howard JH. ASO Author Reflections: Utility of Prognostic Nomograms for Extremity Soft Tissue Sarcoma. Ann Surg Oncol 2022; 29:3302-3303. [DOI: 10.1245/s10434-021-11225-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 12/06/2021] [Indexed: 11/18/2022]
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