Prognosis in soft tissue sarcoma

Necrosis Observed on CT Enhancement is of Prognostic Value in Soft Tissue Sarcoma

Fifty-one patients with deep-seated soft tissue sarcoma of the extremities and trunk wall were examined with contrast-enhanced CT for presence of nonenhanced tumor areas (CT necrosis). After a median follow-up time of 3 years, 19 of the 41 patients with CT necrosis had developed metastases, compared to none of the 10 patients who had tumors without CT necrosis. Tumors with CT necrosis were larger than tumors without, but in tumors of similar size, absence of CT necrosis was a favorable prognostic sign.

Prognostic impact of immunohistochemical expression of ezrin in highly malignant soft tissue sarcomas

PURPOSE

Ezrin is a cytoskeleton linker protein that is actively involved in regulating the growth and metastatic capacity of cancer cells. It has recently been reported to be involved in dissemination of pediatric soft tissue sarcoma (STS).

EXPERIMENTAL DESIGN

To further evaluate the prognostic value of ezrin in STS progression, we screened 50 primary STSs of high malignancy grade using immunohistochemistry. At the initial surgery, all patients were without local or distant metastasis. The expression was then compared with the outcome during follow-up for at least 4 years or until the patients' death.

RESULTS

Twenty-five of the 50 STSs analyzed (50%) showed ezrin immunoreactivity in the membrane and cytoplasm of the tumor cells. A significant association was shown between positive expressions of ezrin and death in disease as well as overall survival (P = 0.014 and 0.007, respectively). Similarly, ezrin expression was significantly associated with development of distant metastasis during follow-up (P = 0.031), also excluding locally recurrent disease (P = 0.049). The relative abundance of metastasis in ezrin-positive cases was observed both over time and irrespective of time. In comparison with clinical, histopathologic, and genetic characteristics of the STSs, ezrin expression was found to correlate significantly with an infiltrative growth pattern outside the tumor capsule as well as with copy number gain of chromosomal region 9cen-q22.

CONCLUSION

Our findings suggest that ezrin immunoreactivity could be valuable as an additional prognostic marker in highly malignant STSs and support a causative role of ezrin in STS tumor dissemination.

Insulin-Like Growth Factor Type 1 Receptor Expression Correlates to Good Prognosis in Highly Malignant Soft Tissue Sarcoma

Purpose: To evaluate known and suggested prognostic markers, especially insulin-like growth factor type 1 receptor (IGF-1R), in highly malignant soft tissue sarcomas (STS).

Experimental Design: A cohort of 101 patients with primary STS of high malignancy grade was studied with respect to development of metastasis, local recurrence, and survival during a minimum of 5 years follow-up. All tumors were analyzed by immunohistochemistry for expression of Ki-67, p53, p27, Bcl-2, IGF-1R, and microvessel density. The traditional clinical variables size, malignancy grade (3 or 4), necrosis, mitotic frequency, infiltrative tumor growth, vascular invasion, depth, and surgical margins were also evaluated.

Results: A significant association was shown between high expression of IGF-1R and favorable outcome. Among STS with positive IGF-1R immunoreactivity, cases with high expression (76-100% positive cells) had the best outcome, whereas cases with the lowest expression (1-25% positive cells) had the worst. As expected, large tumor size (>11 cm), presence of necrosis, high mitotic count, intralesional surgery, and deep location were all significantly associated with poor outcome, both in univariate and multivariate analyses. No difference in outcome was observed between cases of malignancy grade 3 versus 4, whereas the included and more objective variables necrosis and mitotic count were found to be reliable prognostic markers.

Conclusion: IGF-1R expression is a common feature of highly malignant STS. Further elucidation of the role of IGF-1R and the IGF system in STS may both provide a basis for development of new prognostic tools in STS, as well as shed light on the basic mechanisms of the STS development.

Size and timing of local recurrence predicts metastasis in soft tissue sarcoma. Growth rate index retrospectively analyzed in 134 patients

Our study combined size and timing of the first local recurrence to create a growth rate index (GRI-ratio of size (cm) to timing (mo)) which we analyzed for an association with metastasis. We analyzed 134 locally recurrent tumors from a series of 460 adult patients with soft tissue sarcoma of the extremities and trunk wall who were diagnosed and treated between 1964 and 1990, with a median follow-up of 10 (2-28) years for survivors. None of the patients had metastases at diagnosis. One half (74) of local recurrences were from inadequately treated primaries, one half (71) were associated with metastases, and two thirds (89) were seen in non-center-treated patients. There were equal numbers of patients with GRI < or = 0.4 (low) and > 0.4 (high). Patients with a low GRI had a better 2-year metastasis-free survival (80 percent) than those with a high GRI (30 percent). High GRIs were associated with large, high grade primary tumors and a short metastasis-free interval in comparison to low GRI tumors. Time to local recurrence strongly correlated with the time to metastasis (R2 0.85, p < 0.001). GRI was a good discriminator of metastasis in patients with tumors larger than 5 cm and of malignancy grade IV. Our study suggests that clinical characteristics (e.g., GRI) of local recurrence rather than presence, per se, are important in predicting tumor behavior.

Prognosis following locally recurrent soft-tissue sarcoma. A staging system based on primary and recurrent tumour characteristics

We have shown that the clinical growth rate of local recurrence from soft-tissue sarcoma could be expressed as a growth-rate index (GRI) which was predictive for metastasis, and which was able to identify 2 equal populations of good (80% 2-year MFS) and poor survivors (33%). We now report the associations between characteristics of the primary and GRI, and combine primary and locally recurrent tumour characteristics in a staging system. We studied 460 adult patients with soft-tissue sarcomas of the extremities and trunk wall who were diagnosed and treated between 1964 and 1990, of whom 134 developed local recurrences and 151 metastases. The association of primary tumour size, histologic malignancy grade, depth, spontaneous necrosis, intratumoral vascular invasion and S-phase fraction with local recurrence, GRI and metastasis were examined. High GRI was associated with primary tumours that were larger, deeper, more malignant, underwent spontaneous tumour necrosis, demonstrated intravascular invasion and had a higher S-phase fraction. The same factors were also strongly associated with the incidence of metastasis. A multivariate analysis found GRI and primary tumour necrosis to be the strongest and most significant prognostic factors. GRI and tumour necrosis were combined in a staging system that identified groups with good survival (79 to 94% 2-year MFS), intermediate survival (61% 2-year MFS) and exceptionally poor survival (6% 2-year MFS). These findings validate our earlier assertion that high GRI reflects highly malignant tumours. A staging system composed of primary tumour necrosis and GRI can identify patients who may be suitable candidates for trials of adjuvant chemotherapy.

[Reconstruction with free vascularized or island flaps of soft tissue loss in the upper limb after tumor resection. 16 cases]

We have reviewed 16 cases of soft tissue sarcomas of the upper limb treated with wide excision of the tumour and immediate soft tissue reconstruction by means of a microvascular flap. 9 patients were males, 7 females; age ranged from 12 to 74 years. All the patients had been referred to us after previous failed or inadequate excisions. All the tumours were high-grade malignancies in an extracompartmental location (stade IIB according to Enneking). Histopathologic diagnosis was: synovial-sarcoma in 11 cases; fibrosarcoma in 2 cases; malignant fibrous histiocytoma in 1 case, soft tissue osteosarcoma in 1 case, epitheloid sarcoma in 1 case. The site of the tumour was the hand in 2 cases, the wrist in 6 cases, the forearm in 5 cases and the elbow in 3 cases. The free flaps used for soft tissue reconstructions were the latissimus dorsi in 6 cases, the dorsalis pedis in 2 cases, the lateral arm flap in 2 cases, the serratus in 1 case, the gracilis in 1 case. The island flaps were the radial forearm flap in 1 case, the posterior interosseous flap in 1 case, the cubital flap in 1 case. 14 cases required immediate associated reconstructive procedures such as tendon transfers or grafts (5 cases), vascularized or non vascularized bone grafts (4 cases), articular allografts (1 case), ligament reconstruction (1 case), nerve grafts (2 cases). Brachytherapy was associated to microsurgical reconstruction in the last 6 cases of this group. The catheters were charged with the radioisotope 5 days after surgery. No complications were observed.(ABSTRACT TRUNCATED AT 250 WORDS)

DNA content as a predictor of clinical outcome in soft tissue sarcoma patients

The prognostic relevance of cellular DNA content has been shown for a variety of human malignancies. However, only a few studies concerning soft tissue sarcomas have been published. Biopsies of 81 patients with soft tissue sarcomas, referred for primary or secondary surgery, were analysed by flow cytometry to determine cellular DNA content of tumours. Most patients (60/81) already had one or more local recurrences at the time of first presentation at Essen University. The median age of the patients was 45 years (range 14-79). 44 (54%) patients had euploid and 37 (46%) had aneuploid tumours. Age, sex, and tumour localisation (trunk versus extremity) were equally distributed between euploid and aneuploid sarcoma patients. The median follow-up was 69 months (range 9-312). The median survival time for euploid and aneuploid tumours was 84 and 30 months, respectively (P < 0.0005). In the univariate analysis, ploidy, S-phase percentage, localisation and tumour grading were significant predictors of survival, whereas in the multivariate analysis, only DNA content and tumour localisation were independent prognostic variables for survival.

Soft tissue sarcoma: the enigma of local recurrence

Local recurrence following the treatment of soft tissue sarcoma has been long recognized as a grave prognostic sign. Nevertheless, many investigators have recently suggested that local recurrence following limited surgery ("local persistence") may be a manifestation of a tumor's size and metastatic potential and not a cause of tumor cell dissemination. The author reviewed the experience of several investigators with local persistence. This event was not found to be a threat to survival. The author offers an explanation for this unexpected finding. Soft tissue tumors vary widely in their metastatic potential, and patients also may vary widely in their ability to resist the distant implantation of circulating tumor cells. Patients with a low level of host resistance may be more susceptible to both distant metastases and local persistence, and vice versa. Weaker patients succumb to their initial tumor. Patients who survive the circulating tumor cells from their primary tumor may be immunologically prepared to survive the local persistence of a similar volume of tumor without developing distant disease.

Histopathological grade and response to chemotherapy in advanced soft tissue sarcomas

In a retrospective analysis, we evaluated the possible significance of histopathological grade with regard to response to chemotherapy in advanced soft tissue sarcomas. In three EORTC protocols, the same dose-schedule was used for patients randomised to treatment with doxorubicin as a single agent (75 mg/m2 every third week). The submitted pathological slides from 94 of these patients were reviewed and graded. The following parameters were subjectively graded (+/++/+ + +): nuclear pleomorphism, necrosis, cellularity and vascularity. Mitoses were counted in 20 high-power fields, and a final grade assigned as I, II, IIIA or IIIB. The results were tested both with regard to response (complete response + partial response vs. no change + progressive disease) and survival. However, no statistically significant correlations or trends could be demonstrated. Thus, tumour grade, although a prognostic factor by itself, does not seem to be able to predict response to chemotherapy in the advanced stage.

Surgery for soft tissue sarcoma in the extremities. A multivariate analysis of the 6-26-year prognosis in 137 patients

In 137 patients with soft tissue sarcomas in the extremities, the influence of patient and tumor characteristics and surgical procedures on prognosis was studied using a multivariate statistical analysis. The minimum follow-up time was 6 years, and no patient was lost to follow-up. Eighty-nine patients were referred with the tumor intact (primary series), while 48 were referred after biopsy or with local recurrence after previous surgery (secondary series). The frequency of amputation was 15 percent in the primary series and 48 percent in the secondary series. A local, function-preserving operation with a wide margin was performed in 37 patients without biopsy (clinical diagnosis alone). Local control of the disease was obtained in all but one of these patients without any adjunctive treatment. Independent, unfavorable factors concerning local recurrence were advancing age, open biopsy, and marginal surgery. Independent, unfavorable factors concerning survival were advancing age, increasing histologic malignancy grade, and ablative surgery. A tumor-related death was observed in 0, 29, 47, and 67 percent of the patients with tumors of malignancy grades I, II, III, and IV, respectively.

Prognostication including DNA analysis in osteosarcoma

In a retrospective study of 83 osteosarcoma patients treated by surgery and adjuvant interferon from 1971 to 1986, the clinical course was related to different clinicopathologic features and tumor DNA content. DNA analysis was feasible in 60 cases. Four tumors were diploid and 56 hyperploid. The 7-year survival rate, estimated by life-table analysis, was 0.44 for the whole series. Multivariate analysis disclosed that male sex, proximal tumor location, and histologic Grade IV were independent risk factors--all approximately of equal strength. DNA analysis did not provide prognostic information, except for tumors with extreme abnormality of the DNA content, which was associated with a very poor prognosis. A prognostication model was created, based on the number of risk factors present. The 7-year survival rate for patients with none, one, two, or three risk factors was 0.80, 0.59, 0.42, and 0.13, respectively. The estimated 7-year rate of local recurrence was 0.29: 0.07 after ablative surgery and 0.54 after local surgery. Among patients who were free of metastasis 1 year after diagnosis, local recurrence reduced the 7-year survival rate from 0.86 to 0.48. In high-grade osteosarcoma, conventional clinicopathologic features and local tumor control remain the most important prognostic factors.