Prognostic factors in adult soft-tissue sarcomas of the head and neck

Global frequency and distribution of head and neck sarcomas in adulthood: a systematic review

PURPOSE

Head and neck sarcomas (HNS) constitute a rare and heterogeneous cancer entity. Management remains a challenge due their rarity and different biological behaviour among tens of subtypes. This systematic review aimed to describe HNS global frequency and distribution in adulthood.

METHODS

A systematic review was performed using PICOTS search strategies for qualitative question and it was written in accordance with PRISMA 2020 Statement. 70,653 publications were identified, and 15 variables were evaluated for a total of 2428 patients.

RESULTS

We identified 47 studies from 21 different countries from 5 different continents. Most of studies (83.3%) were performed in single institutions and America and Asia overruled for number of papers included (21 and 10, respectivelly). Osteosarcoma was more frequent, followed by chondrosarcoma, angiosarcoma and malignant fibrous histiocytoma. Early stage accounted for almost 80% of cases; advanced stage prevailed in developing countries. 1783 patients (90.1%) underwent surgery and 780 (39.4%) had adjuvant therapy. 50.8% of patients experienced tumour recurrence and the lowest mortality rate was reported in Europe (29.9%).

CONCLUSIONS

HNS holds a relative poor prognosis possibly explained by the heterogeneity of the disease. Treatment of HNS has shown to be highly diverse among different countries, underlining the importance of uniformed treatment guidelines to achieve better patient management and to improve survival outcomes.

Sarcomas of the Larynx: One Institution's Experience and Treatment Protocol Analyses

Soft tissue sarcomas in the head and neck are rare malignancies. They occur in this area in less than 1% of all malignant tumors. Some authors have described the development of sarcoma from the mesenchymal tissue in the larynx. The histological diagnosis of a sarcoma depends on the immunohistochemical investigation. In particularly difficult diagnoses, electron microscopy has to be used. The treatment recommendation depends on the histological type of sarcoma. We analysed and summarized data on the diagnostic criteria and therapy for sarcoma of the larynx presented in the literature. We present three new cases of laryngeal sarcoma and describe the analyses of the published diagnostic and treatment schedules of laryngeal sarcomas. We developed a treatment protocol recommendation for laryngeal sarcoma based on an analysis of literature data and case reports. This recommendation is based on histological type, staging, grading, size, and survival data.

Radiation Therapy in Adult Soft Tissue Sarcoma-Current Knowledge and Future Directions: A Review and Expert Opinion

Simple Summary

Radiation therapy (RT) is an integral part of the treatment of adult soft-tissue sarcomas (STS). Although mainly used as perioperative therapy to increase local control in resectable STS with high risk features, it also plays an increasing role in the treatment of non-resectable primary tumors, oligometastatic situations, or for palliation. This review summarizes the current evidence for RT in adult STS including typical indications, outcomes, side effects, dose and fractionation regimens, and target volume definitions based on tumor localization and risk factors. It covers the different overall treatment approaches including RT either as part of a multimodal treatment strategy or as a sole treatment and is accompanied by a summary on ongoing clinical research pointing at future directions of RT in STS.

Abstract

Radiation therapy (RT) is an integral part of the treatment of adult soft-tissue sarcomas (STS). Although mainly used as perioperative therapy to increase local control in resectable STS with high risk features, it also plays an increasing role in the treatment of non-resectable primary tumors, oligometastatic situations, or for palliation. Modern radiation techniques, like intensity-modulated, image-guided, or stereotactic body RT, as well as special applications like intraoperative RT, brachytherapy, or particle therapy, have widened the therapeutic window allowing either dose escalation with improved efficacy or reduction of side effects with improved functional outcome. This review summarizes the current evidence for RT in adult STS including typical indications, outcomes, side effects, dose and fractionation regimens, and target volume definitions based on tumor localization and risk factors. It covers the different overall treatment approaches including RT either as part of a multimodal treatment strategy or as a sole treatment, namely its use as an adjunct to surgery in resectable STS (perioperative RT), as a primary treatment in non-resectable tumors (definitive RT), as a local treatment modality in oligometastatic disease or as palliative therapy. Due to the known differences in clinical course, general treatment options and, consequently, outcome depending on lesion localization, the main part of perioperative RT is divided into three sections according to body site (extremity/trunk wall, retroperitoneal, and head and neck STS) including the discussion of special applications of radiation techniques specifically amenable to this region. The review of the current evidence is accompanied by a summary on ongoing clinical research pointing at future directions of RT in STS.

Radiotherapy for Adult Soft Tissue Sarcomas of the Head and Neck

OBJECTIVE

Surgery followed by postoperative radiation therapy (RT) is the standard of care for soft tissue sarcomas (STS) of the head and neck that are high grade or have close or positive margins.

METHODS

The authors retrospectively reviewed adult patients with head and neck STS treated with RT at a single institution between 1981 and 2017. All patients who were 19 years and older with STS of the head and neck-excluding rhabdomyosarcoma, angiosarcoma, and Ewing tumors-were included in this study. Toxicity was graded using Common Terminology Criteria for Adverse Events (CTCAE), version 4.

RESULTS

Among 34 patients with head and neck STS treated with postoperative RT (33) or primary RT (1) who met the inclusion criteria, the median age at diagnosis was 45 years (range, 20 to 83). Overall, 37% had T1 tumors, 50% had high-grade histology (grade 3), and 26% had microscopically positive margins. The median RT dose was 65 Gy to the primary site; 29% received elective nodal irradiation. The median follow-up for living patients was 16.6 years (range, 0.6 to 30). At 5 and 10 years, the local control rates were 88% and 80%, the regional control rates were 97% and 97%, the freedom from distant metastases rates were 100% and 100%, the cause-specific survival rates were 88% and 81%, and the overall survival rates were 85% and 69%. Two patients (6%) developed late grade 3+ complications.

CONCLUSION

Our study demonstrates that surgery and radiotherapy for STS of the head and neck have excellent disease outcomes.

Using Image-guided Intensity-modulated Radiotherapy on Patients With Head and Neck Soft-tissue Sarcoma

BACKGROUND

Image-guided intensity-modulated radiotherapy (IG-IMRT) is increasingly being used to treat patients with soft-tissue sarcoma (STS) of the head and neck. Although there is no comparison between IMRT and conventional radiation therapy (CRT) concerning their efficacy. In this analysis, we compared CRT and IMRT outcomes for head and neck STS.

PATIENTS AND METHODS

Sixty-seven patients who underwent radiotherapy between 1994 and 2017 were identified.

RESULTS

The median follow-up was 31 months. Of the 67 patients, 34% were treated with CRT technique and 66% with IG-IMRT. The locoregional relapse rate following IMRT was 21% versus 70% with CRT (p<0.001) and the 5-year locoregional control was 69% versus 28%, respectively (p=0.01). IG-IMRT was associated with non-significant, less acute, and chronic adverse events. In the multivariate analysis, a significant influence of radiation technique on locoregional control was confirmed (p=0.04).

CONCLUSION

IG-IMRT seems to be associated both with higher locoregional control as well as lower acute and chronic toxicities.

Intensity-Modulated Proton and Carbon-Ion Radiation Therapy in the Management of Head and Neck Sarcomas

PURPOSE

We report our experience of intensity-modulated proton and carbon-ion radiotherapy (IMPT/IMCT) for head and neck sarcomas (HNS).

METHODS AND MATERIALS

An analysis of the ongoing prospective data registry from the Shanghai Proton and Heavy Ion Center (SPHIC) for patients with HNS was conducted. The 12- and 24-month rates of local recurrence-free, overall, distant metastasis-free, progression-free survival (LRFS, OS, DMFS, and PFS), and acute/late toxicities were calculated. The prognostic factors for the effectiveness of the treatment were also analyzed.

RESULTS

Between 7/2014 and 5/2018, 51 consecutive patients with HNS received definitive doses of IMCT (41 cases), IMPT (two cases), or their combination (eight cases). One patient had R0 resection and another treated on the Chinese Food and Drug Administration registration trial received IMPT only. Twenty-seven patients were treated according to various dose escalation trials or institutional protocols using IMCT or IMPT + IMCT boost. Twenty-two patients with locoregional recurrence (10 and four patients failed surgery or surgery followed by radiotherapy, respectively) or radiation-induced second primary sarcomas (eight patients) received salvage particle radiotherapy. With a median follow-up time of 15.7 months, four patients with second primary sarcoma died. The 1- and 2-year OS, PFS, LRFS, and DMFS rates for the entire cohort were 92.9% vs 90%, 73.6% vs 57.4%, 88.4% vs 78.9%, and 84.6% vs 76.5%, respectively. Those rates for patients without prior radiotherapy were 100% vs 100%, 82.1% vs 65.8%, 93.6% vs 85.3%, and 88.4% vs 79.5%, respectively. Multivariate analyses revealed that re-irradiation was an independent prognostic factor for both LRFS and PFS (P = 0.015 and 0.037, respectively). In addition, gross tumor volume (GTV) was an independent prognostic factor for PFS (P = 0.048). One patient experienced Grade 3 acute toxicity (oral mucositis); another experienced Grade 4 acute event (hemorrhage) which required embolization. He lately died from hemorrhage (Grade 5) at 3.4 months after the completion of treatment. No patient experienced radiation-induced acute/late toxicity of ≥ Grade 2 otherwise.

CONCLUSION

With few observed acute/late toxicities, IMPT/IMCT provided effective short-term tumor control in our patients with HNS. Further investigations, preferably in a prospective fashion, will be required to confirm the efficacy and toxicities of IMPT/IMCT in this group of patients.

Validation of Neutrophil Count as An Algorithm-Based Predictive Factor of Progression-Free Survival in Patients with Metastatic Soft Tissue Sarcomas Treated with Trabectedin

Introduction: Based on a mathematical model of trabectedin-induced neutropenia, we assessed the predictive value of absolute neutrophil count (ANC) on progression-free survival (PFS) in an independent validation cohort of patients treated with trabectedin. Methods: We collected data from 87 patients in two expert centers who received at least two cycles of trabectedin for soft tissue sarcomas (STS) treatment. Correlations between ANC, patients' characteristics, and survival were assessed, and a multivariate model including tumor grade, performance status, ANC, and hemoglobin level was developed. Results: Therapeutic ANC ≥ 7.5 G/L level was associated with shorter PFS: 3.22 months (95% confidence interval (CI), 1.57⁻4.87) in patients with ANC ≥ 7.5 G/L vs. 5.78 months (95% CI, 3.95⁻7.61) in patients with ANC < 7.5 G/L (p = 0.009). Age, primary localization, lung metastases, dose reduction, hemoglobin, and albumin rates were also associated with PFS. In multivariate analysis, ANC ≥ 7.5 G/L was independently associated with poor PFS and overall survival. Conclusion: We validated increased pre-therapeutic ANC as a predictive factor of short PFS in patients starting trabectedin for STS. ANC appears to have an impact on survival rates and may be used as a decision-making tool for personalizing second-line strategies in patients with metastatic STS.

Adjuvant radiation for positive margins in adult head and neck sarcomas is associated with improved survival: Analysis of the National Cancer Database

BACKGROUND

Adult head and neck (H&N) sarcomas are a rare malignancy with limited data delineating the role of postoperative radiotherapy (PORT), particularly for a positive surgical margin. There are no randomized trials supporting the use of PORT, therefore treatment trends vary between institutions. A positive margin predicts recurrence and poor survival outcomes. This study uses the National Cancer Database (NCDB) to investigate whether PORT improves overall survival (OS) in adult H&N sarcomas with a positive margin and how utilization has changed.

METHODS

Patients (n = 1142) in the NCDB from 2004-2013 with adult H&N sarcomas who underwent resection and had a positive margin.

RESULTS

Factors significantly associated with increased utilization of PORT were: having insurance, salivary gland primary site, high-risk histology, poor differentiation, and a macroscopic positive margin. Treatment with PORT was associated with improved 5-year OS for all patients with a positive margin (57% vs 48%; P = .002), both microscopic (57% vs 49%; P = .010) and macroscopic (57% vs 41%; P = .036). Improved OS was significant after controlling for other known covariates on multivariate analysis (HR: 0.76; [0.64-0.90]; P = .002). Treatment at a community-based facility was an independent predictor for reduced OS (HR: 1.37; [1.15-1.64]; P < .001). The percentage utilization (53%) of PORT for these patients did not change significantly over time.

CONCLUSION

PORT provides a significant survival benefit for adult H&N sarcoma patients with either a microscopic or macroscopic positive margin; however, PORT is underutilized. Treatment at academic/research cancer programs was associated with increased utilization of PORT and improved survival outcomes.

Ending 40 years of silence: Rationale for a new staging system for soft tissue sarcoma of the head and neck

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For 40 years, all soft tissue sarcoma (STS) used the same TNM where T1 was <=5 cm.

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This staging is unsuited for STS of the head and neck (STSHN) since only a minority are >5 cm.

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Despite smaller size, local recurrence is higher in STSHN compared to other STS.

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A new T classification with 2 and 4 cm cut-offs for STSHN was introduced in TNM-8.

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Future requirements for STSHN Stage Group development are mentioned.

The tumor, node, metastases (TNM) anatomic staging system plays a pivotal role in cancer care, research, and cancer control activities. Since the first edition of the American Joint Committee on Cancer TNM staging classification published in 1977, soft tissue sarcomas have been staged in an anatomic site agnostic fashion whereby the primary tumor size (T) was categorized as T1 if <=5 cm and T2 if >5 cm; this remained unchanged through the 7th edition of the TNM. However, soft tissue sarcomas of the head and neck (STSHN) usually present smaller than sarcomas of other sites, but carry a disproportionate risk of local recurrence. Up to 70% of tumors are less than 5 cm at presentation, and therefore classified together as T1. Given the rarity of STSHN, there is a paucity of data to guide progress in their classification. Moreover, the majority of publications only report tumor size as less than or greater than 5 cm, presumably based on conventions of the TNM system that remained unchanged for 40 years, thereby affecting progress of STSHN classification. This formed the impetus for change in the 8th edition in 2 key ways: 1) several soft tissue sarcoma site based changes occurred including STSHN now having its own system, and 2) primary tumor size cut-offs of 2 cm and 4 cm used in STSHN now reflect sizes that head and neck specialists commonly encounter in their practice. This update was pragmatic in modifying the TNM from a system with a T category not serving STSHN and which was originally based on sarcoma data from non-head and neck anatomic sites. The background to this change is outlined which provides a framework in which data can be reported to generate evidence for future staging modifications.

Synovial Sarcoma of the Larynx: Report of a Case and Review of Literature

Sarcomas account for less than 1% of malignant neoplasms arising in the head and neck in adults. Laryngeal synovial sarcoma is an extremely rare form of laryngeal malignancy with less than 20 cases reported in the literature. We report the case of a 48-year-old man with synovial sarcoma of the larynx. He underwent excision of the tumor followed by radiation. He is alive in remission at 36 months. The literature on synovial sarcoma of the larynx is reviewed.

Head and Neck Soft Tissue Sarcomas Treated with Radiation Therapy

Head and neck soft tissue sarcomas (HNSTSs) are rare and heterogeneous cancers in which radiation therapy (RT) has an important role in local tumor control (LC). The purpose of this study was to evaluate outcomes and patterns of treatment failure in patients with HNSTS treated with RT. A retrospective review was performed of adult patients with HNSTS treated with RT from January 1, 1998, to December 31, 2012. LC, locoregional control (LRC), disease-free survival (DFS), overall survival (OS), and predictors thereof were assessed. Forty-eight patients with HNSTS were evaluated. Five-year Kaplan-Meier estimates of LC, LRC, DFS, and OS were 87, 73, 63, and 83%, respectively. Angiosarcomas were found to be associated with worse LC, LRC, DFS, and OS. Patients over the age of 60 had lower rates of DFS. HNSTSs comprise a diverse group of tumors that can be managed with various treatment regimens involving RT. Angiosarcomas have higher recurrence and mortality rates.

Excellent local control and survival after postoperative or definitive radiation therapy for sarcomas of the head and neck

BACKGROUND

To report our results with postoperative or definitive radiation therapy in head and neck sarcomas.

METHODS

We performed a retrospective analysis of 26 patients suffering from head and neck sarcomas, who received postoperative or definitive radiation therapy between 2003 and 2012. Median age was 64 years (19-88) and 69 % were male. Tumor locations were skull (including skin) in 31 %, paranasal sinus/orbita in 27 % and neck (including pharynx/larynx) in 42 %. Median tumor size was 4.6 cm (1-12 cm). 22 patients (85 %) presented in primary situation. Stage at presentation (UICC 7(th) for soft tissue sarcomas) was as follows: Ia:4 %, IIa:50 %, IIb:15 %, III:31 %. All except one patient suffered from high grade lesions (G2/3 FNCLCC), predominantly angiosarcoma (35 %), MFH (19 %) and synovial sarcoma (15 %). Surgery was performed in 21 pts (81 %), resulting in free margins in 10 (38 %), microscopically positive margins in 6 (23 %) and gross residual disease in 5 (19 %). Median dose to the primary tumor region was 66Gy (45-72Gy) in conventional fractionation, using 3D-CRT in 65 %, IMRT in 27 % and electrons in 8 %. 50 % of the patients also received sequential chemotherapy.

RESULTS

Median follow up was 39 months (8-136). We observed three local recurrences, transferring into estimated 3- and 5-year local control rates of 86 %. One additional patient failed distantly, resulting in 3- and 5-year freedom from treatment failure rates of 82 %. Four patients have deceased, transferring into 3- and 5-year overall survival rates of 88 % and 82 %, respectively. Only two of the four deaths were sarcoma related. Maximum acute toxicity (CTCAE 3.0) was grade 1 in 27 % of the patients, grade 2 in 50 % and grade 3 in 23 %. Severe acute toxicity was mainly represented by mucositis and dysphagia. Maximum late toxicity was grade 1 in 31 %, grade 2 in 15 % and grade 3 in 19 % of the patients. Severe late toxicity included skin ulceration (n = 1), dysphagia with persistent tube dependency (n = 1), persistent sinusitis (n = 1) and hearing loss (n = 2).

CONCLUSION

Excellent local control and overall survival rates can be achieved with postoperative or definitive radiation therapy with acceptable acute and late toxicities in patients suffering from sarcomas of the head and neck region.

Outcomes of the treatment of head and neck sarcomas in a tertiary referral center

Head and neck sarcomas are a rare and heterogeneous group of tumors that pose management challenges. We report our experience with these tumors. Forty consecutive patients treated for 44 head and neck sarcomas between 1997 and 2014 were culled from our prospectively maintained head and neck database. Five patients were excluded. The adult cohort consisted 29 (83%) patients of a mean age of 57.7 years, with 33 sarcomas. The most common diagnoses were undifferentiated pleomorphic sarcoma (27%) and chondroblastic osteosarcoma (21%). Clear surgical margins were achieved in 24/33 (73%) lesions. Twenty-two patients received radiotherapy and/or chemotherapy. Fourteen patients developed local (n = 6), regional (n = 1) and distant (n = 7) recurrence. The overall 5-year survival was 66% with a mean survival interval of 66.5 months. Recurrent sarcoma, close (<1 mm) or involved surgical margins and advanced age were associated with statistically significantly reduced survival. The pediatric cohort consisted 6 (17%) patients, with a mean age of 9 years. Five patients had primary embryonal rhabdomyosarcomas and one had chondroblastic osteosarcoma. Clear surgical margins were achieved in five (83%) patients. All patients received adjuvant radiotherapy and/or chemotherapy. Mean survival interval was 102 months. Three patients developed local (n = 1) or distant (n = 2) recurrence. Twenty-three free and 8 pedicled flaps were performed in 25 patients. Eleven out of thirty-nine (28%) lesions in 11 patients developed a complication. In conclusion, head and neck sarcomas are best managed by a multidisciplinary team at a tertiary head and neck referral center and resection with clear margins is vital for disease control.

Role of radiation therapy for non-extremity soft tissue sarcomas

BACKGROUND

Negative surgical margins are uncommon for non-extremity soft tissue sarcomas. Radiation therapy is usually recommended to improve local control; however, appropriate RT dosing is challenging due to nearby dose-limiting normal structures.

MATERIAL AND METHODS

Comprehensive literature search using PubMed (March 2014).

RESULTS

Data suggest radiation therapy is an important modality in maximizing local tumor control in non-extremity sarcomas.

CONCLUSION

The literature supports the use of RT to improve local control for non-extremity soft tissue sarcomas.

Analysis of Clinical Prognostic Factors for Adult Patients with Head and Neck Sarcomas

Objective

To evaluate the treatment, outcome, and prognostic factors in patients with head and neck sarcomas treated in an academic medical center.

Study Design

Case series.

Setting

Academic medical center.

Subjects and Methods

We performed a retrospective analysis of adult patients (n = 97) with primary head and neck sarcomas treated between 2000 and 2012. We analyzed the treatment, outcome, and potential factors predictive of disease-free survival and disease-specific survival. We also evaluated the outcome and prognostic factors in patients with bone and soft tissue sarcomas.

Results

The median overall survival was 6.8 years, with 2-year and 5-year overall survival rates of 78% (95% confidence interval [CI], 66%-86%) and 59% (95% CI, 44%-72%), respectively. Univariable analysis revealed that age at diagnosis (>60 years: hazard ratio [HR], 2.7; 95% CI, 1.2-6.2; P = .01), surgical intervention (HR, 8.3; 95% CI, 3.5-19.5; P < .001), and metastatic disease (HR, 4.3; 95% CI, 1.3-13.6; P = .01) were significantly associated with disease-specific survival.

Conclusion

In this study, patients over the age of 60 years at diagnosis and those with inoperable disease at initial presentation had significantly worse disease-specific survival. Surgical intervention remains the optimal treatment modality for those with resectable disease and was associated with significantly better survival in this heterogeneous series. Further multi-institutional studies are required to better define prognostic factors in individual histological subtypes.

Head and neck sarcomas: analysis of the SEER database

OBJECTIVE

To summarize the epidemiology of sarcomas occurring in the head and neck and identify prognostic factors for patient survival.

STUDY DESIGN AND SETTING

Cross-sectional analysis of the National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) program.

METHODS

The SEER 18 registries, comprising sarcoma diagnoses made from 1973 to 2010, were queried for sarcomas arising in the head and neck. Pediatric and adult patients were analyzed separately, and multivariate and propensity-matched analyses were performed to identify predictors of disease-specific survival.

RESULTS

In all, 11,481 adult cases and 1244 pediatric cases were identified. In adults, the most common histologic subtypes were malignant fibrous histiocytoma (MFH), Kaposi sarcoma, and hemangiosarcoma, while in the pediatric cohort, the most common histologic subtypes were rhabdomyosarcoma, MFH, and osteosarcoma. Cause-specific 2-, 5-, and 10-year survival rates were 76%, 66%, and 61% for adults and 84%, 73%, and 71% for pediatric patients. Multivariate analysis performed for adults revealed that male gender, absence of radiation therapy, and stage I disease were associated with improved cause-specific survival reaching statistical significance. However, a propensity-matched model demonstrated no significant difference in cause-specific survival between patients who received radiation and those who did not.

CONCLUSION

Sarcomas, a heterogeneous group of malignant mesenchymal tumors, are uncommonly found in the head and neck. This study represents the largest analysis of patients with head and neck sarcomas in the literature and demonstrates the impact of age, gender, primary site, histology, and radiation status on overall prognosis.

Soft tissue sarcomas of the head and neck. Clinical and pathological evaluation of 108 cases in Mexico

BACKGROUND

Sarcomas constitute 1% of all malignancies, but 10% occur in the head and neck (HN), and they are poorly understood. We present a large series of Soft Tissue HN sarcomas in Mexican patients with survival analysis.

STUDY DESIGN

This is a retrospective study of cases in a cancer hospital.

METHODS

Review of files and pathology material. Literature review.

RESULTS

We analysed 108 patients (55 men / 53 women). The age at presentation was 37 years. The original diagnosis changed in nine cases (8.3%). The most common subtype was rhabdomyosarcoma. Ninety percent of tumours were deep, 91% were high grade, 44% had metastasis, 63% measured >5 cm, overall 5-year survival (5 y-OS) was 48%, and histological high grade was associated with poor survival (p = 0.026).

CONCLUSION

Sarcomas of the HN are rare. The most affected sites were paranasal sinuses. The majority of tumours were deep, > 5 cm and high grade, 50% had metastasis, the 5 y-OS was 48% and the only independent factor associated with 5 y-OS was histologic grade.

Head and neck sarcomas: a comprehensive cancer center experience

Head/neck sarcomas are rare, accounting for about 1% of head/neck malignancies and 5% of sarcomas. Outcomes have historically been worse in this group, due to anatomic constraints leading to difficulty in completely excising tumors, with high rates of local recurrence. We retrospectively analyzed cases of head/neck soft tissue sarcomas (STS) and osteogenic sarcomas managed in a multi-disciplinary setting at Fox Chase Cancer Center from 1999–2009 to describe clinicopathologic characteristics, treatment, outcomes, and prognostic factors for disease control and survival. Thirty patients with STS and seven patients with osteogenic sarcoma were identified. Most STS were high grade (23) and almost all were localized at presentation (28). Common histologies were synovial cell (6), rhabdomyosarcoma (5), angiosarcoma (4), liposarcoma (4) and leiomyosarcoma (3). The type of primary therapy and disease outcomes were analyzed. Cox proportional hazards regression analysis was performed to identify predictors of disease-free survival (DFS) and overall survival (OS). The HR and 95% CI for Cox model and median DFS/OS analyzed by Kaplan-Meier curves were calculated.

Effective utilization of chest X-ray for follow-up of metastatic lung tumor due to soft tissue sarcoma

Computed tomography (CT) is widely used for follow-up of lung metastasis in patients due to soft tissue sarcoma (STS), the frequency of chest X-ray (CXR) is obviously reduced. This study verified the current status of diagnostic measures and the efficacy of CXR. A retrospective analysis of 18 patients that underwent surgery for lung metastasis due to STS was performed. The investigation compared the follow-up interval using CT after STS surgery, time from STS surgery to lung metastasis, tumor size of lung metastasis, detection rate with CXR, time from detection to surgery for lung metastasis, number of CT scans and follow-up interval using CT after detection of lung metastasis. The follow-up interval when using CT after STS surgery was 3.5 months (m). Time from STS surgery to lung metastasis was 34.3m. Tumor size of lung metastasis was 15 mm, and the detection rate by CXR was 66.7%. The time from detection to surgery for lung metastasis was 4.8m, the number of CT scans was 3.1, and the interval was markedly shortened to 1.6m. Follow-up should be performed by CXR if the tumor is detected by CXR. CT evaluation is required when the tumor size has increased, and prior to surgery for lung metastasis.

Prognostic factors and treatment strategies for adult head and neck soft tissue sarcoma

Adult head and neck soft tissue sarcomas are rare and display a variety of histological types and clinical characteristics; they are also associated with a variety of mortality risks. The purpose of this study was to examine all patients treated at the Instituto Nacional de Cancerologia for head and neck sarcoma during a 5-year period. Fifty-one adult patients were examined and treated for head and neck sarcomas from 2004 to 2009. The 51 tumours were histologically re-evaluated by expert pathologists and classified as low, intermediate or high grade sarcomas. A multivariate analysis was performed to evaluate the surgical margins, histological grades, and clinical stages as prognostic factors for the disease. Adult head and neck soft tissue tumours are rare, and they are associated with poor prognosis for patients, especially at clinical stages III and IV. The average survival rate after 2 years is 45%, and most of these patients die because of disease progression and metastases.

Maxillary Sinus Sarcomas: Epidemiological and Clinicopathological Experience of 25 Years in a National Reference Cancer Center

The aim of this study was to report our experience with malignant soft tissue tumors of the maxillary sinus in the period between 1985 to 2010. This is a retrospective case study in a tertiary cancer center setting. Review of patient's records and new evaluation of pathological specimens were made for 20 patients (14 men and 6 women) still met present criteria. After review the most common histological diagnoses were malignant peripheral nerve sheath tumor and malignant fibrous histiocytoma. There are male sex predilection, the median age was 38.9 years; 95% of tumors were >5 cm, 80% were high grade, 0% have metastatic disease at the diagnosis and the tumors were initially treated by surgical resection had better survival (p = 0.02). We present the results of a one of the larger series published to date in maxillary sinus sarcomas where analyzed the clinicopathological characteristics of 20 cases.

Radiotherapy following gross total resection of adult soft tissue sarcoma of the head and neck

PURPOSE

This study reports the outcomes of adults with soft tissue sarcoma (STS) of the head and neck following resection and postoperative radiotherapy (RT), and provides a framework for explaining the issues that radiation oncologists must understand to manage patients with this diverse group of tumors.

METHODS AND MATERIALS

Twenty-four patients met the following inclusion criteria of this study: age ≥19 years, head or neck primary site, STS, with the exception of rhabdomyosarcoma, Ewing, or angiosarcoma variants, and curative-attempt treatment with gross total tumor resection followed by RT.

RESULTS

All patients underwent gross total tumor resection followed by adjuvant RT at our institution during the 28-year period between June 1, 1981, and December 31, 2009. This is a mature study with a median follow-up of 11 years (range, 0.6-27 years). No patient was lost to follow-up. All recurrences were at the primary site. No patient developed an isolated regional or distant recurrence. No patient developed synchronous nodal or distant recurrences at the time of local recurrence. Half of the recurrences presented within 1 year of completing RT, but there were 2 cases where we did not detect recurrence until years 6 and 8 after RT. No recurrence was successfully salvaged. The actuarial rate of local control and relapse-free survival was 83% (95% CI [confidence interval], 63%-94%) at 5 years and 73% (95% CI, 51%-87%) at 10 years. The incidence of moderate to severe treatment complications was 4%.

CONCLUSIONS

Our series documents that gross total resection followed by RT cures most patients (75%) with the most common types of STS of the head and neck. All recurrences were local, meaning near the primary site in tissue that received the full RT prescription dose. For this reason, modifying the approach to treatment of the primary tumor site is the only strategy that will meaningfully improve outcomes for this group of patients.

Adult head and neck soft tissue sarcomas: treatment and outcome

We have retrospectively analysed the experience of a musculoskeletal oncological unit in the management of adult head and neck soft tissue sarcomas from 1990 to 2005. Thirty-six patients were seen, of whom 24 were treated at this unit, the remainder only receiving advice. The median age of the patients was 46 years. Most of the sarcomas were deep and of high or intermediate grade with a median size of 5.5 cm. Eleven different histological subtypes were identified. Wide excision was possible only in 21% of the cases. 42% of the patients developed local recurrence and 42% developed metastatic disease usually in the lungs. Overall survival was 49% at 5 years. Tumour size was the most important prognostic factor. Adult head and neck soft tissue sarcomas have a high mortality rate with a high risk of local recurrence and metastatic disease. The rarity of the disease would suggest that centralisation of care could lead to increased expertise and better outcomes.

Management of adult soft tissue sarcomas of the head and neck

Adult soft tissue sarcoma of the head and neck are rare and represent a heterogeneous group of tumours of different histological variants. Management of these neoplasms presents a great challenge. Malignant fibrous histiocytoma, fibrosarcoma, angiosarcoma and malignant peripheral nerve sheath tumour are the most frequently found sarcoma types in the head and neck. Although traditional morphological assessment is the foundation of clinical decision making, the role of immunohistochemistry and molecular biology are useful for diagnosis, prognosis and identification of possible targets for molecular therapy. The most frequently involved tumour sites are scalp/face, sinonasal tract/anterior skull base and parotid/neck. The management of soft tissue sarcomas in the head and neck is primarily surgical. Since it is difficult to obtain wide margins during surgical treatment in head and neck sarcomas, because of anatomic constraints, most patients undergo post-operative irradiation. Survival varies from 50 to 80%. Prognostic factors are tumour grade, margin status and tumour size. With further insight into the biology of soft tissue sarcoma, modern imaging techniques and new treatment options, we will most certainly be able to improve clinical outcome in patients with soft tissue sarcoma in the upcoming years.

Definitive radiotherapy and single-agent radiosensitizing ifosfamide in patients with localized, irresectable soft tissue sarcoma: a retrospective analysis

Background and Purpose

Standard therapy for soft-tissue sarcomas remains complete resection. For primary radiotherapy local control rates of 30-45% have been reported. We analyzed retrospectively 11 cases of radiochemotherapy with single-agent ifosfamide in patients with macroscopic soft-tissue sarcomas.

Patients and Methods

The patients were treated in irresectable high risk situations. Radiation therapy was performed with median 60 Gy. During the first and fifth week the concomitant chemotherapy with ifosfamide was added. Two patients received trimodal therapy with additional regional hyperthermia.

Results

The therapy was completed in 73% of the patients. Average local control time was 91 months, median disease-free-survival/overall-survival was 8/26 months. Five-year rates for local control/disease free survival/overall survival were 70%/34%/34%. The limited prognosis is mainly caused by systemic treatment failure.

Conclusions

The data strongly suggest a better outcome of radiochemotherapy with ifosfamide compared to radiotherapy alone and radiotherapy in combination with other radiosensitizers.

The role of surgery and radiotherapy in treatment of soft tissue sarcomas of the head and neck region: review of 30 cases

BACKGROUND

Thirty adult patients with head and neck soft tissue sarcoma (HNSTS) treated between 1987 and 2000 were retrospectively analysed.

PATIENTS AND METHODS

The most frequent histopathological subtypes were chondrosarcomas (27%) and malignant fibrous histiocytoma (20%). The surgical resection was performed in 25 of the 30 patients (83%). Twenty-three patients in the surgical resection arm received postoperative radiotherapy.

RESULTS

Five-year local control rates for patients with negative surgical margins (n=9), microscopically positive disease (n=10), gross residual disease (n=6) and inoperable cases (n=5) were 64, 70, 20 and 0%, respectively. However, there was no significant difference in local control between patients with negative or microscopically positive disease who received postoperative radiotherapy (71 vs. 70%). The patients who received doses>or=60 Gy had significantly higher local control rates than the ones who received doses lower than 60 Gy (p=0.048). The local control rates were lower in patients with grade 2-3 tumours when compared with grade 1 tumours (44 vs. 83%). The median overall survival of whole group was 31 months. Median survivals of patients receiving both surgery and radiotherapy with negative and microscopically positive margins were significantly better than patients who were not treated with surgery (34.8 and 36 vs. 13.3 months).

CONCLUSION

Our results confirm that the optimal treatment of HNSTSs is complete surgical excision, and that postoperative adjuvant radiotherapy clearly improves local control.

Sarcomas of head and neck - A 10 yrs experience

38 cases of sarcoma of head and neck region were analysed in a retrospective way in relation to age, anatomic location, histological, clinical profile, and surgical approaches. Compared to other types of head and neck neoplasms, such as squamous cell carcinoma, soft tissue sarcomas have low rates of regional metastases. However the biological behaviour of soft tissue sarcoma is more aggressive specially in paediatric age group. In the present series, CT scan was considered as the primary modality of investigation. Surgery generally has been recommended as the primary method of treatment for achieving local control, except in those high-grade tumours arising in sites not amenable to resection. 3-year and 5-year survival rates in this present series 50% and 31.6% respectively.

Primary paraspinal leiomyosarcoma invading the cervical spinal canal successfully treated with surgery, radiotherapy, and chemotherapy

✓A primary paraspinal leiomyosarcoma invading the spine is an exceedingly rare neoplasm that may clinically mimic a schwannoma. The authors report a case involving a 45-year-old man with a primary leiomyosarcoma of the cervical paraspinal musculature that invaded the spinal canal at C1–2 and subsequently metastasized to the lungs and pancreas. Aggressive treatment consisting of resection of the primary tumor, adjunctive radiation therapy and chemotherapy, and surgical debulking of metastatic disease resulted in local tumor control at the primary site and long-term survival of the patient.

Synovial sarcoma of the parapharyngeal space

Synovial sarcoma is a rare soft tissue sarcoma in the head and neck region and parapharyngeal space. A 21-year-old girl presented with a 6-month history of progressive right arm pain, neck mass and upper aerodigestive tract obstruction. On physical examination there was a large painless mass arising from the right-sided parapharyngeal space causing airway obstruction and with no cervical lymphadenopathy. Initial magnetic resonance imaging (MRI) revealed a large tumor in the right-sided parapharyngeal space. She underwent near total resection of the tumor. Pathologic report disclosed the diagnosis of synovial sarcoma. She then received postoperative adjuvant external radiotherapy to the primary site and a dose of 60 Gy was delivered. Less than 8 months after the completion of the treatment she developed widespread lung metastases. Herein we describe the clinical, radiological and pathological finding of the case.

Is routine chest radiography a useful test in the follow up of all adult patients with soft tissue sarcoma?

Following treatment for localized soft tissue sarcoma the risk of relapse is either locally or in the lungs. In Edinburgh patients are reviewed every 6 months with a chest X-ray (CXR). The radiation exposure over a 10 year follow up remains small, but it is unclear if all patients, irrespective of the initial grade of their primary tumour, require this. To determine the pick up rate of lung metastases by routine CXR over a 10 year period and to review the primary histology. Adult patients on routine follow up between 1994 and 2004 were identified and the notes of those with lung metastases reviewed. Data was collected on their initial histology, and date and method of diagnosis of lung metastases. 179 patients were under follow up. 24 (13%) developed lung metastases. For 2, notes were not found. 6 (27%) had metastases diagnosed by routine CXR, 9 (41%) had metastases diagnosed by non routine CXR and 7 (32%) had metastases diagnosed by CT. On review of histology none were grade 1, 4 (18%) were grade 2 and 18 (82%) were grade 3. 155 patients received. 6 monthly CXR for 10 years with no detection of lung metastases. Lung metastases occurred in a minority of patients (13%) and most (82%) occurred in patients with grade 3 tumours. No patients with grade 1 tumours developed lung metastases. Thus routine CXR may be appropriate on grade 3 tumours, but not on lower grade tumours where other risk factors are absent.

Optimizing localization accuracy in head and neck, and brain radiotherapy

The purpose of this study was to investigate the impact on localization of utilizing contrast-enhanced CT scans and the formal input of a radiologist in the planning process. 25 head and neck/brain patients had pre- and post-contrast CT scans in the treatment position. Radiotherapy treatment was planned on the unenhanced CT images as per standard practice. Retrospectively, their scans (unenhanced and enhanced) were re-contoured by two oncologists and a radiologist. These new contours were compared with the original unenhanced treatment contours and differences in contour volume, geographical isocentre position and tolerance coverage of the associated planning target volumes (PTVs) were evaluated using the original plans. The use of contrast enhanced CT data during localization by the oncologist shows little change in gross tumour volumes (GTVs) or PTVs, geographical position or tolerance coverage for the targets in the brain studied here. Larger changes in mean volume are seen for the head and neck cases alone. Changes are greater and statistically significant (p < 0.05, Wilcoxon signed rank test) for localization by the radiologist. Furthermore, when comparing the original PTV marked by the oncologist with a new PTV re-contoured by the oncologist, but based on a GTV marked-up by the radiologist, again statistically significant (p < 0.01) changes in percentage volume are noted. Intraoperator precision is good, percentage volume differences being of the order 3-6%. PTVs also show improved standard deviations compared with GTVs. Geographic shifts are generally within our departmental tolerance levels for daily patient setup. Comparing precision of unenhanced data with enhanced, mean percentage volume changes are smaller, but not statistically significant. The use of enhanced scan data for localization has little effect on size, geographical position or tolerance coverage of PTVs marked up by the oncologists in this study. However, more important is the input from a radiologist. Statistically significant differences due to mark-up on enhanced scans by the radiologist are shown. Furthermore, significant differences are also seen between PTVs based on oncologist-generated GTVs, and those based on radiologist-generated GTVs.

Prognostic factors in adult soft tissue sarcomas of the head and neck: A single-centre experience

Adult soft tissue sarcomas of the head and neck are rare and consist of a variety of histopathological subtypes and sites. The purpose of this study was to review patients treated for adult soft tissue sarcomas of the head and neck at our institute. The medical records of 41 adult patients treated for head and neck soft tissue sarcomas between 1983 and 2004 were reviewed. Thirty-six tumours were histologically reviewed. Histopathological revision showed that 7% of the original sarcomas were found not to be sarcomas and 39% of the sarcoma subtypes changed. Multivariate analysis showed that surgical margin status and lymph node metastases are the most important prognostic factors. Review of histopathological examination of tumours showed a change in subtype in a substantial number of head and neck sarcomas. Negative surgical margins are an important prognostic factor, but are difficult to obtain in head and neck sarcomas.

Soft-tissue sarcomas of the head and neck: a retrospective analysis of the Alberta experience 1974 to 1999

BACKGROUND

Soft-tissue sarcomas (STS) of the head and neck constitute a heterogeneous group of rare malignant tumors occurring in an uncommon site. The most common subtypes of STS in the head and neck are malignant fibrous histiocytoma, dermatofibrosarcoma protuberans, and fibrosarcoma. Evidence based subtype-specific treatment decisions are often not possible.

METHODS

The medical records of 110 patients diagnosed with head and neck sarcomas were reviewed. All were treated at one of the two major Cancer Centers in Alberta, Canada, between 1974 and 1999. Potential prognostic factors including age, sex, tumor size, histology, grade, tumor location (superficial or deep), and use of adjuvant treatment were evaluated. Cox proportional hazards models were developed to study the impact of these covariates on survival.

RESULTS

The median duration of follow-up was 61.5 months. Five year overall, disease specific, and relapse free survival were 65.8%, 83.4%, and 74.2%, respectively. With use of a Cox proportional-hazards model, tumor stage and grade were important prognostic factors affecting survival.

CONCLUSIONS

Tumor size and grade were important prognostic factors affecting survival. Tumor location in relation to the superficial fascia (depth) was the best predictor of outcome. The overall and disease-free survival in this patient group was excellent. However, this likely caused by the high proportion of patients with low-grade tumors in our study.

Sarcoma of the larynx: treatment results and literature review

BACKGROUND

Sarcomas of the larynx are rare neoplasms that constitute less than 1% of laryngeal malignancies. A Medline search found no large series focusing on laryngeal sarcomas. We reviewed the cases of laryngeal sarcomas treated in our cancer center and compared our experiences and treatment results with those from other centers.

METHODS

A retrospective review of 10 patients with laryngeal sarcoma treated in our institute between 1980 and 2000 was done to identify tumor characteristics, therapeutic modalities, and treatment outcomes.

RESULTS

The patients showed a male predominance (9/10) and presented 8 types of pathology. Nine patients underwent surgery, including 2 total laryngectomy, 4 partial laryngectomy, and 3 endoscopic laser cordectomy. During a median follow-up of 92 months, the 5-year overall survival and disease-specific survival were 76% and 90%, respectively. Two patients developed recurrence, including 1 local recurrence and 1 distant metastasis.

CONCLUSION

Surgical intervention was the first choice in the treatment of laryngeal sarcomas. The prognosis is relatively good when compared with sarcoma originating from other anatomic sites.

Adult head and neck soft tissue sarcomas

BACKGROUND

The purpose was to determine the optimal treatment for adult patients with head and neck soft tissue sarcomas.

METHODS

We conducted a review of the pertinent literature.

RESULTS

Local control after surgery alone or combined with radiotherapy was obtained in approximately 60% to 70% of the patients. The probability of local control is influenced by histologic grade, tumor size, and surgical margins. Patients with high-grade tumors and/or positive margins have improved local control if adjuvant radiotherapy is used. Distant metastases occurred in 10% to 30% of patients. The 5-year overall and cause-specific survival rates varied from approximately 60% to 70% and are affected by age, histologic grade, previous treatment of tumor, invasion of deep structures, and adequacy of surgery.

CONCLUSIONS

The optimal treatment for adult head and neck soft tissue sarcomas is surgery. Adjuvant radiotherapy improves outcomes for those with high-grade tumors and/or positive margins. Radiotherapy alone will cure a small subset of patients with unresectable tumors.