Postoperative nomogram for 12-year sarcoma-specific death

Multi-institutional validation of a new renal cancer-specific survival nomogram

PURPOSE

We tested the hypothesis that the prediction of renal cancer-specific survival can be improved if traditional predictor variables are used within a prognostic nomogram.

PATIENTS AND METHODS

Two cohorts of patients treated with either radical or partial nephrectomy for renal cortical tumors were used: one (n = 2,530) for nomogram development and for internal validation (200 bootstrap resamples), and a second (n = 1,422) for external validation. Cox proportional hazards regression analyses modeled the 2002 TNM stages, tumor size, Fuhrman grade, histologic subtype, local symptoms, age, and sex. The accuracy of the nomogram was compared with an established staging scheme.

RESULTS

Cancer-specific mortality was observed in 598 (23.6%) patients, whereas 200 (7.9%) died as a result of other causes. Follow-up ranged from 0.1 to 286 months (median, 38.8 months). External validation of the nomogram at 1, 2, 5, and 10 years after nephrectomy revealed predictive accuracy of 87.8%, 89.2%, 86.7%, and 88.8%, respectively. Conversely, the alternative staging scheme predicting at 2 and 5 years was less accurate, as evidenced by 86.1% (P = .006) and 83.9% (P = .02) estimates.

CONCLUSION

The new nomogram is more contemporary, provides predictions that reach further in time and, compared with its alternative, which predicts at 2 and 5 years, generates 3.1% and 2.8% more accurate predictions, respectively.

Management of primary liver sarcomas

BACKGROUND

Primary hepatic sarcoma is a rare entity. The objectives of the study were to define treatment and long-term outcome and to identify prognostic factors.

METHODS

Between January 1981 and December 2004, 30 patients with primary sarcoma of the liver and 5 patients with primary carcinosarcoma of the liver were treated. Patient demographics, tumor characteristics, treatment, and actuarial survival were analyzed.

RESULTS

Of the 30 patients with primary hepatic sarcoma (10 epithelioid hemangioendothelioma, 5 embryonal sarcoma, 5 angiosarcoma, 3 solitary fibrous tumor, and 7 other types), 11 underwent R0-resection and had a 5-year disease-specific survival of 64%. Of these 11 patients, 4 had low-grade sarcoma and have not developed tumor recurrence. In the group of 7 patients with high-grade sarcomas who underwent R0-resection, both patients with angiosarcoma died within 11 months, whereas the 5 patients with embryonal sarcoma had a 5-year disease-free and disease-specific survival of 80%. Six of the 10 patients with an epithelioid hemangioendothelioma were managed without surgery, as they had diffuse, slowly progressing, or stable lesions; these patients had a 5-year disease-specific survival of 67%. Of the remaining 13 patients in whom R0-resection was not performed, there were no 3-year survivors. The prognosis for patients with primary carcinosarcoma of the liver was poor, with all but 1 patient dying within a year and no 3-year survivors.

CONCLUSIONS

The outcome of patients with primary hepatic sarcoma depends primarily on tumor histology and the ability to achieve complete tumor resection. Improvements in outcome will require the development of more effective systemic therapies.

Extremity soft tissue sarcoma: adding to the prognostic meaning of local failure

BACKGROUND

We explored the prognostic meaning of local relapse and surgical margins in adult soft tissue sarcoma of the extremities.

METHODS

Out of a series of 1017 patients with extremity soft tissue sarcoma treated over 20 years, we picked a group of 238 patients operated on at our institution for their first local relapse: 88 after their primary operation performed at the same center and 150 elsewhere. At operation for relapse, margins were microscopically negative in 77% and 75% of patients, respectively. Median follow-up was 107 months.

RESULTS

The 10-year mortality rate was 22% in the absence of local relapse, whereas in locally relapsing patients it was 54% and 43%, respectively, for patients first operated on at our institute and for those who were not. The hazard ratio of positive versus negative surgical margins was 1.7 for cause-specific death and 2.1 for distant metastases in patients first operated on at our institute, as opposed to 1.2 and 1.3 for the others.

CONCLUSIONS

Local relapse was an unfavorable prognostic factor. In the face of a consistent surgical policy for local relapse in a single-institution setting, patients relapsing after the first operation performed at our institution received rescue treatment less frequently than those previously operated on outside a referral center. This is likely due to an inherently higher tumor aggressiveness. In the presence of such a higher aggressiveness, the adequacy of surgical margins at operation for first relapse seemed more critical prognostically. This may have clinical and speculative implications.

Adjuvant therapy for extremity sarcomas

Extremity soft tissue sarcomas (STS) represent a rare, heterogeneous malignancy. Surgery is the primary treatment for patients with no evidence of metastatic disease, and for small low-grade superficial tumors in which adequate margins can be obtained, it may be the only therapy indicated. For large, deep tumors or tumors that are close to important neurovascular structures or bone, the addition of radiotherapy to resection has improved local control and increased limb salvage without affecting overall survival. Adjuvant chemotherapy has been an issue of considerable debate. Because 50% of patients with high-risk tumors will develop metastatic disease, effective systemic treatment with chemotherapy is needed. Unfortunately, studies have shown minimal improvement in overall survival when chemotherapy is added to the local treatment of high-risk extremity STS. More recently, a few trials of neoadjuvant chemotherapy consisting of mesna, doxorubicin, ifosfamide, and dacarbazine and high-dose doxorubicin and ifosfamide have shown some early promising results, but at the price of increased toxicity. Targeted therapy has shown some of its best results with gastrointestinal stromal tumors, but so far there has been little success in treating extremity STS. At this time, high-dose adjuvant or neoadjuvant chemotherapy should be given in the setting of a clinical trial to patients with high-risk tumors who can tolerate a potentially toxic chemotherapeutic regimen. The goal of these trials should be to assess new combination therapies, possibly including targeted therapies, for the management of large high-grade, high-risk soft tissue sarcomas.

Nomograms Provide Improved Accuracy for Predicting Survival after Radical Cystectomy

AIMS

To develop multivariate nomograms that determine the probabilities of all-cause and bladder cancer-specific survival after radical cystectomy and to compare their predictive accuracy to that of American Joint Committee on Cancer (AJCC) staging.

METHODS

We used Cox proportional hazards regression analyses to model variables of 731 consecutive patients treated with radical cystectomy and bilateral pelvic lymphadenectomy for bladder transitional cell carcinoma. Variables included age of patient, gender, pathologic stage (pT), pathologic grade, carcinoma in situ, lymphovascular invasion (LVI), lymph node status (pN), neoadjuvant chemotherapy (NACH), adjuvant chemotherapy (ACH), and adjuvant external beam radiotherapy (AXRT). Two hundred bootstrap resamples were used to reduce overfit bias and for internal validation.

RESULTS

During a mean follow-up of 36.4 months, 290 of 731 (39.7%) patients died; 196 of 290 patients (67.6%) died of bladder cancer. Actuarial all-cause survival estimates were 56.3% [95% confidence interval (95% CI), 51.8-60.6%] and 42.9% (95% CI, 37.3-48.4%) at 5 and 8 years after cystectomy, respectively. Actuarial cancer-specific survival estimates were 67.3% (62.9-71.3%) and 58.7% (52.7-64.2%) at 5 and 8 years, respectively. The accuracy of a nomogram for prediction of all-cause survival (0.732) that included patient age, pT, pN, LVI, NACH, ACH, and AXRT was significantly superior (P=0.001) to that of AJCC staging-based risk grouping (0.615). Similarly, the accuracy of a nomogram for prediction of cancer-specific survival that included pT, pN, LVI, NACH, and AXRT (0.791) was significantly superior (P=0.001) to that of AJCC staging-based risk grouping (0.663).

CONCLUSIONS

Multivariate nomograms provide a more accurate and relevant individualized prediction of survival after cystectomy compared with conventional prediction models, thereby allowing for improved patient counseling and treatment selection.

Soft-tissue sarcomas and reconstruction options: twenty-two years of experience

Soft tissue sarcomas (STS) are particularly rare malignancies that constitute less than 1% of all malignancies. In recent years, prognostic clinical factors have been defined that help to stratify patients regarding their risk for local and distant recurrence and death from disease. Tumor grade, size, depth, completeness of resection, and presentation status are among the independent prognostic factors. At present, the treatment of these tumors constitutes a wide or marginal excision, adequate primary reconstruction, and radiotherapy. Surgery has generally been recommended as the primary method of treatment for achieving local control. Modern reconstructive surgery, especially musculocutaneous, either pedicle or free flaps, has made more extensive resections possible, while providing acceptable cosmetic and functional results. This study deals with our experience in the treatment of resectable STS with selective combination of treatment modalities.

Clinicopathologic prognostic factors in myxoid liposarcoma: a retrospective study of 49 patients with long-term follow-up

BACKGROUND

The main goal of this retrospective study was to investigate prognostic factors influencing the survival of myxoid liposarcoma (MLS) with emphasis on the role of transitional areas (TLS) and round cell morphology (RCLS).

METHODS

From 1977 to 2004, 49 patients-28 men (57%) and 21 women (43%) with a median age of 44 years (range, 7-83 years)-were diagnosed with an MLS. In 42 patients, the histology could be reviewed, and tumors were classified as MLS, TLS, or RCLS. Clinicopathologic factors were analyzed for influence on survival by univariate and multivariate methods.

RESULTS

The median follow-up of 49 patients was 101 months (range, 4-550 months). Of the 42 patients for whom histology was reviewed, 16 tumors were classified as MLS (38%), 19 as TLS (45%), and 7 as RCLS (17%). Sixteen patients (33%) developed a local recurrence after a median follow-up of 21 months (range, 2-108 months). Thirteen patients (27%) developed metastases. The median interval between diagnosis and metastasis was 41 months (range, 0-222 months). Median survival after metastasis was 18 months (range, 1-179 months). The 5- and 10-year disease-specific survival rates were 85% and 72%, whereas the 5- and 10-year overall survival rates were 83% and 68%, respectively. Age at presentation (P = .02), tumor grade (P = .01), and tumor size (P = .005) were significant prognostic factors associated with survival. Tumor grade was the only independent prognostic variable that remained significant with multivariate analysis. A TLS presentation had no negative influence on patient survival.

CONCLUSIONS

Age at presentation, tumor grade, and tumor size had a negative influence on survival by univariate analysis, whereas tumor grade was the only independent prognostic factor by multivariate analysis. TLS was not associated with poor outcome.

Subtype specific prognostic nomogram for patients with primary liposarcoma of the retroperitoneum, extremity, or trunk

OBJECTIVE

To determine the prognostic significance of histologic subtype in a large series of patients with primary liposarcoma (LS) and to construct a LS-specific postoperative nomogram for disease-specific survival (DSS).

SUMMARY BACKGROUND DATA

Nomograms, used to define and predict outcome following operative intervention, may contain variables not conventionally used in standard staging systems. A 12-year DSS postoperative nomogram for all sarcomas has already been established.

METHODS

From a single-institution prospective sarcoma database, patients with primary extremity, truncal, or retroperitoneal LS treated between 1982 and 2005 were identified. Histology was reviewed by a sarcoma pathologist and divided into 5 subtypes. A nomogram predictive of 5- and 12-year DSS was developed.

RESULTS

Of 801 patients with primary LS resected with curative intent, 369 (46%) presented with well-differentiated, 143 (18%) dedifferentiated, 144 (18%) myxoid, 81 (10%) round cell, and 64 (8%) pleomorphic histology. The median tumor burden was 15 cm (range, 1-139 cm). At last follow-up, 560 patients were alive with a median follow-up time of 45 months (range, 1-264 months) and 51 months for surviving patients. The 5- and 12-year DSS rates were 83% (95% confidence interval [CI], 80%-86%) and 72% (95% CI, 67%-77%), respectively. The nomogram was drawn on the basis of a Cox regression model. The independent predictors of DSS were age, presentation status, histologic variant, primary site, tumor burden, and gross margin status. The nomogram was internally validated using bootstrapping and shown to have excellent calibration. The concordance index was 0.827 compared with 0.776 for the general sarcoma postoperative nomogram for 12-year DSS.

CONCLUSION

The LS-specific nomogram based on histologic subtype provides more accurate survival predictions for patients with primary LS than the previously established generic sarcoma nomogram. DSS nomograms aid in more accurate counseling of patients, identification of patients appropriate for adjuvant therapy, and stratification of patients for clinical trials and molecular analysis.

The role of hyperthermia in combined treatment in the management of soft tissue sarcoma

For high-risk soft tissue sarcomas (HR-STS) of adults, new treatment strategies are needed to improve outcome with regard to local control and overall survival. Systemic chemotherapy has been integrated either after (adjuvant) or before (neoadjuvant) optimal local treatment by surgery and radiotherapy in HR-STS. This short overview summarizes the results of the combination with regional hyperthermia as a new treatment strategy to open a new therapeutic window.

Utility of positron emission tomography in sarcomas

PURPOSE OF REVIEW

Positron emission tomography using [18F]fluoro-2-deoxy-D-glucose has been studied as a tool to help predict the malignant potential of sarcomas, prognosis of patients and response to chemotherapy, and to detect disease recurrence. Recent developments in the use of [18F]fluoro-2-deoxy-D-glucose positron emission tomography in the clinical management of patients with suspected or diagnosed sarcomas are presented.

RECENT FINDINGS

[18F]fluoro-2-deoxy-D-glucose positron emission tomography should not be used in lieu of histology to diagnose sarcomas, but may aid in biopsy planning. [18F]fluoro-2-deoxy-D-glucose positron emission tomography should not replace magnetic resonance imaging and computed tomography imaging for staging or surveillance. In soft tissue sarcomas, [18F]fluoro-2-deoxy-D-glucose uptake correlates with histologic grade and risk of tumor recurrence. Reduction in [18F]fluoro-2-deoxy-D-glucose uptake is an early predictor of histologic response of osteosarcoma, Ewing's and soft tissue sarcomas to chemotherapy, and has correlated with clinical outcomes in Ewing's, soft tissue sarcomas and gastrointestinal stromal tumor.

SUMMARY

[18F]fluoro-2-deoxy-D-glucose positron emission tomography will likely play increasingly important prognostic and predictive roles in the management of sarcomas. Available data suggest that positron emission tomography is useful clinically in predicting response to therapy early in the course of treatment for both cytotoxic chemotherapy and kinase inhibitors. Additional study to determine the optimal semiquantitative measure of [18F]fluoro-2-deoxy-D-glucose accumulation in sarcoma and standardization of positron emission tomography methods is needed.

Estimates of stage-specific survival are altered by changes in the 2002 American Joint Committee on Cancer staging system for melanoma

BACKGROUND

The objectives of the current study were to examine how the estimated stage-specific survival is altered in the 2002 American Joint Committee on Cancer (AJCC) melanoma staging system compared with the 1997 AJCC staging system and to contrast the predictive accuracy of the 2 staging systems.

METHODS

There were 5847 consecutive melanoma patients who presented to Memorial Sloan-Kettering Cancer Center from 1996 to 2004 and who were entered prospectively into a data base. These patients were staged according to both the 1997 and 2002 AJCC staging criteria. Overall survival estimates were determined using the Kaplan-Meier method. The overall predictive accuracy of the two staging systems was compared using concordance estimation.

RESULTS

In total, 1035 patients were shifted to a lower stage in the 2002 staging system, whereas only 15 patients were upstaged. The number of patients with Stage I melanoma increased by 697 under the 2002 system (n = 2166 patients) compared with the 1997 system (n = 1463 patients). Because of the changes in 2002, the estimated 5-year overall survival for patients with Stage II melanoma decreased considerably, from 79% (1997) to 64% (2002). With the initiation of subgroups in 2002, it became apparent that patients with Stage III melanoma were very heterogeneous in terms of their survival probabilities (5-yr overall survival ranged from 70% in patients with Stage IIIA disease to 24% in patients with Stage IIIC disease). Furthermore, in the 2002 system, there was substantial prognostic overlap between Stage II and Stage III. Despite the increased complexity of the 2002 system, the 2 staging systems had similar concordance estimates: 58% for the 1997 staging system compared with 58% (ignoring the subgroups) and 59% (with subgroups) for the 2002 system.

CONCLUSIONS

Estimates of stage-specific survival were altered substantially by the changes made in the 2002 AJCC staging system for melanoma, particularly for Stage II. Stage subgroups that were added in the 2002 system resulted in a large diversity of risk within Stage III. This must be taken into account to stratify patients properly for clinical trials. The increased complexity of the 2002 system did not improve its predictive ability over the simpler 1997 system, highlighting the importance of developing individualized risk-prediction models.

Malignant peripheral nerve sheath tumors

BACKGROUND

The authors explored the prognostic factors and clinical outcomes of patients who had malignant peripheral nerve sheath tumors (MPNST) with and without neurofibromatosis type 1 (NF-1).

METHODS

Two hundred five patients with localized MPNST who underwent surgery at the Istituto Nazionale per lo Studio e la Cura dei Tumori (Milan, Italy) over 25 years were reviewed. Forty-six patients had concomitant NF-1 syndrome, and 159 patients did not. Local recurrence, distant metastases, and survival rates were studied.

RESULTS

One hundred thirty patients presented with primary disease, and 75 patients had locally recurrent tumors. The disease-specific mortality rate was 43% at 10 years, with a continuously disease-free survival rate of no greater than 40%. Presentation with either primary or recurrent disease, tumor size, and tumor site (trunk vs. extremity) were the strongest independent predictors of survival. Margin status and radiation therapy also played a role, mostly related to their effect on local outcome. Pathologic grade influenced distant metastases, but only a trend for survival could be observed. No significant independent differences between patients with and without NF-1 were observed.

CONCLUSIONS

To the authors' knowledge, this was among the largest single-institution series to date. The results confirmed that patients with MPNST share similar prognostic factors with patients who have other soft tissue sarcomas and have some of the worst clinical outcomes. The presence of NF-1 syndrome per se did not affect survival, but patients with NF-1 were more likely to have larger tumors. Therefore, such patients should be followed carefully to detect disease as early as possible.

Validation of a postresection pancreatic adenocarcinoma nomogram for disease-specific survival

PURPOSE

Nomograms are statistically based tools that provide the overall probability of a specific outcome. They have shown better individual discrimination than the current TNM staging system in numerous patient tumor models. The pancreatic nomogram combines individual clinicopathologic and operative data to predict disease-specific survival at 1, 2, and 3 years from initial resection. A single US institution database was used to test the validity of the pancreatic adenocarcinoma nomogram established at Memorial Sloan-Kettering Cancer Center.

PATIENTS AND METHODS

The nomogram was created from a prospective pancreatic adenocarcinoma database that included 555 consecutive patients between October 1983 and April 2000. The nomogram was validated by an external patient cohort from a retrospective pancreatic adenocarcinoma database at Massachusetts General Hospital that included 424 consecutive patients between January 1985 and December 2003.

RESULTS

Of the 424 patients, 375 had all variables documented. At last follow-up, 99 patients were alive, with a median follow-up time of 27 months (range, 2 to 151 months). The 1-, 2-, and 3-year disease-specific survival rates were 68% (95% CI, 63% to 72%), 39% (95% CI, 34% to 44%), and 27% (95% CI, 23% to 32%), respectively. The nomogram concordance index was 0.62 compared with 0.59 with the American Joint Committee on Cancer (AJCC) stage (P = .004). This suggests that the nomogram discriminates disease-specific survival better than the AJCC staging system.

CONCLUSION

The pancreatic cancer nomogram provides more accurate survival predictions than the AJCC staging system when applied to an external patient cohort. The nomogram may aid in more accurately counseling patients and in better stratifying patients for clinical trials and molecular tumor analysis.

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.

Primary multidisciplinary management of extremity soft tissue sarcomas

Soft tissue sarcomas (STS) are a rare and heterogeneous group of malignancies that most commonly present as large painless masses deep in the muscular compartments of the extremities. Investigation and treatment of these patients must be undertaken at a tertiary referral unit. Staging studies must include a high-quality magnetic resonance imaging (MRI) scan of the local site and a computed tomography (CT) scan of the chest to investigate for possible metastatic disease. Review of biopsy material must be undertaken by an experienced musculoskeletal pathologist. Currently, histologic diagnosis and grade are assigned to the tumor, but in tumors such as synovial sarcoma and Ewing's family of tumors, molecular evaluation is becoming crucial for diagnostic, prognostic, and therapeutic reasons. Surgical resection of sarcomas with negative surgical margins remains the mainstay of treatment. Surgical treatment alone is indicated for small superficial masses that are not adjacent to bone or neurovascular structures. However, in large deep masses where surgical margins are likely to be close in order to preserve important neurovascular structures and bone, combined treatment using surgical resection and radiation results in acceptable local control rates and reasonable patient function. It is incumbent on the management team to decide on timing of radiotherapy as a practice. This decision is based on several factors but potential complications must be taken into account. In this regard the long-term effects on normal tissues must be considered. Functional outcome has become an essential consideration when recommending treatment. If promising techniques become available to reduce the incidence of wound complications or to decrease the dose of radiation to normal tissue, preoperative radiation should be considered in light of its lower incidence of long-term effects that result in reduction in patient function.

Adult-type soft tissue sarcomas in pediatric-age patients: experience at the Istituto Nazionale Tumori in Milan

PURPOSE

Nonrhabdomyosarcoma soft tissue sarcomas are a heterogeneous group of tumors for which optimal treatment remains controversial. We report on a large group of 182 patients younger than 18 years old treated at a single institution over a 25-year period.

PATIENTS AND METHODS

In this relatively homogeneous subgroup of adult-type histotypes, surgery was the mainstay of treatment; radiotherapy was administered to 73 patients, and chemotherapy was administered to 114 patients (70 received chemotherapy as adjuvant therapy).

RESULTS

Overall survival at 5 years was 89% in patients who underwent complete resection at diagnosis, 79% in patients who had marginal resection, 52% in initially unresected patients, and 17% in patients with metastases at onset. Outcome was unsatisfactory in patients with large and high-grade tumors, even after gross resection; adjuvant chemotherapy seemed to improve the results in this group. Initially unresected patients who responded well to chemotherapy and subsequently underwent complete resection had an event-free survival rate of approximately 70%. The rate of response to chemotherapy was 58%.

CONCLUSION

The identification of prognostic variables should enable risk-adapted therapies to be planned. Patients with initially unresectable disease and patients with resected large and high-grade tumors are at high risk of metastases and treatment failure. Although the limits of this retrospective analysis are self-evident, our data would suggest that intensive chemotherapy (with an ifosfamide-doxorubicin regimen) might have a more significant role in these patients than what is generally assumed.

Prediction of recurrence after radical surgery for gastric cancer: a scoring system obtained from a prospective multicenter study

OBJECTIVE

The aim of this prospective multicenter study was to define a scoring system for the prediction of tumor recurrence after potentially curative surgery for gastric cancer.

SUMMARY BACKGROUND DATA

The estimation of the risk of recurrence in individual patient may be relevant in clinical practice, to apply adjuvant therapies after surgery, and plan an adequate follow-up program. Only a few studies, most of which were retrospective or performed on a limited number of patients, have developed a prognostic score in patients with gastric cancer.

METHODS

A total of 536 patients who underwent UICC R0 resection between 1988 and 1998 at 3 surgical departments in Italy were considered. All patients were followed up using a standard protocol after discharge from the hospital. The mean follow-up period was 56 +/- 44 months, and 94 +/- 29 months for surviving patients. The scoring system was calculated on the basis of a logistic regression model, where the presence of the recurrence was the dependent variable, and clinicopathologic variables were the covariates.

RESULTS

Recurrence occurred in 272 of 536 patients (50.7%). The scoring system for the prediction of the risk in individual cases gave values ranging from 1.4 to 99.9; the model distributed most cases in the extremes of the range. The risk of recurrence increased remarkably with score values; it was only 5% in patients with a score below 10, up to 95.4% in patients with a score of 91 to 100. No recurrence was observed in 43 patients with a score below 4, whereas all of the 56 patients with a score over 97 presented a recurrence. The model correctly predicted recurrence in 227 of 272 patients (sensitivity, 83.5%), whereas the absence of recurrence was correctly predicted in 214 of 264 patients (specificity, 81.1%); the overall accuracy was 82.2%. Prognostic score was clearly superior to UICC tumor stage in predicting recurrence. The high effectiveness of the score was confirmed in preliminary data of a validation study.

CONCLUSIONS

The scoring system obtained with a regression model on the basis of our follow-up data is useful for defining subgroups of patients at a very low or very high risk of tumor recurrence after radical surgery for gastric cancer. Final results of the validation study are essential for a clinical application of the model.

Carbonic anhydrase IX as a marker for poor prognosis in soft tissue sarcoma

PURPOSE

Hypoxia is associated with malignant progression and poor outcome in several human tumors, including soft tissue sarcoma. Recent studies have suggested that carbonic anhydrase (CA) IX is an intrinsic marker of hypoxia, and that CA IX correlates with poor prognosis in several types of carcinoma. The aim of this study was to quantify the extent of CA IX expression and to investigate whether CA IX is a marker for poor prognosis in soft tissue sarcoma patients at high risk of developing metastasis.

EXPERIMENTAL DESIGN

Archival paraffin-embedded blocks were retrieved from 47 patients with deep, large, high-grade soft tissue sarcoma. Sections from two separate and representative tumor areas were immunostained for CA IX, and the CA IX-positive area fraction was quantified by image analysis, excluding areas of normal stroma and necrosis that were identified from serial H&E-stained sections. Patients were then subject to survival analysis.

RESULTS

CA IX-positive area fractions of viable tumor tissue varied significantly between tumors (range, 0-0.23; median, 0.004), with positive membranous CA IX staining in 66% (31 of 47) of the tumors. Patients with CA IX-positive tumors had a significantly lower disease-specific and overall survival than patients with CA IX-negative tumors (P = 0.033 and P = 0.044, respectively).

CONCLUSIONS

These data suggest that CA IX, a potential intrinsic marker of hypoxia, predicts for poor prognosis in patients with deep, large, high-grade soft tissue sarcoma. Larger studies are required to determine whether CA IX has independent prognostic value in this group of tumors.

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.

Validation and adaptation of a nomogram for predicting the survival of patients with extremity soft tissue sarcoma using a three-grade system

BACKGROUND

A nomogram for predicting long term tumor-specific death in patients with soft tissue sarcoma (STS) was developed at the Memorial Sloan-Kettering Cancer Center (MSKCC).

METHODS

To assess the performance of the MSKCC nomogram, 642 consecutive patients with extremity STS who underwent surgery over a 20-year span at a single referral center were analyzed. Nomogram predictions were based on tumor size, depth, site, patient age, histologic subtype, and grade. The latter, at variance with the system in use at the MSKCC, was classified as Grade 1-3 according to the French Federation of Cancer Centers Sarcoma Group (FNCLCC) system. The statistical approach used for nomogram performance assessment was that of "validation by calibration" proposed by Van Houwelingen.

RESULTS

Graphic comparison of observed and predicted sarcoma-specific survival curves showed that predictions by the nomogram were quite accurate, within 10% of actual survival for all prognostic strata. Statistical analysis showed that such predictions could be improved by employing approximately 25% shrinkage to achieve good calibration. The contribution of histologic grade was highly significant in both univariate analysis (P < 0.001) and multivariate analysis (P < 0.001), and a survival trend across the 3 grade categories was observed. Based on those findings, a nomogram that included the FNCLCC histologic grade classification was produced.

CONCLUSIONS

Results of the current study confirmed that the MSKCC nomogram is a valuable tool for individual prognostic assessment. A nomogram that included the FNCLCC histologic grade classification was proposed and was validated internally.

A tool for predicting breast carcinoma mortality in women who do not receive adjuvant therapy

BACKGROUND

Among the several proposed risk classification schemes for predicting survival in women with breast carcinoma, one of the most commonly used is the Nottingham Prognostic Index (NPI). The goal of the current study was to use a continuous prognostic model (similar to those that have already been demonstrated to possess greater predictive accuracy than risk group-based models in other malignancies) to predict breast carcinoma mortality more accurately compared with the NPI.

METHODS

A total of 519 women who had been treated with mastectomy and axillary lymph node dissection at Memorial Sloan-Kettering Cancer Center (New York, NY) between 1976 and 1979 met the following requirements for study inclusion: confirmation of the presence of invasive mammary carcinoma, no receipt of neoadjuvant or adjuvant systemic therapy, no previous history of malignancy, and negative lymph node status as assessed on routine histopathologic examination. Paraffin blocks were available for 368 of the 519 eligible patients. All available axillary lymph node tissue blocks were subjected to enhanced pathologic analysis. The competing-risk method was used to predict disease-specific death, and the accuracy of the novel prognostic model that emerged from this process was evaluated using the concordance index. Jackknife and 10-fold cross-validation predictions yielded by this new model were compared with predictions yielded by the NPI.

RESULTS

Of the 348 women for whom complete data were available, 73 died of disease; the 15-year probability of breast carcinoma-related death was 20%. On the basis of these 348 cases, the authors developed a prognostic model that took patient age, disease multifocality, tumor size, tumor grade, lymphovascular invasion, and enhanced lymph node staining into account, and using competing-risks regression analysis, they found that this new model predicted disease-specific death more accurately compared with the NPI.

CONCLUSIONS

The authors have developed a model for predicting breast carcinoma-specific death with improved accuracy. This tool should be useful in counseling patients with regard to their specific need for adjuvant therapy.

Therapeutisches Management intraabdomineller und retroperitonealer Weichgewebssarkome

In this article, we review the diagnostics, therapy, follow-up, and prognosis of intra-abdominal and retroperitoneal soft tissue sarcomas. There are descriptions and discussion of the surgical techniques, advantages and disadvantages of various types and combinations of adjuvant and neoadjuvant therapies, therapy in case of nonresectability, and procedures for desmoid tumors. Further, treatment results, control methods, and studies on new therapeutic approaches are presented.

Prognostic nomogram for patients undergoing resection for adenocarcinoma of the pancreas

BACKGROUND

Predictive nomograms are becoming increasingly used to define and predict outcome. They can be developed at presentation or following treatment and include variables not conventionally used in standard staging systems.

METHODS

We use a predictive nomogram based on prospectively collected data from 555 pancreatic resections for adenocarcinoma at a single institution. At last follow-up, 481 (87%) had died, defining a mature and comprehensive database. We used a 1-, 2-, and 3-year follow-up, as the number of patients alive beyond 3 years is sufficiently limited to provide insufficient events.

RESULTS

Based on a Cox model, we then developed a nomogram that predicts the probability that a patient will survive pancreatic cancer for 1, 2, and 3 years from the time of the initial resection, assuming that there is not death from an alternate cause. Calibration between observed and corrected is good, and variables not conventionally associated with standard staging systems improved the predictivity of the model.

CONCLUSIONS

This nomogram can serve as a basis for investigating other potentially predictive variables that are proposed of prognostic importance for patients undergoing resection for adenocarcinoma of the pancreas.

Management of prostate-specific antigen relapse in prostate cancer: a European Consensus

A European Consensus on the management of prostate-specific antigen (PSA) relapse in patients with prostate cancer has been formulated. The key recommendations proposed are that total PSA is the best detection tool for prostate cancer, with free and complexed PSA having a role in the PSA range 1-4 ng/ml. PSA relapse after radical prostatectomy (RP) has been defined as a value of 0.2 ng/ml with one subsequent rise, while the ASTRO definition should be used after radiotherapy. A PSA level of less than 0.4 ng/ml after hormonal therapy can be considered an indicator of a positive response. Continuous assessment using nomograms or artificial neural networks will help to determine whether progression after local therapy is distant or local, which is the basis for treatment decisions. Secondary treatment after local failure of RP should be initiated when PSA levels reach 1.0-1.5 ng/ml and salvage radiotherapy can be considered with or without hormonal therapy. Local failure after radiotherapy can be treated with a choice of high-intensity-focused ultrasound, salvage RP (only in highly selected patients), cryotherapy or external beam radiation. Treatment of distant failure involves hormonal manipulation, the type and the timing of which is based on both physician and patient preferences.

TNM: evolution and relation to other prognostic factors

The TNM Classification describes the anatomic extent of cancer. TNM's ability to separately classify the individual tumor (T), node (N), and metastasis (M) elements and then group them into stages differs from other cancer staging classifications (e.g., Dukes), which are only concerned with summarized groups. The objectives of the TNM Classification are to aid the clinician in the planning of treatment, give some indication of prognosis, assist in the evaluation of the results of treatment, and facilitate the exchange of information. During the past 50 years, the TNM system has evolved under the influence of advances in diagnosis and treatment. Radiographic imaging (e.g., endoscopic ultrasound for the depth of invasion of esophageal and rectal tumors) has improved the accuracy of the clinical T, N, and M classifications. Advances in treatment have necessitated more detail in some T4 categories. Developments in multimodality therapy have increased the importance of the "y" symbol and the R (residual tumor) classification. New surgical techniques have resulted in the elaboration of the sentinel node (sn) symbol. The use of immunohistochemistry has resulted in the classification of isolated tumor cells and their distinction from micrometastasis. The most important challenge facing users of the TNM Classification is how it should interface with the large number of non-anatomic prognostic factors that are currently in use or under study. As non-anatomic prognostic factors become widely used, the TNM system provides an inviting foundation upon which to build a prognostic classification; however, this carries a risk that the system will be overwhelmed by a variety of prognostic data. An anatomic extent-of-disease classification is needed to aid practitioners in selecting the initial therapeutic approach, stratifying patients for therapeutic studies, evaluating non-anatomic prognostic factors at specific anatomic stages, comparing the weight of non-anatomic factors with extent of disease, and communicating the extent of disease data in a uniform manner. Methods are needed to express the overall prognosis without losing the vital anatomic content of TNM. These methods should be able to integrate multiple prognostic factors, including TNM, while permitting the TNM system to remain intact and distinct. This article discusses examples of such approaches.

Validation of the postoperative nomogram for 12-year sarcoma-specific mortality

BACKGROUND

On the basis of a prospectively followed cohort of adult patients with primary soft tissue sarcoma (STS) who were treated at Memorial Sloan-Kettering Cancer Center (MSKCC; New York, NY), a nomogram for predicting sarcoma-specific mortality was developed. Although this nomogram was found to be accurate by internal validation tests, it had not been validated in an external patient cohort, and thus its universal applicability remained unproven.

METHODS

Between 1975 and 2002, 1167 adult patients (age > or = 16 years) underwent treatment for primary STS at the University of California-Los Angeles (UCLA; Los Angeles, CA). All patients treated with an ifosfamide-based chemotherapy protocol (n = 238) were excluded from the current analysis. The remaining 929 patients constituted the population on which the validation study was performed. The nomogram validation process comprised two activities. First, the extent of discrimination was quantified using the concordance index. Second, the level of calibration was assessed by grouping patients with respect to their nomogram-predicted mortality probabilities and then comparing group means with observed Kaplan-Meier estimates of disease-specific survival.

RESULTS

With median follow-up intervals of 48 months for all patients and 60 months for surviving patients, the 5-year and 10-year disease-specific survival rates were 77% (95% confidence interval [CI], 74-80%) and 71% (95% CI, 67-75%), respectively. Application of the nomogram to the UCLA data set yielded a concordance index of 0.76, and the observed correspondence between predicted and actual outcomes suggested a high level of calibration.

CONCLUSIONS

In the current study, the MSKCC Sarcoma Nomogram was found to provide accurate survival predictions when it was applied to an external cohort of patients who were treated at UCLA.

Postoperative nomogram for disease-specific survival after an R0 resection for gastric carcinoma

PURPOSE

Few published studies have addressed individual patient risk after R0 resection for gastric cancer. We developed and internally validated a nomogram that combines these factors to predict the probability of 5-year gastric cancer-specific survival on the basis of 1,039 patients treated at a single institution.

METHODS

Nomogram predictor variables included age, sex, primary site (distal one-third, middle one-third, gastroesophageal junction, and proximal one-third), Lauren histotype (diffuse, intestinal, mixed), number of positive lymph nodes resected, number of negative lymph nodes resected, and depth of invasion. Death as a result of gastric cancer was the predicted end point. The concordance index was used as an accuracy measure, with bootstrapping to correct for optimistic bias. Calibration plots were constructed.

RESULTS

Gastric cancer-specific survival at 5 years was 50%. A nomogram was constructed on the basis of a Cox regression model. The bootstrap-corrected concordance index was 0.80. When compared with the predictive ability of American Joint Committee on Cancer stage, the nomogram discrimination was superior (P <.001). Nomogram calibration appeared to be excellent.

CONCLUSION

A nomogram was developed to predict 5-year disease-specific survival after R0 resection for gastric cancer. This tool should be useful for patient counseling, follow-up scheduling, and clinical trial eligibility determination.

Applications of Fourier transform infrared microspectroscopy in studies of benign prostate and prostate cancer. A pilot study

Fourier transform infrared (FTIR) microspectroscopy has been applied to a study of prostate cancer cell lines derived from different metastatic sites and to tissue from benign prostate and Gleason-graded malignant prostate tissue. Paraffin-embedded tissue samples were analysed by FTIR, after mounting onto a BaF(2) plate and subsequent removal of wax using Citroclear followed by acetone. Cell lines were analysed as aliquots of cell suspension held between two BaF(2) plates. It was found that the ratio of peak areas at 1030 and 1080 cm(-1), corresponding to the glycogen and phosphate vibrations respectively, suggests a potential method for the differentiation of benign from malignant cells. The use of this ratio in association with FTIR spectral imaging provides a basis for estimating areas of malignant tissue within defined regions of a specimen. Initial chemometric treatment of FTIR spectra, using the linear discriminant algorithm, demonstrates a promising method for the classification of benign and malignant tissue and the separation of Gleason-graded CaP spectra. Using the principle component analysis, this study has achieved for the first time the separation of FTIR spectra of prostate cancer cell lines derived from different metastatic sites.

Localized extremity soft tissue sarcoma: improved knowledge with unchanged survival over time

PURPOSE

The objective of this study was to define whether survival of patients with extremity soft tissue sarcoma (STS), stratified for known risk factors, has improved over the last 20 years.

PATIENTS AND METHODS

From January 1982 to December 2001, 1,706 patients with primary and recurrent STS of the extremities were treated at our institution and were prospectively followed. From this cohort, we selected 1,261 patients who underwent complete macroscopic resection and had one of the following histopathologies: fibrosarcoma, liposarcoma, leiomyosarcoma, malignant fibrous histiocytoma, or synovial sarcoma. Median follow-up was 55 months. Patient, tumor, and treatment factors were analyzed as prognostic factors.

RESULTS

The 5-year disease-specific actuarial survival was 79% (78% for patients treated from 1982 to 1986, 79% for patients treated from 1986 to 1991, 79% for patients treated from 1992 to 1996, and 85% for patients treated from 1997 to 2001; P = not significant). For high-risk patients (high-grade, > 10 cm, deep tumors; n = 247), 5-year disease-specific survival was 51% (50% for patients treated from 1982 to 1986, 45% for patients treated from 1986 to 1991, 52% for patients treated from 1992 to 1996, and 61% for patients treated from 1997 to 2001; P = not significant). Tumor depth, size, grade, microscopic margin status, patient age, presentation status (primary tumor versus local recurrence), location (proximal versus distal), and certain histopathologic subtypes were significant prognostic factors for disease-specific survival on multivariate analysis; however, time period of treatment was not.

CONCLUSION

Prognosis of patients with extremity STS, stratified for known risk factors, has not improved over the last 20 years, indicating that current therapy has reached the limits of efficacy.

Amputation for soft-tissue sarcoma

Soft-tissue sarcomas are a group of rare malignant tumours, many of which arise in the limbs. Most are treated with a combination of wide local excision and radiotherapy, but a small number--including proximal, large, high-grade, or recurrent tumours, or those involving major neurovascular structures--necessitate major amputation including forequarter or hindquarter amputation. These uncommon operations should remain in the surgical armamentarium for carefully selected patients. Those being considered for amputation should be referred to a tertiary sarcoma unit for examination of all other options, such as limb-salvage surgery, tumour downstaging with chemotherapy or radiotherapy (perhaps with subsequent limb-salvage surgery), or novel techniques such as isolated limb perfusion. Only after careful assessment should amputation be carried out. Outcomes after major amputation are highly variable, but such procedures can confer useful palliation to patients with distressing symptoms (pain, bleeding, fungation), long-term disease-free survival with reasonable function in carefully selected patients, and cure in some.

Should tumor depth be included in prognostication of soft tissue sarcoma?

BACKGROUND

Most staging systems for soft tissue sarcoma are based on histologic malignancy-grade, tumor size and tumor depth. These factors are generally dichotomized, size at 5 cm. We believe it is unlikely that tumor depth per se should influence a tumor's metastatic capability. Therefore we hypothesized that the unfavourable prognostic importance of depth could be explained by the close association between size and depth, deep-seated tumors on average being larger than the superficial ones. When tumor size is dichotomized, this effect should be most pronounced in the large size (>5 cm) group in which the size span is larger.

METHODS

We analyzed the associations between tumor size and depth and the prognostic importance of grade, size and depth in a population-based series of 490 adult patients with soft tissue sarcoma of the extremity or trunk wall with complete, 4.5 years minimum, follow-up.

RESULTS

Multivariate analysis showed no major prognostic effect of tumor depth when grade and size were taken into account. The mean size of small tumors was the same whether superficial or deep but the mean size of large and deep-seated tumors were one third larger than that of large but superficial tumors. Tumor depth influenced the prognosis in the subset of high-grade and large tumors. In this subset deep-seated tumors had poorer survival rate than superficial tumors, which could be explained by the larger mean size of the deep-seated tumors.

CONCLUSION

Most of the prognostic value of tumor depth in soft tissue sarcomas of the extremity or trunk wall can be explained by the association between tumor size and depth.

Surgical margins and reresection in the management of patients with soft tissue sarcoma using conservative surgery and radiation therapy

BACKGROUND

Patients with localized soft tissue sarcoma (STS) who present to specialist centers after undergoing apparent macroscopic total resection often have a significant incidence of residual tumor and may benefit from reresection of the tumor bed. The potential benefits of such reresection have not been documented adequately.

METHODS

The clinicopathologic features and disease outcome for 666 consecutive patients with localized STS who presented after undergoing apparent macroscopic total tumor resection were analyzed to elucidate the relative merits of reresection. Actuarial univariate and multivariate methods were used to compare disease outcome of patients who presented with positive or uncertain microscopic resection margins according to whether they underwent reresection. All patients received adjuvant radiation therapy.

RESULTS

Two hundred and ninety-five patients underwent reresection of their tumor bed, and residual tumor was found in 136 patients (46%), including macroscopic tumor in 73 patients (28%). Final resection margins among patients who underwent reresection were negative in 257 patients (87%), positive in 35 patients (12%), and uncertain in 3 patients (1%). Patients who did not undergo reresection had final margins that were negative in 117 patients (32%), positive in 47 patients (13%), and uncertain in 207 patients (56%). Local control rates at 5 years, 10 years, and 15 years for patients who underwent reresection were 85%, 85%, and 82%, respectively; for patients who did not undergo reresection, the respective local control rates were 78%, 73%, and 73% (P = 0.03). Reresection remained a significant determinant of local control when other prognostic factors were incorporated into a multivariate proportional hazards regression analysis. A similar beneficial effect of reresection was found for metastasis free survival and disease specific survival.

CONCLUSIONS

Patients with localized STS who were referred to a specialist center after undergoing apparent macroscopic total resection of their tumor had a high incidence of residual tumor in their tumor bed and benefited from undergoing reresection, even if radiation was administered routinely.

Prognostic factors for patients with localized soft-tissue sarcoma treated with conservation surgery and radiation therapy: an analysis of 1225 patients

BACKGROUND

Prognostic factors for patients with soft-tissue sarcoma who are treated with conservative surgery and radiation are documented poorly.

METHODS

The clinicopathologic features and disease outcome for 1225 patients with localized sarcoma who were treated with conservative surgery and radiation were reviewed retrospectively. Actuarial univariate and multivariate statistical methods were used to determine significant prognostic factors for local control, metastatic recurrence, and disease specific survival.

RESULTS

The median follow-up of surviving patients was 9.5 years. The respective local control rates at 5 years, 10 years, and 15 years were 83%, 80%, and 79%. Factors predictive of local recurrence were positive or uncertain resection margins; tumors located in the head and neck and the deep trunk; presentation with local recurrence; patient age > 64 years; malignant fibrous histiocytoma, neurogenic sarcoma. or epithelioid sarcoma histopathology; tumor measuring > 10 cm in greatest dimension; and high pathologic grade. Freedom from metastasis at 5 years, 10 years, and 15 years was 71%, 68%, and 66%, respectively. Factors that were predictive of metastatic recurrence were high tumor grade; large tumor size (> 5 cm); and leiomyosarcoma, rhabdomyosarcoma, synovial sarcoma, or epithelioid sarcoma. The respective disease specific survival rates at 5 years, 10 years, and 15 years were 73%, 68%, and 65%. Adverse factors for disease specific survival were high tumor grade; large tumor size (> 5 cm); tumors located in the head and neck and deep trunk; rhabdomyosarcoma, epithelioid sarcoma, or clear cell sarcoma; patient age > 64 years; and positive or uncertain resection margins.

CONCLUSIONS

Soft-tissue sarcoma comprises a heterogeneous group of diseases. Prognostic factors for local recurrence, metastatic recurrence, lymph node recurrence, disease free survival, and disease specific survival are different, and optimal treatment strategies need to take this complexity into account.

Sequencing radiotherapy for soft tissue sarcoma when re-resection is planned

PURPOSE

To evaluate whether disease outcome for localized soft-tissue sarcoma (STS) excised before referral to a specialist center and there re-resected was influenced by the timing of radiation therapy (XRT)-before or after re-resection.

MATERIALS AND METHODS

Two hundred ninety-five consecutive patients with localized grossly excised STS were retrospectively evaluated for local control, freedom from metastasis, disease-free survival, and disease-specific survival, according to whether they had XRT before (121) or after (174) re-resection of their tumor bed. Univariate and multivariate statistical techniques were employed.

RESULTS

At re-resection, residual STS was found in 159 patients (54%), including gross tumor in 73 (25%). The incidence of residual disease was lower in those receiving preoperative XRT (median dose 50 Gy) (36%) than in those having postoperative RT (median dose 60 Gy) (54%) (p = 0.024). With a median follow-up of 9.1 years, the local control rates for all patients at 5, 10, and 15 years were 86%, 84%, and 81%, respectively, and there were no differences between the two XRT sequences. In multivariate regression, there was no evidence that XRT sequence influenced local control, metastatic control, disease-free survival, or disease-specific survival. There was a trend toward fewer XRT-related late complications with preoperative XRT, but this was not significant, and the incidence of complications was low (5% at 15 years).

CONCLUSIONS

Patients who present after total but oncologically inadequate excision of STS can receive approximately 50 Gy before re-resection or approximately 60 Gy after re-resection, with approximately equivalent, satisfactory local control and overall disease outcome. Decisions as to the most appropriate treatment sequence for any individual patient can be made regardless of considerations as to the effectiveness of one sequence compared with the other.

A competing-risks nomogram for sarcoma-specific death following local recurrence

The majority of staging systems focus on the definition of stage, and, therefore, prediction of prognosis. In the current era of clinical trial research, it has become apparent that the clinical stage alone is not sufficient to assess patient risk of treatment failure. As the number of biological markers increases, our ability to partition the traditional disease classification system improves, and our ability to predict patient success continues to increase. One approach to quantifying individual patient risk is through the nomogram. Nomograms are graphical representations of statistical models, which provide the probability of treatment outcome based on patient-specific covariates. We will focus on the use of the nomogram when the response variable is time to failure and there are multiple, possibly dependent, competing causes of failure. In this setting, estimation of the failure probability through direct application of the Cox proportional hazards model provides the probability of failure (for example, death from cancer) assuming failure from a dependent competing cause will not occur. In many clinical settings this is an unrealistic assumption. The purpose of this study is to illustrate the use of the conditional cumulative incidence function for providing a patient-specific prediction of the probability of failure in the setting of competing risks. A competing risks nomogram is produced to estimate the probability of death due to sarcoma for patients who have already developed a local recurrence of their initially treated soft-tissue sarcoma.