Surgical management of sarcomas

Chemotherapy improves distant control in localized high-grade soft tissue sarcoma of the extremity/trunk

Background

Soft tissue sarcomas (STS) are rare and heterogeneous tumors making chemotherapy use controversial. Our goal was to identify a subset of patients with primary STS that benefit with the addition of chemotherapy.

Methods

A retrospective chart review included intermediate to high-grade localized primary STS of the extremity/trunk, and tumor size > 5 cm. The effect of chemotherapy was evaluated for local control (LC), distant control (DC), progression free survival (PFS), and overall survival (OS).

Results

In this cohort (n = 273), patients were treated with surgery (98%), radiation (81%), and chemotherapy (24.5%). With a median follow-up of 51 months, the entire cohort’s 5-year LC, DC, PFS, and OS are 79.1%, 59.9%, 43.8%, and 68.7%, respectively. The addition of chemotherapy did not provide a DC benefit (p = 0.238) for the entire cohort. High-grade disease (n = 210) experienced a 5-year benefit in DC (68% vs. 54.4%, p = 0.04), which was more pronounced with MAI (Mesna, Adriamycin, Ifosfamide) based regimens (74.2%, p = 0.016), and a 5-year PFS (50.8% vs 45%, p = 0.025) and OS benefit (76.2% vs 70%, p = 0.067) vs. no chemotherapy. On multivariate analysis of the high-grade subset, chemotherapy independently predicted for a DC benefit (HR 0.48 95% CI 0.26–89, p = 0.019). The benefit of chemotherapy was more pronounced with MAI, showing a significant benefit in DC (HR 0.333 95% CI 0.145–0.767, p = 0.01) and PFS (HR 0.52 95% CI 0.28–0.99, p = 0.047).

Conclusion

In patients with localized STS > 5 cm, the high-grade subset had a distant control benefit with the addition of chemotherapy, leading to improved progression free survival. This is more pronounced with the use of MAI and should be considered in patients eligible for this regimen.

Risk-stratified patients with resectable soft tissue sarcoma benefit from epirubicin-based adjuvant chemotherapy

As adjuvant chemotherapy (AC) for soft tissue sarcomas is controversial, we performed a retrospective analysis of patients seen at Washington University in St. Louis to evaluate whether it benefited our patient population. Patients were risk-assessed using the Memorial Sloan Kettering Predictive Nomogram (MSKPN). We defined high-risk patients by a MSKPN 4-year postoperative probability of sarcoma-specific death of ≥0.3 and investigated if they benefited from AC. Retrospective review was performed on patients seen between 15 February 1996 and 6 February 2010. A propensity score method in the logistic regression framework was used to model the likelihood of receiving AC. To make causal inference on the effect of AC on survival outcomes, a propensity score inverse probability of treatment weighting approach was applied to survival analysis. Overall, 135 high-grade patients were assessed, 33 were treated with Ifosfamide/Epirubicin (I/Epi) and 102 were non AC patients. The stratified MSKPN risk was not significantly associated with any survival endpoint in the whole cohort, but trended for overall survival (OS) when evaluated against non AC patients. After adjustment for MSKPN risk and other variables, patients not receiving chemotherapy had significantly worse OS, recurrent free survival, and disease-specific survival (DSS) with adjusted hazard ratios of 4.18 (95% CI: 2.22-7.90), 8.96 (95% CI: 3.85-20.83), and 5.42 (95% CI: 2.09-14.06), respectively. In retrospective analyses, risk-stratified patients with soft tissue sarcoma benefited from I/Epi-based AC. Randomized I/Epi versus I/Doxorubicin clinical trials may determine the optimal adjuvant treatment.

A review of controversies in the management of soft tissue sarcomas

Soft tissue sarcomas (STS) constitute a rare and challenging group of solid tumor in the field of oncology. Unlike other malignancies STS can affect a wide variety of anatomical regions in the body with varied histo-pathological variants and clinical outcomes. There are controversies in the diagnosis and management of STS due to rarity and heterogeneity of the disease entity. Due to dedicated research and advances made in the field of imaging, pathology, surgery, radiotherapy and chemotherapy certain controversies were laid to rest and treatment approach to STS could be standardized to a large extent in the recent past. A review of controversies related to STS was performed in this article and an attempt was made to present a balanced view pertaining to these issues.

["Dangerous" cutaneous polyp. Exophytic cutaneous myxofibrosarcoma]

Malignant skin tumors are seldom polypoid lesions. Thus lesions presenting as large skin tags, as in this case, may initially not be recognized and treated as a malignancy. Often such protuberant lesions are removed by shave biopsy. Then, as in this case, the clinician is very surprised to receive the diagnosis of myxofibrosarcoma (MFS). This case shows how important it is to further investigate a common tumor, like a large skin tag, when its clinical appearance is unusual. Myxofibrosarcoma or myxoid malignant fibrous histiocytoma is one of the common, perhaps most common, sarcoma in adults. Clinical presentation as a large skin tag is extremely uncommon. The rapid growth of the polypoid sarcoma indicates the need for completely operative removal. The behavior of the MFS depends on the degree of malignancy, depending on the tumor size, depth of penetration and local control. While smaller dermal or subcutaneous localized MFS hold potentially a risk of recurrence, do larger examples with a high tumor grade and seated in the deep soft tissue posses a variable metastatic potential. Despite large variability of cell number, cellular atypia and the numbers of mitotic figures all myxofibrosarcoma have in common the multinodular structure with incomplete septa, the mucinous stroma and curvilinear fine vessels.

Tumor rupture predicts early metastasis and poor prognosis in stage III soft tissue sarcomas

BACKGROUND

Tumor rupture is considered a R2 resection and is not uncommonly encountered when attempting a tumor-free resection, especially in high-risk soft tissue sarcomas. The predictive value of tumor rupture for metastasis development and its impact on metastasis-free interval needs to be investigated and further taken into consideration in preoperative planning.

METHODS

From January 1993 to December 2009, 276 cases of stage III soft tissue sarcoma were collected from Tianjin Medical University Cancer Institution and Hospital. The clinical characteristics and histopathological features were retrospectively reviewed and analyzed with treatment modalities, tumor rupture status for disease-specific survival (DSS), distant recurrence-free survival (DRFS), and metastasis-free interval (MFI).

RESULTS

Of the 276 patients who underwent surgical resection of their tumors, 53 patients experienced a tumor rupture. Median follow-up period was 68 months. Two-year and 5-year overall survival rates for patients with tumor rupture were 46 and 27% compared with 76 and 57% for patients without tumor rupture, respectively. Median overall survival for patients with tumor rupture was 24 months compared with 56 months for those without. In multivariate analysis, FNCLCC grade III, tumor>10 cm, tumor rupture, and no chemotherapy were associated with decreased DSS and DRFS. Tumor rupture predicted shorter MFI of 5 months compared with 15 months of those without tumor rupture.

CONCLUSIONS

Tumor rupture was associated with decreased DSS and DRFS in stage III sarcomas. It also predicted early metastasis and directly impacted patient's survival. Additional procedures should be investigated to avoid tumor rupture.

The management of soft tissue sarcoma

SUMMARY

Soft tissue sarcomas are a rare group of mesenchymal tumours that display cardinal signs, which can raise suspicion to their diagnosis. Management in a sarcoma treatment centre by its multidisciplinary team has improved outcome. Good local disease control with limb salvage and adjuvant radiotherapy has considerably reduced the morbidity of previous limb amputation. By the early involvement of a plastic surgeon, tissue reconstruction is optimised and wound complications reduced. This article looks at the contemporary management of soft tissue sarcoma and, in particular, its relevance to the plastic surgeon today.

Primary spindle cell sarcoma of the vagina treated with neoadjuvant radiation and pelvic exenteration

OBJECTIVE

Malignant neoplasms of the vagina are rare gynecologic tumors. Primary vaginal sarcomas are even more unusual lesions, representing fewer than 2% of malignant vaginal lesions.

CASE

We present a case of a primary vaginal spindle cell sarcoma, treated with neoadjuvant radiation followed by total pelvic exenteration. The patient remains without evidence of disease 2 years after surgery.

CONCLUSIONS

The mainstay of treatment of vaginal sarcomas is surgical. Neoadjuvant radiation treatment may decrease surgical morbidity and lead to long-term cure.