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Abouarab MH, Salem IL, Degheidy MM, Henn D, Hirche C, Eweida A, Uhl M, Kneser U, Kremer T. Therapeutic options and postoperative wound complications after extremity soft tissue sarcoma resection and postoperative external beam radiotherapy. Int Wound J 2017; 15:148-158. [PMID: 29205902 DOI: 10.1111/iwj.12851] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Accepted: 10/11/2017] [Indexed: 01/31/2023] Open
Abstract
Soft tissue sarcomas occur most commonly in the lower and upper extremities. The standard treatment is limb salvage surgery combined with radiotherapy. Postoperative radiotherapy is associated with wound complications. This systematic review aims to summarise the available evidence and review the literature of the last 10 years regarding postoperative wound complications in patients who had limb salvage surgical excision followed by direct closure vs flap coverage together with postoperative radiotherapy and to define the optimal timeframe for adjuvant radiotherapy after soft tissue sarcomas resection and flap reconstruction. A literature search was performed using PubMed. The following keywords were searched: limb salvage, limb-sparing, flaps, radiation therapy, radiation, irradiation, adjuvant radiotherapy, postoperative radiotherapy, radiation effects, wound healing, surgical wound infection, surgical wound dehiscence, wound healing, soft tissue sarcoma and neoplasms. In total, 1045 papers were retrieved. Thirty-seven articles were finally selected after screening of abstracts and applying dates and language filters and inclusion and exclusion criteria. Plastic surgery provides a vast number of reconstructive flap procedures that are directly linked to decreasing wound complications, especially with the expectant postoperative radiotherapy. This adjuvant radiotherapy is better administered in the first 3-6 weeks after reconstruction to allow timely wound healing and avoid local recurrence.
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Affiliation(s)
- Mohamed H Abouarab
- Department of Plastic and Reconstructive Surgery and Burns, Faculty of Medicine, University of Alexandria, Alexandria, Egypt.,Department of Hand, Plastic, and Reconstructive Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Iman L Salem
- Department of Plastic and Reconstructive Surgery and Burns, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - Magdy M Degheidy
- Department of Plastic and Reconstructive Surgery and Burns, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - Dominic Henn
- Department of Hand, Plastic, and Reconstructive Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Christoph Hirche
- Department of Hand, Plastic, and Reconstructive Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Ahmad Eweida
- Department of Hand, Plastic, and Reconstructive Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany.,Head, Neck and Endocrine Surgery Unit, Department of Surgery, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - Matthias Uhl
- Department of Radiation Oncology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic, and Reconstructive Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Thomas Kremer
- Department of Hand, Plastic, and Reconstructive Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
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Nathenson MJ, Sausville E. Looking for answers: the current status of neoadjuvant treatment in localized soft tissue sarcomas. Cancer Chemother Pharmacol 2016; 78:895-919. [PMID: 27206640 PMCID: PMC7577379 DOI: 10.1007/s00280-016-3055-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Accepted: 05/04/2016] [Indexed: 12/19/2022]
Abstract
PURPOSE Sarcomas are a rare and heterogeneous variant of cancer. The standard of care treatment involves surgical resection with radiation in high-risk patients. Despite appropriate treatment approximately 50 % of patients will suffer and die from recurrent disease. The purpose of this article is to review the current evidence concerning the use of neoadjuvant chemotherapy with or without radiation in soft tissue sarcomas. METHODS An in-depth literature search was conducted using Ovid Medline and PubMed. RESULTS The most active chemotherapeutic agents in sarcoma are anthracyclines and ifosfamide. Adjuvant chemotherapy trials show only minimal benefit. Neoadjuvant chemotherapy offers the potential advantage of reducing the extent of surgery, increasing the limb salvage rate, early exposure of micrometastatic disease to chemotherapy, and assessment of tumor response to chemotherapy. Some retrospective and phase II trials suggest a benefit to neoadjuvant chemotherapy. Unfortunately, no clearly positive phase III prospectively randomized trials exist for neoadjuvant therapy in soft tissue sarcomas. CONCLUSIONS The current neoadjuvant chemotherapy trials that do exist are heterogeneous resulting in conflicting results. However, neoadjuvant chemotherapy with or without radiation can be considered in patients with high-risk disease in an attempt to improve long-term outcomes.
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Affiliation(s)
- Michael J Nathenson
- Department of Sarcoma Medical Oncology, MD Anderson Cancer Center, 1515 Holcombe Blvd Unit 450, Houston, TX, 77030, USA.
| | - Edward Sausville
- Department of Medicine, University of Maryland Medical Center, 22 South Greene Street Suite 9d10, Baltimore, MD, 21201, USA
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Wilkinson MJ, Smith HG, Pencavel TD, Mansfield DC, Kyula‐Currie J, Khan AA, McEntee G, Roulstone V, Hayes AJ, Harrington KJ. Isolated limb perfusion with biochemotherapy and oncolytic virotherapy combines with radiotherapy and surgery to overcome treatment resistance in an animal model of extremity soft tissue sarcoma. Int J Cancer 2016; 139:1414-22. [PMID: 27116656 PMCID: PMC5082541 DOI: 10.1002/ijc.30162] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 04/15/2016] [Indexed: 11/18/2022]
Abstract
The management of locally advanced or recurrent extremity sarcoma often necessitates multimodal therapy to preserve a limb, of which isolated limb perfusion (ILP) is a key component. However, with standard chemotherapeutic agents used in ILP, the duration of response is limited. Novel agents or treatment combinations are urgently needed to improve outcomes. Previous work in an animal model has demonstrated the efficacy of oncolytic virotherapy when delivered by ILP and, in this study, we report further improvements from combining ILP‐delivered oncolytic virotherapy with radiation and surgical resection. In vitro, the combination of radiation with an oncolytic vaccinia virus (GLV‐1h68) and melphalan demonstrated increased cytotoxicity in a panel of sarcoma cell lines. The effects were mediated through activation of the intrinsic apoptotic pathway. In vivo, combinations of radiation, oncolytic virotherapy and standard ILP resulted in delayed tumour growth and prolonged survival when compared with standard ILP alone. However, local disease control could only be secured when such treatment was combined with surgical resection, the timing of which was crucial in determining outcome. Combinations of oncolytic virotherapy with surgical resection and radiation have direct clinical relevance in extremity sarcoma and represent an exciting prospect for improving outcomes in this pathology. What's new? The management of locally advanced or recurrent extremity sarcoma often necessitates multimodal therapy to preserve a limb, of which isolated limb perfusion (ILP) is a key component. But the response to standard ILP is short‐lived in the majority of cases, making novel agents or treatment combinations urgently needed. Previous work in an animal model has demonstrated the effectiveness of combining oncolytic virotherapy with ILP. However, local disease progression was delayed rather than prevented. This paper demonstrates that durable local disease control can be achieved when ILP‐delivered oncolytic virotherapy is utilised as an induction therapy prior to surgical resection and radiotherapy.
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Affiliation(s)
- Michelle J. Wilkinson
- Targeted Therapy TeamThe Institute of Cancer ResearchLondonUnited Kingdom
- Sarcoma/Melanoma Unit, Department Of Academic SurgeryThe Royal Marsden Hospital NHS Foundation TrustLondonUnited Kingdom
| | - Henry G. Smith
- Targeted Therapy TeamThe Institute of Cancer ResearchLondonUnited Kingdom
- Sarcoma/Melanoma Unit, Department Of Academic SurgeryThe Royal Marsden Hospital NHS Foundation TrustLondonUnited Kingdom
| | - Timothy D. Pencavel
- Targeted Therapy TeamThe Institute of Cancer ResearchLondonUnited Kingdom
- Sarcoma/Melanoma Unit, Department Of Academic SurgeryThe Royal Marsden Hospital NHS Foundation TrustLondonUnited Kingdom
| | - David C. Mansfield
- Targeted Therapy TeamThe Institute of Cancer ResearchLondonUnited Kingdom
| | - Joan Kyula‐Currie
- Targeted Therapy TeamThe Institute of Cancer ResearchLondonUnited Kingdom
| | - Aadil A. Khan
- Targeted Therapy TeamThe Institute of Cancer ResearchLondonUnited Kingdom
| | - Gráinne McEntee
- Targeted Therapy TeamThe Institute of Cancer ResearchLondonUnited Kingdom
| | - Victoria Roulstone
- Targeted Therapy TeamThe Institute of Cancer ResearchLondonUnited Kingdom
| | - Andrew J. Hayes
- Sarcoma/Melanoma Unit, Department Of Academic SurgeryThe Royal Marsden Hospital NHS Foundation TrustLondonUnited Kingdom
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Rastrelli M, Campana LG, Valpione S, Tropea S, Zanon A, Rossi CR. Hyperthermic isolated limb perfusion in locally advanced limb soft tissue sarcoma: A 24-year single-centre experience. Int J Hyperthermia 2015; 32:165-72. [DOI: 10.3109/02656736.2015.1101170] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Colombo C, Baratti D, Kusamura S, Deraco M, Gronchi A. The role of hyperthermic intraperitoneal chemotherapy (HIPEC) and isolated perfusion (ILP) interventions in sarcoma. J Surg Oncol 2014; 111:570-9. [PMID: 25351775 DOI: 10.1002/jso.23808] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 08/13/2014] [Indexed: 01/28/2023]
Abstract
Locally advanced sarcomas in the extremity and in the retroperitoneum/abdominal cavity (peritoneal sarcomatosis, PS) can be managed administering chemotherapy locally using isolated limb perfusion (ILP) and hyperthermic intraperitoneal chemotherapy (HIPEC), respectively. In this review, the authors discuss the pros and cons of the use of these locoregional therapies in locally advanced soft tissue sarcoma, with a view to establishing their role in the multidisciplinary approach to these difficult diseases.
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Affiliation(s)
- Chiara Colombo
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
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Deroose JP, Burger JWA, van Geel AN, den Bakker MA, de Jong JS, Eggermont AMM, Verhoef C. Radiotherapy for soft tissue sarcomas after isolated limb perfusion and surgical resection: essential for local control in all patients? Ann Surg Oncol 2010; 18:321-7. [PMID: 21049306 PMCID: PMC3032224 DOI: 10.1245/s10434-010-1400-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2010] [Indexed: 11/18/2022]
Abstract
Background Standard treatment for localized soft tissue sarcoma (STS) is resection plus adjuvant radiotherapy (RTx). In approximately 10% of cases, resection would cause severe loss of function or even require amputation because of the extent of disease. Isolated limb perfusion (ILP) with tumor necrosis factor alpha (TNF-α) and melphalan can achieve regression of the tumor, facilitating limb-saving resection. RTx improves local control but may lead to increased morbidity. Methods In our database of over 500 ILPs, 122 patients with unifocal STS were treated by ILP followed by limb-sparing surgery. All included patients were candidates for amputation. Results Surgery resulted in 69 R0 resections (57%), and in 53 specimens (43%) resection margins contained microscopic evidence of tumor (R1). Histopathological examination revealed >50% ILP-induced tumor necrosis in 59 cases (48%). RTx was administered in 73 patients (60%). Local recurrence rate was 21% after median follow-up of 31 months (2–182 months). Recurrence was significantly less in patients with >50% ILP-induced necrosis versus ≤50% necrosis (7% vs. 33%, P = 0.001). A similar significant correlation was observed for R0 versus R1 resections (15% vs. 28%, P = 0.04). In 36 patients with R0 resection and >50% necrosis, of whom 21 were spared RTx, no recurrences were observed during follow-up. Conclusions In patients with locally advanced primary STS, treated with ILP followed by R0 resection, and with >50% ILP-induced necrosis in the resected specimen, RTx is of no further benefit.
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Affiliation(s)
- Jan P Deroose
- Division of Surgical Oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, The Netherlands
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Bonvalot S, Rimareix F, Causeret S, Le Péchoux C, Boulet B, Terrier P, Le Cesne A, Muret J. Hyperthermic Isolated Limb Perfusion in Locally Advanced Soft Tissue Sarcoma and Progressive Desmoid-Type Fibromatosis with TNF 1 mg and Melphalan (T1-M HILP) Is Safe and Efficient. Ann Surg Oncol 2009; 16:3350-7. [DOI: 10.1245/s10434-009-0733-9] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2009] [Indexed: 11/18/2022]
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Revolutionizing the treatment of locally advanced extremity soft tissue sarcomas: a review on TNFα-based isolated limb perfusion. Eur Surg 2009. [DOI: 10.1007/s10353-009-0479-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Santillan AA, Delman KA, Beasley GM, Mosca PJ, Hochwald SN, Grobmyer SR, Andtbacka RH, Noyes RD, Kane JM, Ross MI, Tyler DS, Zager JS. Predictive factors of regional toxicity and serum creatine phosphokinase levels after isolated limb infusion for melanoma: a multi-institutional analysis. Ann Surg Oncol 2009; 16:2570-8. [PMID: 19543771 DOI: 10.1245/s10434-009-0563-9] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2008] [Revised: 04/08/2009] [Accepted: 05/05/2009] [Indexed: 11/18/2022]
Abstract
BACKGROUND Isolated limb infusion (ILI) is a minimally invasive technique delivering regional chemotherapy to treat in-transit extremity melanoma. Determining perioperative factors that could predict toxicity is important to optimize strategies to improve clinical outcomes after regional chemotherapy in melanoma. METHODS Perioperative factors from 171 ILI patients performed at eight centers from 2001 to 2008 were reviewed. The Wieberdink limb toxicity scale and creatine phosphokinase (CK) levels were used to measure toxicity. Logistic regression analysis was used to estimate the association between toxicity and perioperative parameters. RESULTS Mild (grades I-II) and severe (grades >or=III) limb toxicity developed in 68% and 32% of patients, respectively. Melphalan adjusted for ideal body weight (aIBW) and papaverine were used in 47% and 63% of patients, respectively. Median peak CK for all patients was 563 U/l, and median peak occurred at postoperative day 4. On univariate analysis, papaverine and high CK levels (>563 U/l) were significantly associated with higher toxicity. On the contrary, aIBW was significantly associated with a lower risk of severe toxicity. Perfusate blood gas at 30 min [pH, PaO(2), and base excess (BE) ], limb temperature, and ischemia time were not predictive of limb toxicity. On multivariate analysis, severe toxicity was associated with female sex (P = 0.01), papaverine (P = 0.01), and high peak CK levels (P < 0.01). Independent predictors of high CK levels included younger age, unadjusted melphalan dose, and low PaO(2) at 30 min. CONCLUSIONS ILI can be performed with an acceptable morbidity. Papaverine use, female gender, and high peak CK were associated with higher limb toxicity. CK levels can be diminished significantly with aIBW.
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Affiliation(s)
- Alfredo A Santillan
- Division of Cutaneous Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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Cherix S, Speiser M, Matter M, Raffoul W, Liénard D, Theumann N, Mouhsine E, Mirimanoff RO, Leyvraz S, Lejeune FJ, Leyvraz PF. Isolated limb perfusion with tumor necrosis factor and melphalan for non-resectable soft tissue sarcomas: Long-term results on efficacy and limb salvage in a selected group of patients. J Surg Oncol 2008; 98:148-55. [DOI: 10.1002/jso.21081] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Möller MG, Lewis JM, Dessureault S, Zager JS. Toxicities associated with hyperthermic isolated limb perfusion and isolated limb infusion in the treatment of melanoma and sarcoma. Int J Hyperthermia 2008; 24:275-89. [PMID: 18393005 DOI: 10.1080/02656730701805520] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Hyperthermic isolated limb perfusion (HILP) and isolated limb infusion (ILI) may play a significant role in the treatment of patients with recurrent or in transit extremity melanoma or sarcoma that is unresectable. These procedures may be indicated when patients are otherwise faced with the possibility of a debilitating amputation. Not entirely benign treatment modalities, HILP and ILI can be associated with regional and systemic toxicities. We conducted a literature search of published studies using HILP and ILI for the treatment of extremity sarcomas and melanomas, and associated toxicities was performed. The regional toxicities of HILP and ILI are similar. The most common toxicities reported are mild to moderate. However, when severe regional toxicity occurs, albeit infrequently (<5%), fasciotomies or even amputation may be necessary. Some studies have showed a relationship between acute regional toxicities and long term regional morbidity. Systemic toxicity appears to be more frequent when TNF-alpha is used in combination with other drugs during HILP, however the use of TNF-alpha in the United States is limited to trials. Although regional toxicities are similar, systemic toxicity of ILI is minimal compared to HILP. ILI is easier to repeat, technically less complex, and may be more acceptable in infirmed patients. Long term morbidity and outcomes for ILI are still being evaluated. Both of these techniques may be suitable options in patients with unresectable advanced or recurrent, or in transit extremity melanoma or sarcoma.
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Affiliation(s)
- Mecker G Möller
- H Lee Moffitt Cancer Center and Research Institute, University of South Florida, Tampa. FL 33612, USA
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Gimbel MI, Delman KA, Zager JS. Therapy for Unresectable Recurrent and In-Transit Extremity Melanoma. Cancer Control 2008; 15:225-32. [DOI: 10.1177/107327480801500305] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Unresectable recurrent and in-transit extremity melanoma presents a dilemma for the treating physician. While the disease is confined to the involved limb, the survival mimics that of multiple nodal metastases, with a 10-year survival rate of approximately 40%. This represents late-stage disease for which curative treatment options are limited. Methods To review the current treatment strategies for stage IIIB (N2c) in-transit and recurrent melanoma focusing on the options for unresectable disease, MEDLINE was searched for studies of known and experimental treatments for in-transit and recurrent extremity melanoma. Further results were obtained after review of the initial citations. Results For unresectable recurrences and in-transit metastases, therapies are limited to palliative (radiation), local (intratumoral injection, laser ablation and electroporation), regional (isolated limb perfusion/infusion), and systemic (chemotherapy) when local or regional techniques are not feasible. Conclusions In this patient population, intratumoral techniques have a limited role with current treatment regimens, but with the development of new drugs, these techniques may have more utility. If not contraindicated, regional techniques provide the greatest control and have minimal operative morbidity. Until new regimens are available, systemic therapy continues to be associated with considerable toxicity and only marginal response rates.
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Affiliation(s)
- Mark I. Gimbel
- Surgical Oncology at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Keith A. Delman
- Department of Surgery at Emory University School of Medicine, Atlanta, Georgia
| | - Jonathan S. Zager
- Cutaneous Oncology at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
- Sarcoma Programs at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
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Gibbs J. Soft tissue and bone sarcoma group, 25th anniversary meeting on sarcomas, april 5-7, 2001, aarhus, denmark. Sarcoma 2008; 5:157-84. [PMID: 18521443 PMCID: PMC2408367 DOI: 10.1080/135771401200xxxxx] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- J Gibbs
- Division of Surgery Roswell Park Cancer Institute Elm and Carlton Streets Buffalo NY 14263 USA
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Hoven-Gondrie ML, Thijssens KMJ, Van den Dungen JJAM, Loonstra J, van Ginkel RJ, Hoekstra HJ. Long-term locoregional vascular morbidity after isolated limb perfusion and external-beam radiotherapy for soft tissue sarcoma of the extremity. Ann Surg Oncol 2007; 14:2105-12. [PMID: 17457649 PMCID: PMC1914247 DOI: 10.1245/s10434-007-9365-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2006] [Accepted: 11/27/2006] [Indexed: 11/23/2022]
Abstract
Background Isolated limb perfusion (ILP) with tumor necrosis factor alpha (TNF-α) and melphalan, followed by delayed surgical resection and adjuvant external-beam radiotherapy is a limb salvage treatment strategy for locally advanced soft tissue sarcomas. The long-term vascular side effects of this combined procedure were evaluated. Methods Thirty-two patients were treated for a locally advanced sarcoma of the upper (n = 5) or lower limb (n = 27). All patients underwent a noninvasive vascular work-up. Results Five patients underwent a leg amputation, in two cases due to critical leg ischemia 10 years after ILP. With a median follow-up of 88 (range, 17–159) months, none of the patients with a salvaged lower leg (n = 22) experienced peripheral arterial occlusive disease. Ankle-brachial index (ABI) measurements in the involved leg (median, 1.02; range, .50–1.20) showed a significant decrease compared with the contralateral leg (median, 1.09; range, .91–1.36, P = .001). Pulsatility index (PI) was decreased in the treated leg in 17 of 22 patients at the femoral level (median, 6.30; range, 2.1–23.9 vs. median, 7.35; range, 4.8–21.9; P = .011) and in 19 of 20 patients at popliteal level (median, 8.35; range, 0–21.4 vs. median, 10.95; range, 8.0–32.6; P < .0005). In patients with follow-up of >5 years, there was more often a decrease in ABI (P = .024) and PI at femoral level (P = .011). Conclusions ILP followed by resection and external-beam radiotherapy can lead to major late vascular morbidity that requires amputation. Objective measurements show a time-related decrease of ABI and femoral PI in the treated extremity.
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Affiliation(s)
- Miriam L. Hoven-Gondrie
- Department of Surgical Oncology, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB Groningen, the Netherlands
| | - Katja M. J. Thijssens
- Department of Surgical Oncology, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB Groningen, the Netherlands
| | - Jan J. A. M. Van den Dungen
- Departments of Vascular Surgery, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB Groningen, the Netherlands
| | - Jan Loonstra
- Departments of Vascular Surgery, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB Groningen, the Netherlands
| | - Robert J. van Ginkel
- Department of Surgical Oncology, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB Groningen, the Netherlands
| | - Harald J. Hoekstra
- Department of Surgical Oncology, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB Groningen, the Netherlands
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Mundt AJ, Vijayakumar S, Nemunaitis J, Sandler A, Schwartz H, Hanna N, Peabody T, Senzer N, Chu K, Rasmussen CS, Kessler PD, Rasmussen HS, Warso M, Kufe DW, Gupta TD, Weichselbaum RR. A Phase I trial of TNFerade biologic in patients with soft tissue sarcoma in the extremities. Clin Cancer Res 2005; 10:5747-53. [PMID: 15355902 DOI: 10.1158/1078-0432.ccr-04-0296] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE TNFerade is a second-generation replication-deficient adenovector carrying a transgene encoding human tumor necrosis factor alpha under control of a radiation- induced promoter. The objective of this study was to assess the tolerance of combining TNFerade and radiation therapy in patients with soft tissue sarcomas of the extremity. EXPERIMENTAL DESIGN TNFerade was administered in combination with single-daily fractionated radiation therapy in 14 patients with soft tissue sarcoma of the extremities. Three escalating dose levels of TNFerade (4 x 10(9) -4 x 10(11) particle units) were planned, given in 1 log increments by intratumoral injections, twice weekly during week 1 and once weekly during weeks 2-5 of radiation therapy. RESULTS TNFerade was well tolerated with no dose-limiting toxicities noted. Grade 1-2 chills (50.0%), fever (43.0%), fatigue (36.0%), and flu-like symptoms (21.0%) were the most common side effects. Serum-tumor necrosis factor alpha levels were low in all of the patients (<15 pg/mL). No patients had virus-detected blood, sputum, or urine cultures. Of the 13 evaluable patients, 11 received TNFerade preoperatively, and 2 received the treatment for palliation. Eleven patients (85%) showed objective or pathological tumor responses (2 complete and 9 partial), and 1 had stable disease. Partial responses were achieved despite some of these tumors being very large (up to 675 cm(2)). Of the 11 patients who underwent surgery, 10 (91%) showed a pathological complete response/partial response. CONCLUSION TNFerade + radiation therapy was well tolerated in the treatment of patients with soft-tissue sarcoma of the extremity. The high number of objective responses observed warrants additional studies of this approach in a larger controlled prospective trial.
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Affiliation(s)
- Arno J Mundt
- University of Chicago Medical Center, Chicago, Illinois, USA.
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Rossi CR, Mocellin S, Pilati P, Foletto M, Nitti D, Lise M. TNFalpha-based isolated perfusion for limb-threatening soft tissue sarcomas: state of the art and future trends. J Immunother 2003; 26:291-300. [PMID: 12843791 DOI: 10.1097/00002371-200307000-00001] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The management of limb-threatening soft tissue sarcomas has not yet been standardized. Although local disease control does not affect overall survival, amputation or highly mutilating surgery may be required, which impairs the patient's quality of life. Various neoadjuvant approaches have been proposed to allow limb-sparing surgery for these locally advanced tumors. With TNFalpha-based hyperthermic isolated limb perfusion, the majority of patients can be spared amputation, with acceptable rates of locoregional and systemic complications. As yet, no other available treatment seems to give comparable results when applied to limb-threatening soft tissue sarcomas. Nevertheless, several issues remain to be addressed, such as the type and dose of drugs, repeatability of the procedure, association with radiotherapy, further indications, and evaluation of response. The authors describe the principles underlying TNFalpha-based hyperthermic isolated limb perfusion, review the worldwide experience so far published, and discuss the above issues. The potential future developments of this locoregional therapeutic approach will also be reported.
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Affiliation(s)
- Carlo Riccardo Rossi
- Department of Oncological and Surgical Sciences, University of Padova, Italy. carlor.rossi2unipd.it
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Lejeune FJ, Kroon BB, Di Filippo F, Hoekstra HJ, Santinami M, Liénard D, Eggermont AM. Isolated Limb Perfusion. Surg Oncol Clin N Am 2001. [DOI: 10.1016/s1055-3207(18)30034-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Eroglu A, Kocaoglu H, Demirci S, Akgül H. Isolated limb perfusion with cisplatin and doxorubicin for locally advanced soft tissue sarcoma of an extremity. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2000; 26:213-21. [PMID: 10753532 DOI: 10.1053/ejso.1999.0779] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIMS To identify independent adverse clinico-pathological factors for disease-free and overall survival in patients undergoing isolated limb perfusion (ILP) with cisplatin and doxorubicin for locally advanced soft tissue sarcoma (STS) of an extremity. METHODS A retrospective analysis was carried out, using a univariate method and a multivariate analysis, to look at the patient, tumour and treatment associated with prognostic factors in 37 patients with locally advanced STSs of the limbs who underwent ILP with cisplatin and doxorubicin. Patient's age, gender, presenting status, tumour location, tumour grade, tumour stage according to TNM classification, tumour size and radiotherapy (RT) were analysed. Survival curves were calculated according to the Kaplan-Meier method. A Cox proportional hazard model was used to indicate which factors related to overall survival and the recurrence-free interval after ILP. RESULTS No major systemic toxicity was seen. Regional toxicity was limited. Limb salvage was achieved in 94.6% of the patients. The estimated 5-year overall and disease-free survival rates were 62% and 54%, respectively. It was found that tumour stage, tumour grade, presenting status, RT and tumour size were associated with cumulative overall survival when the Kaplan-Meier method was applied (P<0.05). By Cox proportional hazards model, only tumour grade (P=0. 0254) was found to have significant influence on overall survival; however, tumour stage (P=0.0157) and RT (P=0.0014) were related to disease-free survival. CONCLUSIONS ILP and delayed excision followed by RT achieves good limb salvage rates and may improve survival.
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Affiliation(s)
- A Eroglu
- Department of Surgical Oncology, Ankara University Medical School, Ankara, Turkey
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Abstract
Surgery is, and always has been, the main treatment modality of solid tumours. For a long period, it consisted of a number of surgical procedures dictated by basic oncologic principles, most of which are still adhered to. Over the last few decades, increased understanding of the disease, new or improved diagnostic facilities, novel and perfected adjuvant treatments, improved surgical techniques and daring challenges to established dogmas have all contributed to the development of surgical oncology. The heritage from the past came under close scrutiny, and the fruits of basic and clinical science were added to an ever expanding body of knowledge. It is impossible to review all developments in surgical oncology of the last 25 years in one comprehensive paper. Therefore we have restricted ourselves to those items that appear most representative for the changes that have taken place, and those diseases that have the greatest numerical impact.
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Affiliation(s)
- A J Bremers
- Department of Oncologic Surgery, Leiden University Medical Center, Leiden, The Netherlands
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Abstract
Soft tissue sarcomas are a heterogeneous group of tumors, consisting of numerous histiotypes that all share a putative common mesenchymal origin. Although prognosis of these tumors is determined by clinical parameters (size, location, and resection margin status) and pathologic features (mitotic activity and necrosis), the histologic subtype has never been shown to be a consistent independent prognostic factor. Some relevant differences among these histiotypes are emerging, in specific biological parameters such as proliferation indices, in integrin expression profiles, and with regard to drug sensitivity. Several biological factors are considered to be prognostically important. Most attention is directed to regulators of cell-cycle progression. The significance of p53 dysregulation is confirmed by the inhibition of cellular proliferation, both in in-vitro and in in-vivo sarcoma models, after reintroduction of wild type p53. A multidisciplinary approach is essential for the optimal treatment of soft tissue sarcomas. Multimodality treatment has led to a patient-tailored approach with limb-sparing resections integrated with external and/or interstitial irradiation. The value of chemotherapy both in the neoadjuvant and the adjuvant setting, although of critical value in other sarcomas such as Ewing's sarcoma and osteosarcoma, remains to be established for soft tissue sarcomas.
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Affiliation(s)
- L Y Dirix
- Department of Medical Oncology, University Hospital Leuven-Gasthuisberg, Leuven, Belgium
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Drory VE, Lev D, Groozman GB, Gutmann M, Klausner JM. Neurotoxicity of isolated limb perfusion with tumor necrosis factor. J Neurol Sci 1998; 158:1-4. [PMID: 9667770 DOI: 10.1016/s0022-510x(98)00098-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Hyperthermic isolated limb perfusion (HILP) with tumor necrosis factor alpha (TNFalpha) is effective for advanced melanoma and sarcoma of the limbs. Ten patients undergoing HILP with TNFalpha were evaluated by neurological examinations, nerve conduction studies (NCS), sympathetic skin responses (SSR) and conventional and quantitative electromyography (EMG), performed before, 7 days and 6 weeks following HILP. Seven patients showed minimal clinical signs of peripheral nerve damage following HILP; in two the injury was evident electrophysiologically: 7 days following HILP five patients had paresthesias and/or hypoesthesia, one had a mild foot drop and one had autonomic disturbances in the affected limb. SSR was low in two patients in the affected limb, sensory nerve action potentials were not elicited in one, with normal motor NCS and EMG. At 6 weeks, four patients continued to have mild paresthesias and one had dysautonomia of the perfused limb. Sensory responses and SSR did not change, motor abnormalities were not found. These findings show that HILP with TNFalpha induces a mild, mainly sensory neuropathy in perfused limbs, not disturbing functionality and improving over time.
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Affiliation(s)
- V E Drory
- Department of Neurology and EMG Laboratory, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel-Aviv University, Israel.
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