Neoadjuvant Treatment of Locally Advanced Soft Tissue Sarcoma of the Limbs: Which Treatment to Choose?

Local tumour response to neoadjuvant therapy with 2-aminoethyl dihydrogen phosphate in dogs with soft tissue sarcoma

BACKGROUND

In cases of soft tissue sarcoma (STS), neoadjuvant therapy is indicated to downstage the tumour prior to surgery to achieve enhanced local tumour control. The antineoplastic phospholipid compound 2-aminoethyl dihydrogen phosphate (2-AEH2F) is an alkyl phosphate ester capable of inhibiting cell proliferation and inducing cell death by modifying the asymmetry of phospholipids in the cytoplasmic membrane OBJECTIVES: This clinical study was designed to investigate local antitumoural effects of neoadjuvant therapy with 2-AEH2F in dogs with naturally occurring STS MATERIAL AND METHODS: Dogs (n = 11) received four consecutive weekly intravenous injections of 2-AEH2F (70 mg/kg) prior to tumour resection. Tomographic (CT) and thermal (TE) images were used to investigate changes in tumour size and local temperature in response to treatment RESULTS: Comparative analysis of CT images (n = 9/11) failed to reveal complete or partial remission according to selected assessment criteria (RECIST, WHO and volumetric). Comparative analysis of TE images (n = 10/11) revealed significantly (p = 0.01416) lower temperatures in tumoural areas relative to surrounding tissues over the course of treatment CONCLUSIONS: 2-AEH2F had no cytoreductive effects when used at doses and intervals described in this study. However, significant drop in skin temperatures recorded in tumoural areas suggest induction of physiological changes.

Oncological outcome after hyperthermic isolated limb perfusion for primarily unresectable versus locally recurrent soft tissue sarcoma of extremities

INTRODUCTION

The management of locally advanced extremity soft tissue sarcomas, particularly in terms of a limb salvage strategy, represents a challenge, especially in recurrent tumors. In the context of a patient-tailored multimodal therapy, hyperthermic isolated limb perfusion (ILP) is a promising limb-saving treatment option. We report the outcome of patients with primarily irresectable and locally recurrent soft tissue sarcoma (STS) treated by ILP.

PATIENTS AND METHODS

Data about patient demographics, clinical und histopathological characteristics, tumor response, morbidity and oncological outcome of all patients with STS, who underwent an ILP at our institution in a 10-year period, were retrospectively detected and analyzed.

RESULTS

The cohort comprised 30 patients. Two patients were treated with ILP for palliative tumor control, 13 patients because of a local recurrent soft tissue sarcoma (rSTS) and 15 patients because of primarily unresectable soft tissue sarcoma (puSTS). 25 of the 28 patients with curative intention received surgery after ILP (11 pts with rSTS and 14 pts with puSTS). Histopathologically we observed complete response in 6 patients (24%) and partial responses in 19 patients (76%) with a significant better remission in patients with puSTS (p = 0,043). Limb salvage rate was 75%. Mean follow-up was 69 months [range 13-142 months]. Seven (7/11; 64%) patients with rSTS and one (1/14; 7%) patient with puSTS developed local recurrence after ILP and surgery, whereas eight (8/13; 62%) rSTS patients and seven (7/15; 47%) puSTS patients developed distant metastasis. During follow-up, eight patients (28.5%) died of disease (5/13; 38%) rSTS and 3/15 (20%) puSTS. ILP in the group of previously irradiated sarcoma patients (n = 13) resulted in a limb salvage rate of 69% and was not associated in an increased risk for adverse events.

DISCUSSION

ILP for advanced extremity STS is a treatment option for both puSTS and rSTS resulting in good local control and should be considered in multimodal management. ILP is also a good option for patients after radiation history.

Evaluation of 18F-FDG PET and DWI Datasets for Predicting Therapy Response of Soft-Tissue Sarcomas Under Neoadjuvant Isolated Limb Perfusion

Our purpose was to evaluate and compare the clinical utility of simultaneously obtained quantitative ¹⁸F-FDG PET and diffusion-weighted MRI datasets for predicting the histopathologic response of soft-tissue sarcoma (STS) to neoadjuvant isolated limb perfusion (ILP). Methods: In total, 37 patients with a confirmed STS of the extremities underwent ¹⁸F-FDG PET/MRI before and after ILP with melphalan and tumor necrosis factor-α. For each patient, the maximum tumor size, metabolic activity (SUV), and diffusion restriction (apparent diffusion coefficient, ADC) were determined in pre- and posttherapeutic examinations, and percentage changes during treatment were calculated. Mann-Whitney U testing and receiver-operating-characteristic analysis were used to compare the results of the different quantitative parameters to predict the histopathologic response to therapy. Results from histopathologic analysis after tumor resection served as the reference standard, and patients were defined as responders or nonresponders based on the grading scale by Salzer-Kuntschik. Results: Histopathologic analysis categorized 22 (59%) patients as responders (grades I-III) and 15 (41%) as nonresponders (grades IV-VI). Under treatment, tumors in responders showed a mean reduction in size (-9.7%) and metabolic activity (SUV_peak, -51.9%; SUV_mean, -43.8%), as well as an increase of the ADC values (ADC_min, +29.4%; ADC_mean, +32.8%). The percentage changes in nonresponders were -6.2% in tumor size, -17.3% in SUV_peak, -13.9% in SUV_mean, +15.3% in ADC_min, and +14.6% in ADC_mean Changes in SUV and ADC_mean significantly differed between responders and nonresponders (<0.01), whereas differences in tumor size and ADC_min did not (>0.05). The corresponding AUCs were 0.63 for tumor size, 0.87 for SUV_peak, 0.82 for SUV_mean, 0.63 for ADC_min, 0.84 for ADC_mean, and 0.89 for ratio of ADC_mean to SUV_peak Conclusion: PET- and MRI-derived quantitative parameters (SUV and ADC_mean) and their combination performed well in predicting the histopathologic therapy response of STS to neoadjuvant ILP. Therefore, integrated PET/MRI could serve as a valuable tool for pretherapeutic assessment as well as monitoring of neoadjuvant treatment strategies of STS.

Isolated limb perfusion for soft tissue sarcoma: Current practices and future directions. A survey of experts and a review of literature

Soft tissue sarcomas constitute 1% of adult malignant tumors. They are a heterogeneous group of more than 50 different histologic types. Isolated limb perfusion is an established treatment strategy for locally advanced sarcomas. Since its adoption for sarcomas in 1992, after the addition of TNFα, few modifications have been done and although indications for the procedure are essentially the same across centers, technical details vary widely. The procedures mainly involves a 60 min perfusion with melphalan and TNFα under mild hyperthermia, achieving a limb preservation rate of 72-96%; with an overall response rates from 72 to 82.5% and an acceptable toxicity according to the Wieberdink scale. The local failure rate is 27% after a median follow up of 14-31 months compared to 40% of distant recurrences after a follow up of 12-22 months. Currently there is no consensus regarding the benefit of ILP per histotype, and the value of addition of radiotherapy or systemic treatment. Further developments towards individualized treatments will provide a better understanding of the population that can derive maximum benefit of ILP with the least morbidity.

Tumor necrosis and clinical outcomes following neoadjuvant therapy in soft tissue sarcoma: A systematic review and meta-analysis

BACKGROUND

The prognostic role of tumor necrosis following neoadjuvant therapy is established in bone sarcomas but remains unclear in soft tissue sarcomas (STS).

METHODS

We searched MEDLINE, MEDLINE in progress, EMBASE and Cochrane to identify studies that investigated neoadjuvant therapy in STS. Studies were required to report survival data based on extent of necrosis, or provided individual patient data allowing estimation thereof. Hazard ratios (HR) for relapse-free (RFS) and overall survival (OS) and odds ratios (OR) for recurrence at 3 years and for death at 5 years were pooled in a random effect meta-analysis. Associations between patient characteristics and attainment of ≥90% necrosis were explored.

RESULTS

21 studies comprising 1663 patients were included. Extremity tumors were most common (n = 1554; 93%). Induction regimens included chemotherapy with radiotherapy (n = 924; 56%), chemotherapy alone (n = 412; 25%), radiotherapy alone (n = 78; 5%), isolated limb perfusion (ILP) (n = 231; 14%), and targeted therapy/radiotherapy (n = 18; 1%). Patients with <90% necrosis had higher hazard of recurrence (hazard ratio [HR] 1.47; 95% CI: 1.06-2.04; p = 0.02) and death (HR 1.86; 95% CI: 1.41-2.46; p < 0.001). Risk of recurrence at 3 years (OR = 3.35; 95% CI: 2.27-4.92; p < 0.001) and of death at 5 years (OR 2.60; 95% CI: 1.59-4.26; p < 0.001) were similarly increased. Compared to other modalities, ILP was associated with higher odds of achieving ≥90% necrosis (OR 12.1; 95% CI: 3.69-39.88; p < 0.001).

CONCLUSION

Tumour necrosis <90% following neoadjuvant therapy is associated with increased recurrence risk and inferior OS in patients with STS.

Retrospective Analysis of Spectrum of Presentation and Treatment Outcome in Extremity Sarcomas: A Single-Centre Experience

INTRODUCTION

The most common site for soft tissue sarcoma is extremity. As complete surgical resection is possible in majority, outcome of this subset is relatively better. There is paucity of data regarding extremity soft tissue sarcoma (STS) from sub-Himalayan and hilly geographical regions.

MATERIALS AND METHODS

Retrospective analysis was done for extremity STS visiting the study center over a period of 5 years. Data were collected and analyzed for demography, disease characteristics, treatment modalities, and outcome.

RESULT

Extremity STS constituted 32.8% of all STS enlisted. Most common subtype noted was pleomorphic STS. Metastatic disease at presentation was noted among 7/43 cases with lung being the most common metastasis site. Wide local excision was done in 37 cases while amputation was required in 5 cases. Adjuvant radiotherapy was given in 27 cases while 18 cases received adjuvant chemotherapy. At median follow-up of 47 months, the overall survival and event-free survival were noted as 47.64% and 41.49%, respectively.

CONCLUSION

This study depicts single-center experience of extremity STS. The population analyzed was from sub-Himalayan region with significant lost to follow-up. Pooling of data from different centers has been advocated to derive conclusive results.

Sequential histological findings and clinical response after carbon ion radiotherapy for unresectable sarcoma

Background and purpose

The efficacy of carbon ion radiotherapy (CIRT) for bone and soft tissue sarcoma has been reported recently. Although histological assessment after CIRT requires skilled interpretation, little information is presently available. In this study, we report sequential histological findings after treatment with CIRT, and evaluate the association between these findings and clinical response.

Material and methods

Seven patients with unresectable sarcoma underwent needle biopsy 12 times at an average of 14.3 months after CIRT and were included in this study.

Results

One patient underwent two biopsies after CIRT for chordoma. Although a few suspected residual chordoma cells were observed at 19 and 30 months after CIRT, the tumor continued to shrink at 75 months. Immunohistochemical analysis of post-CIRT specimens revealed CK AE1/3, EMA, and S100 expression, as in the pre-CIRT specimen. In total, viable tumor cells were found in 9 of 12 specimens; however, only 2 patients showed recurrent masses on radiological examination. The other 5 patients had stable disease.

Conclusions

Viable tumor cells after CIRT did not always cause recurrence. This may be due to observation of dying cells or radiation-induced deformed cells. Histological evaluation after CIRT should be done carefully.

Looking for answers: the current status of neoadjuvant treatment in localized soft tissue sarcomas

PURPOSE

Sarcomas are a rare and heterogeneous variant of cancer. The standard of care treatment involves surgical resection with radiation in high-risk patients. Despite appropriate treatment approximately 50 % of patients will suffer and die from recurrent disease. The purpose of this article is to review the current evidence concerning the use of neoadjuvant chemotherapy with or without radiation in soft tissue sarcomas.

METHODS

An in-depth literature search was conducted using Ovid Medline and PubMed.

RESULTS

The most active chemotherapeutic agents in sarcoma are anthracyclines and ifosfamide. Adjuvant chemotherapy trials show only minimal benefit. Neoadjuvant chemotherapy offers the potential advantage of reducing the extent of surgery, increasing the limb salvage rate, early exposure of micrometastatic disease to chemotherapy, and assessment of tumor response to chemotherapy. Some retrospective and phase II trials suggest a benefit to neoadjuvant chemotherapy. Unfortunately, no clearly positive phase III prospectively randomized trials exist for neoadjuvant therapy in soft tissue sarcomas.

CONCLUSIONS

The current neoadjuvant chemotherapy trials that do exist are heterogeneous resulting in conflicting results. However, neoadjuvant chemotherapy with or without radiation can be considered in patients with high-risk disease in an attempt to improve long-term outcomes.

Soft tissue sarcoma in the dog - part 1: a current review

Soft tissue sarcomas are derived from tissues of mesenchymal origin. Although local recurrence following surgical resection is the characteristic challenge in their management, 40% dogs with high-grade tumours may also develop metastatic disease, despite successful local control. Soft tissue sarcoma is a complex disease and there are many uncertainties regarding the biology and optimal clinical management. There are currently no diagnostic tests that can reliably predict the amount of surgical margin required for a particular tumour, so there can be a mismatch between treatment and disease. Historically, the tendency has been to always recommend wide excision margins but this is not fully supported by recent evidence. A selection bias for less aggressive soft tissue sarcomas in primary care practice can account for good outcomes that are achieved despite narrow surgical excision margins. On the other hand, inappropriately conservative treatment will adversely affect outcomes for patients with more aggressive disease. This review provides an update on the current understanding of management of canine soft tissue sarcomas.

Preoperative therapy with pazopanib in high-risk soft tissue sarcoma: a phase II window-of-opportunity study by the German Interdisciplinary Sarcoma Group (GISG-04/NOPASS)

INTRODUCTION

For resectable soft tissue sarcoma (STS), radical surgery, usually combined with radiotherapy, is the mainstay of treatment and the only potentially curative modality. Since surgery is often complicated by large tumour size and extensive tumour vasculature, preoperative treatment strategies with the aim of devitalising the tumour are being explored. One option is treatment with antiangiogenic drugs. The multikinase inhibitor pazopanib, which possesses pronounced antiangiogenic effects, has shown activity in metastatic and unresectable STS, but has so far not been tested in the preoperative setting.

METHODS AND ANALYSIS

This open-label, multicentre phase II window-of-opportunity trial assesses pazopanib as preoperative treatment of resectable STS. Participants receive a 21-day course of pazopanib 800 mg daily during wait time for surgery. Major eligibility criteria are resectable, high-risk adult STS of any location, or metachronous solitary STS metastasis for which resection is planned, and adequate organ function and performance status. The trial uses an exact single-stage design. The primary end point is metabolic response rate (MRR), that is, the proportion of patients with >50% reduction of the mean standardised uptake value (SUVmean) in post-treatment compared to pre-treatment fluorodeoxyglucose positron emission tomography CT. The MRR below which the treatment is considered ineffective is 0.2. The MRR above which the treatment warrants further exploration is 0.4. With a type I error of 5% and a power of 80%, the sample size is 35 evaluable patients, with 12 or more responders as threshold. Main secondary end points are histopathological and MRI response, resectability, toxicity, recurrence-free and overall survival. In a translational substudy, endothelial progenitor cells and vascular epithelial growth factor receptor are analysed as potential prognostic and predictive markers.

ETHICS AND DISSEMINATION

Approval by the ethics committee II, University of Heidelberg, Germany (2012-019F-MA), German Federal Institute for Drugs and Medical Devices (61-3910-4038155) and German Federal Institute for Radiation Protection (Z5-22463/2-2012-007).

TRIAL REGISTRATION NUMBER

NCT01543802, EudraCT: 2011-003745-18; Pre-results.

Plastic Surgery in the Multimodal Treatment Concept of Soft Tissue Sarcoma: Influence of Radiation, Chemotherapy, and Isolated Limb Perfusion on Plastic Surgery Techniques

Surgical intervention is the mainstay treatment for soft tissue sarcomas (STSs). The significance of adjuvant and neoadjuvant therapies, such as chemotherapy, radiation, and isolated limb perfusion, remains under controversial discussion. The goal of this review is to discuss the effects of the aforementioned treatment modalities and their timing of application in plastic surgery techniques. Furthermore, options of reconstruction in cases of complications caused by adjuvant and neoadjuvant therapies are discussed. When compared with adjuvant radiation, neoadjuvant treatment can reduce negative side effects such as fibrosis and edema because radioderma can be removed during the subsequent surgical procedure. Furthermore, there have not been any reports of negative effects of neoadjuvant radiation on microsurgical procedures. However, the dose of neoadjuvant radiation correlates with increased risks of impaired wound healing postoperatively. Thus, a patient-specific approach to decide whether radiation should be performed adjuvant or neoadjuvant is necessary. Preoperative irradiation should be considered in cases where functional structures are exposed after tumor resection, in order to ensure the best possible functionality. Adjuvant radiation should be considered in all other cases because of its known superior wound healing. As for chemotherapy, no negative influence of its use adjuvant or neoadjuvant to reconstructive procedures, such as local or free flaps, has been reported. Lastly, small sample size studies have not shown increased risks of microsurgical failure or wound complications after isolated limb perfusion. The findings of this review suggest that the chronological order of the discussed therapeutic approaches is not a decisive factor in the surgical outcome of reconstructive procedures for STS.

Multiparametric Assessment of Treatment Response in High-Grade Soft-Tissue Sarcomas with Anatomic and Functional MR Imaging Sequences

PURPOSE

To determine the added value of quantitative diffusion-weighted and dynamic contrast material-enhanced imaging to conventional magnetic resonance (MR) imaging for assessment of the response of soft-tissue sarcomas to neoadjuvant therapy.

MATERIALS AND METHODS

MR imaging examinations in 23 patients with soft-tissue sarcomas who had undergone neoadjuvant therapy were reviewed by two readers during three sessions: conventional imaging (T1-weighted, fluid-sensitive, static postcontrast T1-weighted), conventional with diffusion-weighted imaging, and conventional with diffusion-weighted and dynamic contrast-enhanced imaging. For each session, readers recorded imaging features and determined treatment response. Interobserver agreement was assessed and receiver operating characteristic analysis was performed to evaluate the accuracy of each session for determining response by using results of the histologic analysis as the reference standard. Good response was defined as less than or equal to 5% residual viable tumor.

RESULTS

Of the 23 sarcomas, four (17.4%) showed good histologic response (three of four with >95% granulation tissue and <5% necrosis, one of four with 95% necrosis and <5% viable tumor) and 19 (82.6%) showed poor response (viable tumor range, 10%-100%). Interobserver agreement was substantial or excellent for imaging features in all sequences (k = 0.789-1.000). Receiver operating characteristic analysis showed an increase in diagnostic performance with the addition of diffusion-weighted and dynamic contrast-enhanced MR imaging for prediction of response compared with that for conventional imaging alone (areas under the curve, 0.500, 0.676, 0.821 [reader 1] and 0.506, 0.704, 0.833 [reader 2], respectively).

CONCLUSION

Adding functional sequences to the conventional MR imaging protocol increases the sensitivity of MR imaging for determining treatment response in soft-tissue sarcomas.

Combined radiation therapy and sunitinib for preoperative treatment of soft tissue sarcoma

BACKGROUND

Antiangiogenic substances and radiation therapy (RT) may have synergistic effects and improve irradiation efficacy. We present a cohort study evaluating the toxicity of combined sunitinib and RT as neoadjuvant treatment of extremity and retroperitoneal soft tissue sarcoma (STS).

METHODS

Sixteen patients with locally advanced extremity (6/16) or retroperitoneal (10/16) STS were treated with continuous-dosing sunitinib (15/16: 37.5 mg daily; 1/16: 25 mg daily) and standard RT (45-50.4 Gy) preoperatively. Surgery was scheduled 5-9 weeks following neoadjuvant treatment. The primary goal of the study was to determine combined treatment toxicity according to the Common Terminology Criteria for Adverse Events. Secondary goals were the evaluation of postoperative morbidity and treatment response.

RESULTS

Eight of 16 patients developed grade 3, and one patient developed grade 4, hematological toxicity. One patient experienced grade 3 hand-foot syndrome. The most frequent treatment toxicities of any grade were hematological (15/16) or dermatological (9/16). Three patients had partial response, 11 had stable disease, and 2 had progressive disease according to Response Evaluation Criteria in Solid Tumors (RECIST). Fourteen of 16 patients underwent surgery; tumors were not removed in two patients because of patient refusal or intercurrent metastatic disease. The proportion of tumor necrosis exceeded 90 % in 5 of 14 patients, and 4 patients had postoperative complications requiring reintervention.

CONCLUSIONS

Preoperative treatment with concurrent sunitinib and RT was tolerable, and postoperative morbidity did not increase. Combined treatment with RT and sunitinib was also feasible in patients with retroperitoneal STS, and warrants further investigation.

Phase I trial of concurrent sunitinib and radiation therapy as preoperative treatment for soft tissue sarcoma

INTRODUCTION

Although the introduction of multimodal treatment of soft tissue sarcoma improved local tumour control, local failure still occurs in a good number of patients. Therefore, further improvement of current treatment strategies is necessary. The proposed study treatment will combine standard external beam radiation and the orally administered receptor tyrosine kinase inhibitor sunitinib.

METHODS AND ANALYSIS

Patients with soft tissue sarcoma will receive sunitinib and irradiation as neoadjuvant treatment. Radiotherapy will be administered as intensity modulated radiation therapy with a total dose of 50.4 Gy in 28 fractions (5 1/2 weeks). Patients will receive sunitinib daily for 2 weeks prior to and then concurrently with irradiation. Sunitinib will be given in two dose levels. The first dose level will be 25 mg sunitinib per os daily. The second dose level will be 37.5 mg. A dose modification schedule according to a 3+3 design will be applied. Restaging and tumour resection will be performed 6 weeks after completion of sunitinib and irradiation. Primary outcome measures will be the dose-limiting toxicity and maximal tolerated dose of sunitinib administered concurrently with irradiation. Toxicity of the study treatment will be documented according to Common Terminology Criteria of Adverse Events (CTCAE) 4.0. Secondary outcome measures will be the response to the study treatment and morbidity of the tumour resection. Imaging response will be determined according to Response Evaluation Criteria in Solid Tumors (RECIST) criteria comparing MRI performed prior to and 6 weeks after completion of study treatment. Pathological response will be determined evaluating the fraction of non-viable tumour in the resection specimen. Resection morbidity will be evaluated according to CTCAE 4.0.

ETHICS AND DISSEMINATION

Approval was obtained from the ethics committee II of the University of Heidelberg, Germany (Reference number 2011-064F-MA). Furthermore, the study was approved by the German Federal Institute for Drugs and Medical Devices (Reference number 4037708).

TRIAL REGISTRATION EUDRACT

2007-002864-87 Clinicaltrials.gov: NCT01498835.

Neoadjuvant treatment improves capsular integrity and the width of the fibrous capsule of high-grade soft-tissue sarcomas

BACKGROUND

Neoadjuvant treatment is thought to improve resection with margin-negative surgery in locally advanced soft-tissue sarcomas (STS). Treatment-induced alterations of the tumor peripheryhave not yet been microscopically evaluated.

OBJECTIVE

This histopathological study compared limb STS with primary resection and those that had undergone neoadjuvant treatment, emphasizing microscopic changes of the fibrous capsule (FC) and reactive zone (RZ) after neoadjuvant treatment.

PATIENTS AND METHODS

Patients with primary high-grade limb sarcomas (N = 76) which have not previously been treated were included. Of those, 37 were primarily resected and 39 were treated with one of the following neoadjuvant treatment modalities: 7x chemotherapy (CTX), 3x radiotherapy (RT), 15x isolated limb perfusion (ILP), 8x CTX + RT, and 6x CTX + ILP. Sizes of the FC and RZ were microscopically measured, and FC-integrity was documented. Histopathologic regression was expressed as a percent.

RESULTS

Only 35.1% of untreated sarcomas showed an intact FC. We observed significantly higher capsular integrity after treatment (76.9%). Additionally, the average width of the FC (0.21 mm vs. 0.61 mm) and RZ (0.67 mm vs. 1.48 mm) increased significantly. The extent of histopathologic regression showed a correlation with capsular integrity and width. The combination of two treatment modalities (CTX + RT or ILP) showed strongest effects at the tumor periphery.

CONCLUSIONS

Neoadjuvant treatment stabilizes the tumor periphery in STS (e.g., the capsule). Concerning local treatment strategies, these novel histopathologic insights might significantly influence the decision as to whether primary resection is advisable in advanced local soft-tissue sarcoma.

Hyperthermic isolated limb perfusion for extremity soft tissue sarcomas: systematic review of clinical efficacy and quality assessment of reported trials

BACKGROUND AND OBJECTIVES

Extremity soft tissue sarcomas (STS) are managed with radiotherapy and limb-sparing surgery however aggressive or recurrent cases require amputation. Hyperthermic isolated limb perfusion (HILP) has been proposed as an alternative. Our aim was to systematically review phase II HILP trials, assess tumor response, limb salvage (LS), and quality of scientific publications on this technique.

METHODS

We conducted a literature search of electronic databases (MEDLINE, EMBASE, Scopus, Cochrane Library) and clinical trial registries for phase II HILP trials on non-resectable extremity STS. Outcomes of interest were complete response (CR), partial response (PR), and LS rates. Quality of published trials was assessed using a quality checklist.

RESULTS

Of 518 patients across 12 studies, 408 had some response (CR or PR), and 428 had the limb spared. Median CR, PR, and LS rates were 31%, 53.5%, and 82.5%, respectively. Median Wieberdink loco-regional toxicity rates were 3.8%, 45.5%, 17%, 1%, and 0% for levels 1-5, respectively. No trial fulfilled either all ideal or essential quality criteria. Seven trials did not include statistical methodology.

CONCLUSION

HILP seems effective in treating advanced extremity STS. However, poor publication quality hinders results validity. Technical and methodological standardization, well-designed, multi-institutional trials are warranted.

Size-based clinical response evaluation is insufficient to assess clinical response of sarcomas treated with isolated limb perfusion with TNF-α and melphalan

BACKGROUND

The clinical assessment of the response of sarcomas to preoperative treatment is usually defined using size-based evaluation standards. For nonresectable sarcomas, hyperthermic isolated limb perfusion with TNF-α and melphalan (TM-ILP) yields high response rates. Based on our experience, we assume that anatomic radiological response criteria are insufficient to assess the degree of regression after TM-ILP.

METHODS

The clinical response of 35 sarcomas to TM-ILP was assessed by unidimensional, bidimensional, and tridimensional size-based anatomical criteria, and responders were identified according to the established thresholds. The same tumors were investigated for pathological response according to the Salzer-Kuntschik regression scale (>90% devitalization) and reviewed for cystic degeneration, hemorrhage, and predominant necrotic or fibrosclerotic regression phenotype.

RESULTS

None of the clinical response criteria were able to reliably identify the pathologic responders. The extent of size changes showed no association with the pathological degree of regression. The number of clinical responders was low compared with the number of pathological responders (RECIST N = 1, WHO N = 3, volumetry N = 3, pathology N = 19). The occurrence of hemorrhage and/or cystic degeneration was more frequently observed in predominant necrotic sarcomas and was associated with an increase in tumor size after TM-ILP. Furthermore, we identified the fibrosclerotic phenotype of regression to be more significantly strongly associated with posttherapeutic shrinkage than necrosis.

CONCLUSIONS

Size-based clinical response evaluation is insufficient to assess clinical response in TM-ILP-treated sarcomas. The size changes of tumors after therapy reflect the type of regression rather than the extent of destruction.

Phase II clinical trial of neoadjuvant trabectedin in patients with advanced localized myxoid liposarcoma

BACKGROUND

To evaluate neoadjuvant trabectedin (1.5 mg/m(2) 24-h i.v. infusion every 3 weeks; three to six cycles) in patients with locally advanced myoxid liposarcoma (ML) previously untreated with chemotherapy or radiation.

PATIENTS AND METHODS

Primary efficacy end point was pathological complete response (pCR) or tumoral regression rate. Objective response according to RECIST (v.1.0) was a secondary end point.

RESULTS

Three of 23 assessable patients had pCR [13%; 95% confidence interval (CI), 3% to 34%]. Furthermore, very good and moderate histological responses were observed in another 2 and 10 patients, respectively. Histological decrement in the cellular and vascular tumor component and maturation of tumor cells to lipoblasts were observed in both myoxid and myoxid/round cell variants. Seven patients had partial response according to RECIST (objective response rate of 24%; 95% CI, 10% to 44%). No disease progression was reported. Neoadjuvant trabectedin was usually well tolerated, with a safety profile similar to that described in patients with soft tissue sarcoma or other tumor types.

CONCLUSION

Trabectedin 1.5 mg/m(2) given as a 24-h i.v. infusion every 3 weeks is a therapeutic option in the neoadjuvant setting of ML.

Long-term survivor of relapsed MFH on the thigh treated with autologous formalin-fixed tumor vaccine (AFTV) combined with limb-sparing surgery and radiotherapy

Malignant fibrous histiocytoma (MFH) is an aggressive spindle cell cancer of soft-tissue sarcoma type in the elderly, mostly affecting the extremities. Lesions > 5 cm, positive margins, and local recurrence are significant poor prognostic indicators. The strongest predictor for distant metastasis was tumor size (> 5 cm), and for overall survival, presence of local recurrence. Limb-sparing extensive tumor resection is preferred to achieve negative surgical margins. However, in some circumstances, amputation is inevitable. Recent studies demonstrated that adjuvant radiotherapy for microscopically positive surgical margins significantly improved local control and disease-free survival rates. Therefore, effective therapeutic strategies against locally relapsed high grade MFH are required to prevent distant metastasis and to achieve long-term disease-free survival. Here, we report local relapse of high grade MFH treated by successive application of autologous formalin-fixed tumor vaccination (AFTV) with limb-sparing surgery and postoperative radiotherapy. The patient is alive and well, disease-free and with no functional impairment, more than five years after treatment.

The diagnosis and treatment of soft tissue sarcomas of the limbs

BACKGROUND

The diagnosis of soft-tissue sarcomas of the limbs is often delayed, sometimes markedly so, even though prompt and appropriate treatment improves survival and lowers the amputation rate.

METHODS

On the basis of a selective literature review and consideration of the relevant guidelines, we developed an algorithm that can serve as a guide to the diagnosis of soft-tissue tumors in general and to the treatment of soft-tissue sarcomas of the limbs.

RESULTS

Surgical resection accompanied by multimodal therapy is the only treatment strategy for soft-tissue sarcoma that provides a chance of cure. Particularly when the tumor is located in the distal part of a limb, plastic-reconstructive surgical techniques often enable adequate local control, along with limb salvage and preservation of function. The role of adjuvant or neo-adjuvant radiotherapy and/or chemotherapy is currently debated. The overall survival rate at 5 years is 87% for low-grade sarcomas and 62% for high-grade sarcomas.

CONCLUSION

Any solid mass of the limbs that has been present for more than four weeks requires diagnostic evaluation. Excisional biopsy is suitable only for epifascial lesions measuring less than 5 cm in diameter. All other lesions should be imaged with MRI and then diagnosed with an incisional biopsy. Patients with soft tissue sarcomas must be treated in an interdisciplinary collaboration so that they can undergo multimodal treatment. The proposed algorithm should help avoid delays in diagnosis and optimize treatment strategies.

Role of chemotherapy in the management of soft tissue sarcomas

Soft tissue sarcomas are a diverse group of rare tumors that comprise 1% of all cancers. Few randomized trials of chemotherapy have been performed but there is a clear role for agents such as doxorubicin and ifosfamide in the palliation of advanced disease. There is uncertainty as to whether sequential single-agent treatment is equivalent to combination chemotherapy. For the majority of histological subtypes adjuvant chemotherapy is not of proven value, although there may be situations where it is advantageous. However, there are other subtypes, such as the Ewing's sarcoma family tumors, for which chemotherapy is an essential part of primary management and has definitely improved survival. Apart from Ewing's sarcoma family tumor and rhabdomyosarcoma, there is increasing specialization of chemotherapy according to histological subtype, such as the use of taxanes for angiosarcoma, gemcitabine and docetaxel for leiomyosarcoma, and trabectedin for leiomyosarcoma and liposarcoma, especially the myxoid/round cell variant. Nevertheless, there are serious limitations to existing treatment and novel therapies need to be developed.

Genomic expression, chemotherapy response, and molecular targets in soft tissue sarcomas of the extremities: promising strategies for treatment selection

Neoadjuvant or adjuvant therapy in soft tissue sarcomas is still controversial, especially in regards to the use of chemotherapy. The identification of predictive factors is crucial to avoid the use of chemotherapy in patients with tumors that carry genetic characteristics associated with resistance. Focusing on gene expression data, we performed a review of the actual state of knowledge in molecular predictive factors for chemotherapy response and new targets of therapy in extremity sarcomas.

Acellular dermal matrix seeded with autologous fibroblasts improves wound breaking strength in a rodent soft tissue damage model in neoadjuvant settings

Soft tissue defects following resectional surgery or trauma often result in deadspaces and require free or pedicled flaps. A programmed formation of filling tissue with enhanced biomechanical properties could be helpful. This study examined the effects on wound healing of acellular dermal matrix (ADM) seeded with autologous fibroblasts in a standardized rodent model. As pre- or postoperative radiotherapy is standard in many treatments of malignancies, we also investigated the effects of additional radiotherapy. Fischer rats were randomised and received a standardized unilateral soft tissue defect at the buttock. The defect was filled with ADM+fibroblasts or ADM alone. Controls received no filling. Either no radiation, adjuvant (postoperative) or neoadjuvant (preoperative) radiation was applied to the defect site. Six weeks later the defect volume was measured by MR-tomography. Wound breaking strength was examined by tensiometry according to German Industrial Standards. Filling of the defect side was significantly larger in ADM and ADM+fibroblast treated groups compared to the control group in all settings. Wound breaking strength in the unimodal setting was significantly improved in the ADM+fibroblasts group compared to the ADM group. In the neoadjuvant setting there was no significant difference between control and ADM group. However, the ADM+fibroblasts groups showed a significantly increased wound breaking strength compared to the control and the ADM-alone group. Seeded or unseeded ADM is able to fill deadspace in this rodent model in all settings. Implanting non-irradiated, vital, proliferating autologous fibroblasts on ADM results in significantly increased wound breaking strength.

Adjuvant chemotherapy in localized soft tissue sarcomas: still not proven

Soft tissue sarcoma is a rare and heterogeneous group of tumors in terms of histological subtypes, molecular alterations, clinical presentation, and prognosis. Yet, these tumors are most often treated similarly in the localized phase. The standard treatment of these patients requires multidisciplinary management, in particular, careful diagnostic procedures and surgery by an expert physician, preceded or followed by external radiotherapy. The utility of adjuvant chemotherapy has been explored in 14 trials comparing adjuvant chemotherapy with no treatment. Several trials reported a lower risk for local relapse and lower risk for metastatic relapse, but only a few small trials reported longer overall survival. A meta-analysis of all trials failed to demonstrate a significant difference in the relapse-free survival (RFS) or overall survival rates. Two additional trials, reported afterward, presented conflicting results, with a significant benefit in terms of the RFS rate for the trial of the Italian Sarcoma Group, but no difference in the RFS or overall survival rate in the most recent European Organization for Research and Treatment of Cancer trial. We conclude that adjuvant chemotherapy has not been proven to improve the outcome of an unselected population of patients. Several hypotheses are proposed to account for this observation.

Microvascular reconstruction after resection of soft tissue sarcoma of the leg

Background

Limb-sparing surgery and satisfactory functional outcome is the goal of extremity soft tissue sarcoma (STS) surgery. Tissue defects after tumour excision are often extensive, and microvascular reconstruction is frequently required.

Methods

Seventy-three patients with STS of the leg requiring microvascular reconstruction were treated between 1985 and 2006. Radiotherapy was delivered if the microscopic surgical margin was less than 2·5 cm.

Results

Mean follow-up was 65·9 months. Seventy-five free flaps were performed, with a success rate of 95 per cent. One patient died within a month of surgery. Five-year local recurrence-free survival was 82 per cent, metastasis-free survival 59 per cent, disease-free survival 56 per cent and disease-specific overall survival 70 per cent. Fifty-five (75 per cent) of the 73 patients were able to walk normally or had only minor walking impairment.

Conclusion

Without microvascular reconstruction, amputation would have been necessary in most patients. Microvascular reconstruction is safe and reliable in lower extremity STS reconstruction.

Neoadjuvant chemoradiation therapy for soft tissue sarcomas of the extremities

INTRODUCTION AND OBJECTIVE

Neoadjuvant and adjuvant therapies for soft tissue sarcomas of the extremities are still controversial. The aim of this study was to analyze the results of a protocol of neoadjuvant chemoradiation therapy for extremity sarcomas.

METHODS

A retrospective analysis was carried out in a consecutive series of 49 adult patients with advanced extremity soft tissue sarcomas that could not be resected with adequate margins during the primary resection. All patients were treated with a protocol of preoperative radiation therapy at a total dose of 30 Gy, concomitant with doxorubicin (60 mg/m(2)) chemotherapy. The main endpoints assessed were local recurrence-free survival, metastasis-free survival and overall survival. The median follow-up time was 32.1 months.

RESULTS

The five-year local recurrence-free survival, metastasis-free survival and overall survival rates were 81.5%, 46.7% and 58.3%, respectively. For high-grade tumors, the five-year metastasis-free and overall survival rates were only 36.3% and 41.2%, respectively. Severe wound complications were observed in 41.8% of the patients who underwent surgery. These complications precluded adjuvant chemotherapy in 73.7% (14/19) of the patients eligible to receive it.

CONCLUSIONS

In this study, neoadjuvant chemoradiation therapy was associated with a good local control rate, but the distant relapse-free rate and overall survival rate were still poor. The high rate of wound complications modified the planning of adjuvant treatment in most patients.

Management of locally recurrent soft tissue sarcoma after prior surgery and radiation therapy

Surgery and radiation therapy are the standard for local tumour control in the treatment of soft tissue sarcoma. Sarcoma recurrence within a previously irradiated area is one of the most problematic therapeutic challenges in soft tissue tumours. Any information on previous therapy needs to be available in detail. In case of recurrent sarcoma not amenable to surgical resection with wide and clear margins, a multimodality therapy needs to be applied. The armamentarium usually looks for a neoadjuvant downstaging of the sarcoma by radiotherapy, chemo-radiotherapy or isolated limb perfusion with all of those strategies bearing benefits, but also specific risks. The potential of repeated radiotherapy and the modality that can be used (intraoperative radiotherapy, brachytherapy) needs to be carefully evaluated. The pathologist saves these major problems in intraoperative frozen section histology or resection margins and thus needs to be aware of the type of cancer cells potentially present within the resection specimen. Plastic and reconstructive surgery to cover the area of re-resection with viable and well-v tissue is absolutely crucial to prevent lymphatic fistula. Thus, adequate treatment of those specific situations usually involves postoperative physiotherapy and a specific rehabilitation, which is extremely important.