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Chmiel P, Rutkowski P, Spałek M, Szumera-Ciećkiewicz A, Czarnecka AM. What is the Optimal Treatment Strategy after Sarcoma R2 Surgery? Curr Treat Options Oncol 2024; 25:798-812. [PMID: 38809411 PMCID: PMC11222198 DOI: 10.1007/s11864-024-01218-z] [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: 05/14/2024] [Indexed: 05/30/2024]
Abstract
OPINION STATEMENT Soft tissue sarcomas (STS) are rare tumours of mesenchymal origin, most commonly occurring in the extremity but also in the retroperitoneum. The curative treatment for STS is radical surgery with wide margins, in some cases in combination with perioperative radiotherapy and chemotherapy. Nonradical resection (R2) of STS has been an emerging issue in recent decades, as optimal subsequent management remains debatable. Similarly, there is still no consensus on optimal surgical margins. Combining multiple treatment modalities in adjuvant therapy can achieve local and distant control in patients following surgery with positive margins. Patients who have undergone nonradical resection therefore require additional surgical interventions, and adjuvant radiotherapy resulting in a better prognosis but a higher number of complications. Following non-radical treatment, patients with limb and trunk wall sarcomas and retroperitoneal sarcomas should also undergo increased oncological surveillance. Given the potential issues that may emerge in such clinical situations, it is crucial to up-date the current guidelines to enhance the long-term prognosis of these patients.
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Affiliation(s)
- Paulina Chmiel
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781, Warsaw, Poland
- Faculty of Medicine, Medical University of Warsaw, 02-091, Warsaw, Poland
| | - Piotr Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781, Warsaw, Poland
| | - Mateusz Spałek
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781, Warsaw, Poland
- Department of Radiotherapy I, Maria Sklodowska-Curie National Research Institute of Oncology, 02-718, Warsaw, Poland
| | - Anna Szumera-Ciećkiewicz
- Department of Pathology, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781, Warsaw, Poland
- Biobank Maria Sklodowska-Curie National Research Institute of Oncology, 02-781, Warsaw, Poland
| | - Anna M Czarnecka
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781, Warsaw, Poland.
- Department of Experimental Pharmacology, Mossakowski Medical Research Institute Polish Academy of Sciences, 02-106, Warsaw, Poland.
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Lawless A, Zhou DDX, McDonough J, Lo H, Mar J, Lazarakis S, Ward I, Connor J, Thompson SR, Coker D, Johnston A, Gyorki DE, Hong AM. The role of radiation therapy in the management of primary retroperitoneal sarcoma: A systematic review and clinical practice guidelines from the Australia and New Zealand Sarcoma Association. Cancer Treat Rev 2023; 120:102620. [PMID: 37657126 DOI: 10.1016/j.ctrv.2023.102620] [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: 07/29/2023] [Revised: 08/25/2023] [Accepted: 08/28/2023] [Indexed: 09/03/2023]
Abstract
While surgery is the mainstay of treatment for localised retroperitoneal sarcoma, the use of radiotherapy (RT) remains controversial. This systematic review aimed to evaluate the role of RT for retroperitoneal sarcoma. A systematic review using the population, intervention, comparison, and outcome model from 1990 to 2022 identified 66 studies (a mixture of preoperative and postoperative RT); one randomised controlled trial (RCT) with two publications, 18 registry studies, and 46 retrospective studies. In the RCT of preoperative RT, there was no difference in local/abdominal recurrence. The pooled analysis of this RCT and a retrospective study showed a significant abdominal recurrence free survival benefit with preoperative RT in low grade liposarcoma. The RCT and the majority of retrospective series found RT did not improve recurrence free survival (11 of 16 no difference in combined local and distant RFS, 11 of 13 no difference in distant metastasis free survival), disease specific survival (9 of 12 studies) or overall survival (33 of 49 studies). The majority of studies found no association between RT and perioperative morbidity. In summary, preoperative RT may improve local control for low grade (well-differentiated or grades 1-2 dedifferentiated) liposarcoma, but not other histological subtypes. There is no strong evidence that perioperative RT provides an overall survival benefit. Patients with low grade retroperitoneal liposarcoma can be considered for preoperative RT to improve abdominal recurrence free survival. The rationale and level of evidence in this scenario should be carefully discussed by the multidisciplinary team with patients. RT should not be routinely recommended for other histological subtypes.
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Affiliation(s)
- Anna Lawless
- Faculty of Medicine and Health, Sydney Medical School, The University of Sydney, Australia; Department of Radiation Oncology, Chris O'Brien Lifehouse, Camperdown, NSW 2050, Australia
| | - Deborah Di-Xin Zhou
- NHMRC Clinical Trials Centre, The University of Sydney, NSW 2006, Australia; Department of Medical Oncology, Chris O'Brien Lifehouse, Camperdown, NSW 2050, Australia
| | - Joshua McDonough
- Mental Health and Suicide Prevention Research and Education Group, Clinical and Health Sciences, University of South Australia, Adelaide, SA 5000, Australia
| | - Helen Lo
- Department of Radiation Oncology, Chris O'Brien Lifehouse, Camperdown, NSW 2050, Australia
| | - Jasmine Mar
- Australia and New Zealand Sarcoma Association, Parkville, Victoria 3010, Australia
| | - Smaro Lazarakis
- Health Sciences Library, Royal Melbourne Hospital, Parkville, Victoria 3010, Australia
| | - Iain Ward
- Christchurch Hospital, Christchurch 8011, New Zealand
| | - Joanna Connor
- Te Pūriri o Te Ora, Auckland City Hospital, 2 Park Road, Grafton, Auckland 1023, New Zealand
| | - Stephen R Thompson
- Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, Randwick, NSW 2031, Australia; School of Clinical Medicine, UNSW Sydney, Randwick Clinical Campus, Australia
| | - David Coker
- Faculty of Medicine and Health, Sydney Medical School, The University of Sydney, Australia; Department of Melanoma and Surgical Oncology, and Upper Gastrointestinal Surgery, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia
| | - Andrew Johnston
- North Island Sarcoma Service, Auckland City Hospital, Auckland 1023, New Zealand
| | - David E Gyorki
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC 3000, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC 3000, Australia
| | - Angela M Hong
- Faculty of Medicine and Health, Sydney Medical School, The University of Sydney, Australia; Department of Radiation Oncology, Chris O'Brien Lifehouse, Camperdown, NSW 2050, Australia.
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Farooqi AS, Guadagnolo BA, Mitra D, Bishop AJ. Radiation Therapy for Retroperitoneal Sarcomas: A Strass-Ful Situation. Curr Oncol 2023; 30:598-609. [PMID: 36661696 PMCID: PMC9857550 DOI: 10.3390/curroncol30010047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/23/2022] [Accepted: 12/29/2022] [Indexed: 01/04/2023] Open
Abstract
Locoregional recurrence (LRR) is the predominant pattern of relapse and often the cause of death in patients with retroperitoneal sarcomas (RPS). As a result, reducing LRR is a critical objective for RPS patients. However, unlike soft tissue sarcomas (STS) of the superficial trunk and extremity where the benefits of radiation therapy (RT) are well-established, the role of RT in the retroperitoneum remains controversial. Historically, preoperative or postoperative RT, either alone or in combination with intraoperative radiation (IORT), was commonly justified for RPS based on extrapolation from the superficial trunk and extremity STS literature. However, long-awaited results were recently published from the European Organization for Research and Treatment of Cancer (EORTC) STRASS study of preoperative radiotherapy plus surgery versus surgery alone for patients with RPS; there was no statistical difference in the primary endpoint of abdominal recurrence-free survival. However, several subset analyses and study limitations complicate the interpretation of the results. This review explores and contextualizes the body of evidence regarding RT's role in managing RPS.
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Affiliation(s)
- Ahsan S. Farooqi
- Unit 97, Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA
| | - B. Ashleigh Guadagnolo
- Unit 97, Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA
| | - Devarati Mitra
- Unit 97, Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA
| | - Andrew J. Bishop
- Unit 97, Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA
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Patkar S, Kattepur AK, Khanna N, Bajpai J. Retroperitoneal Sarcomas: a Current Review on Management. Indian J Surg Oncol 2022; 13:542-558. [PMID: 36187536 PMCID: PMC9515254 DOI: 10.1007/s13193-022-01520-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 02/08/2022] [Indexed: 11/25/2022] Open
Abstract
Retroperitoneal sarcomas are heterogeneous tumours with variable disease biology and outcomes. The prognosis is primarily related to tumour histology and grade as well as the ability to achieve margin negative resection. Surgery involves compartment or contiguous organ resection to achieve the above goal. Careful utilization of neoadjuvant and adjuvant strategies like radiotherapy and/or chemotherapy can lead to improvement in margin status, thereby contributing to better local control and possibly reducing systemic dissemination. Use of targeted therapies has paved newer pathways of treatment integration centred on molecular and genetic targets. The aim of this review is to update the reader on all aspects of retroperitoneal sarcoma management including emphasis on pertinent and landmark trials in this regard.
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Affiliation(s)
- Shraddha Patkar
- Department of Gastrointestinal Oncology, Hepatobiliary Services, Tata Memorial Centre and HBNI, Dr Ernst Borges Marg, Parel, Mumbai 400012 India
| | - Abhay K. Kattepur
- Department of Surgical Oncology, Sri Devaraj Urs Academy of Higher Education and Research, Tamaka, Kolar, Karnataka India
| | - Nehal Khanna
- Department of Radiation Oncology, Tata Memorial Centre and HBNI, Dr Ernst Borges Marg, Parel, Mumbai India
| | - Jyoti Bajpai
- Department of Medical Oncology, Tata Memorial Centre and HBNI, Dr Ernst Borges Marg, Parel, Mumbai India
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Montero A, Nuñez M, Hernando O, Vicente E, Ciervide R, Zucca D, Sanchez E, López M, Quijano Y, Garcia-Aranda M, Alonso R, Valero J, Chen X, Alvarez B, Fernandez-Leton P, Rubio C. Retroperitoneal soft-tissue sarcomas: Radiotherapy experience from a tertiary cancer center and review of current evidence. Rep Pract Oncol Radiother 2020; 25:643-655. [PMID: 32565743 PMCID: PMC7292898 DOI: 10.1016/j.rpor.2020.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 04/14/2020] [Accepted: 05/25/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Surgery remains to be the main therapeutic approach for retroperitoneal sarcomas (RPS) although evidence supports that complementary radiotherapy increases local-control and survival. We present a multidisciplinary management and experience of a tertiary cancer center in the treatment of RPS and analyze current evidence of radiotherapy efficacy. PATIENTS AND METHODS We retrospectively reviewed 19 patients with primary or relapsed RPS treated between November 2009 and October 2018. Multidisciplinary approach comprised complete resection in 15 patients (79%) achieving resection R0 in 11 patients (58%), R1 in 4 patients (21%) and R2 in 2 patients (10%). Seven patients (37%) underwent a preoperative radiation (PRORT), 10 patients (53%), post-operative radiation (PORT) and 2 patients (10%), received radiotherapy exclusively. Ten patients (53%) received adjuvant chemotherapy. RESULTS With a median follow-up of 24 months (2-114 months), actuarial rates of loco-regional relapse free survival (LRFS) at 1, 2 and 3 years were 77%, 77% and 67%, respectively. Actuarial rates of distant-metastases-free survival (DMFS), disease-free survival (DFS) and overall survival (OS) at 1, 2 and 3 years were 100%, 100% and 80% for DMFS; 94%, 77% and 67% for DFS and 100%, 91% and 91% for OS, respectively. Only surgical margins (negative vs. positive) showed significance for 3y-LRFS: 100% vs. 34.3%, p = 0.018. Treatment tolerance was acceptable with no acute or late toxicity higher than grade 2. CONCLUSIONS Complementary radiotherapy appears to be useful and well tolerated for the multidisciplinary management of RPS. Presence of positive surgical margins seems to be the most relevant prognostic factor through the follow-up.
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Affiliation(s)
- A. Montero
- Department of Radiation Oncology, University Hospital HM Sanchinarro, Madrid, Spain
| | - M. Nuñez
- Department of Radiation Oncology, University Hospital HM Sanchinarro, Madrid, Spain
| | - O. Hernando
- Department of Radiation Oncology, University Hospital HM Sanchinarro, Madrid, Spain
| | - E. Vicente
- Department of General Surgery, University Hospital HM Sanchinarro, Madrid, Spain
| | - R. Ciervide
- Department of Radiation Oncology, University Hospital HM Sanchinarro, Madrid, Spain
| | - D. Zucca
- Department of Medical Physics, University Hospital HM Sanchinarro, Madrid, Spain
| | - E. Sanchez
- Department of Radiation Oncology, University Hospital HM Sanchinarro, Madrid, Spain
| | - M. López
- Department of Radiation Oncology, University Hospital HM Sanchinarro, Madrid, Spain
| | - Y. Quijano
- Department of General Surgery, University Hospital HM Sanchinarro, Madrid, Spain
| | - M. Garcia-Aranda
- Department of Radiation Oncology, University Hospital HM Sanchinarro, Madrid, Spain
| | - R. Alonso
- Department of Radiation Oncology, University Hospital HM Sanchinarro, Madrid, Spain
| | - J. Valero
- Department of Radiation Oncology, University Hospital HM Sanchinarro, Madrid, Spain
| | - X. Chen
- Department of Radiation Oncology, University Hospital HM Sanchinarro, Madrid, Spain
| | - B. Alvarez
- Department of Radiation Oncology, University Hospital HM Sanchinarro, Madrid, Spain
| | - P. Fernandez-Leton
- Department of Medical Physics, University Hospital HM Sanchinarro, Madrid, Spain
| | - C. Rubio
- Department of Radiation Oncology, University Hospital HM Sanchinarro, Madrid, Spain
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Intraoperative radiotherapy with low energy x-rays for primary and recurrent soft-tissue sarcomas. Radiat Oncol 2020; 15:110. [PMID: 32410696 PMCID: PMC7227262 DOI: 10.1186/s13014-020-01559-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 05/03/2020] [Indexed: 02/08/2023] Open
Abstract
Background Soft tissue sarcomas (STS) treatment remains a therapeutic challenge. Intraoperative radiotherapy (IORT) resembles a safe and efficient for STS treatment. The first data on electronic-IORT (eIORT) using low-energy photons is herein presented. Methods Thirty-one patients with newly and recurrent STS were retrospectively assessed. EIORT was applied with low-energy photons during surgery. The dose was either prescribed to the applicator surface (spherical applicators) or 5 mm depth (flat applicators). Overall progression-free survival (O-PFS), local progression-free survival (L-PFS), overall survival (OS) and adverse events were evaluated. Results Median follow-up was 4.88 (1.0–8.95) years. Twenty-five patients (80.6%) had recurrent STS with prior treatment. The resection status was R1 in 25.8% and R2 in 6.5%. The distribution was 51.7% for extremities, 35.5% for abdomen and pelvis, 9.7% for thorax and 3.2% for head and neck tumors. The median O-PFS was 11.0 months, with 42.6% 5-year estimated O-PFS. The only local recurrence in the primary setting occurred after 22 months. Median L-PFS in recurrent STS was 12.5 months, with 65.5% 5-year estimated L-PFS. The 5-year OS estimated rate was 94.7% (3 events after 7 years). No G3 toxicity related to eIORT was observed. Two patients exhibited G2 acute neuropathic pain. Late neuropathic pain was seen in 6 patients being 3 graded as G1 and 3 as G2. No wound-related toxicity was found. Conclusion Electronic IORT with low-energy photons is a safe treatment option for STS, yielding similar outcomes as historical series reporting IORT with electrons or HDR brachytherapy.
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Perioperative radiotherapy versus surgery alone for retroperitoneal sarcomas: a systematic review and meta-analysis. Radiol Oncol 2020; 54:14-21. [PMID: 32114526 PMCID: PMC7087419 DOI: 10.2478/raon-2020-0012] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 01/31/2020] [Indexed: 12/31/2022] Open
Abstract
Background There is no clear evidence on whether radiotherapy (RT) improves treatment result in patients with retroperitoneal sarcomas (RPS). Methods A systematic literature search was performed using PubMed, Scopus and CENTRAL databases. Data were retrieved from published comparatives studies in patients with RPS undergoing surgery alone or RT plus surgery. The primary endpoints were the 5-year OS and the median OS. The secondary endpoints were the recurrence-free survival (RFS) and the R0-resection rate. Continuous outcomes were calculated by means of weighted mean difference (WMD). Results Ten out of 374 articles were analyzed. The median OS and the 5-year survival were significantly increased in patients treated with RT and surgery, compared to patients treated with surgery alone (p < 0.00001, p < 0.001). Median RFS was significantly increased in patients treated with either preoperative (p < 0.001) or postoperative (p = 0.001) RT compared to patients that underwent surgery alone. Finally, median R0-resection rate was similar between the two groups (p = 0.56). Conclusion RT along with radical surgery could be the standard of care in at least a subgroup of patients with RPS.
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