Outcome of treatment for limb and limb girdle sarcomas at the Royal Marsden Hospital

Soft-tissue sarcoma in adults: An update on the current state of histiotype-specific management in an era of personalized medicine

Soft-tissue sarcomas (STS) are rare tumors that account for 1% of all adult malignancies, with over 100 different histologic subtypes occurring predominately in the trunk, extremity, and retroperitoneum. This low incidence is further complicated by their variable presentation, behavior, and long-term outcomes, which emphasize the importance of centralized care in specialized centers with a multidisciplinary team approach. In the last decade, there has been an effort to improve the quality of care for patients with STS based on anatomic site and histology, and multiple ongoing clinical trials are focusing on tailoring therapy to histologic subtype. This report summarizes the latest evidence guiding the histiotype-specific management of extremity/truncal and retroperitoneal STS with regard to surgery, radiation, and chemotherapy.

Periscapular amputation as treatment for brachial plexopathy secondary to recurrent breast carcinoma: a case series and review of the literature

AIMS

Recurrent breast carcinoma with brachial plexus involvement is often misinterpreted as a radiation- or chemotherapy-induced brachial plexopathy. We review a case series of 4 patients at our institution within a 1-year period, and describe their diagnostic workup and treatment with a palliative periscapular amputation. Our aim is to describe this entity, indications and benefits of this procedure, when required for progressive disease, with the goal of raising a collective index of suspicion to aid in earlier diagnosis.

METHODS

Four patients with recurrent axillary breast cancer and symptoms consistent with a brachial plexopathy were prospectively collected over a 1-year period. A Pubmed search was conducted; pertinent articles were reviewed and reported.

RESULTS

Patients presented with intractable pain and flaccid paralysis of the ipsilateral limb. All had been previously treated with surgical resection, axillary lymph node dissection, chemotherapy, and radiation therapy. Average time from breast surgery to presentation was 78.75 months (range 11-216 months.) Workup included MRI and biopsy to confirm recurrence. Periscapular amputation was performed for each patient, all of who experienced subjective pain relief postoperatively. Three of the 4 patients are still living; one patient died of disease.

CONCLUSION

Breast cancer survivors presenting with a brachial plexopathy should raise suspicion for recurrent disease. Close evaluation with MRI is the best first step in diagnosis. Although periscapular amputation is an aggressive surgical treatment, it is an acceptable option when disease has progressed to neurovascular involvement and a functionless limb.

A European project on incidence, treatment, and outcome of sarcoma

Background

Sarcomas are rare tumors (1-2% of all cancers) of mesenchymal origin that may develop in soft tissues and viscera. Since the International Classification of Disease (ICD) attributes visceral sarcomas (VS) to the organ of origin, the incidence of sarcoma is grossly underestimated. The rarity of the disease and the variety of histological types (more than 70) or locations account for the difficulty in acquiring sufficient personal experience. In view of the above the European Commission funded the project called Connective Tissues Cancers Network (CONTICANET), to improve the prognosis of sarcoma patients by increasing the level of standardization of diagnostic and therapeutic procedures through a multicentre collaboration.

Methods/Design

Two protocols of epidemiological researches are here presented. The first investigation aims to build the population-based incidence of sarcoma in a two-year period, using the new 2002 WHO classification and the "second opinion" given by an expert regional pathologist on the initial diagnosis by a local pathologist. A three to five year survival rate will also be determined. Pathology reports and clinical records will be the sources of information.

The second study aims to compare the effects on survival or relapse-free period - allowing for histological subtypes, clinical stage, primary site, age and gender - when the disease was treated or not according to the clinical practice guidelines (CPGs).

Discussion

Within CONTICANET, each group was asked to design a particular study on a specific objective, the partners of the network being free to accept or not the proposed protocol. The first protocol was accepted by the other researchers, therefore the incidence of sarcoma will be assessed in three European regions, Rhone-Alpes and Aquitaine (France) and Veneto (Italy), where the geographic distribution of sarcoma will be compared after taking into account age and gender. The conformity of the clinical practice with the recommended guidelines will be investigated in a French (Rhone Alps) and Italian (Veneto) region since the CPGs were similar in both areas.

Evaluating surgery quality in soft tissue sarcoma

To identify pertinent indicators for oncologic outcomes in assessing surgery in soft tissue sarcomas, only local recurrences are considered here. Functional outcomes and treatment morbidity, equally important end-points for evaluating surgery quality, are less frequently reported and are not taken into account in this review. Herein, we review recent publications reporting indicators of surgery quality in soft tissue sarcoma treatment. Local recurrence-free interval is the major end-point in evaluating the quality of surgery. Disease-free survival should not be used because the risk factors for metastases are different from those for local recurrence. Five-year local recurrence-free estimations for limb and trunk wall sarcoma should be below 20%, and best approach 10%. The risk of local recurrence depends on tumour biology (i.e. grade) and quality of surgery as defined by the quality of margins. Better than margin width as measured on the tumour specimen, margin quality determined consensually between surgeons and pathologists is the best indicator for local outcome. Quality of margin should be expressed according the UICC residual disease definitions (R0: in sano, R1: microscopic residual disease, R2: macroscopic residual disease). Other important indicators for surgery quality are treatment in specialised centres, a planned, organised surgery, and treatment within a multidisciplinary team. Soft tissue sarcoma should also be treated in specialised centres. Surgery quality depends on obtained margins that are determined best by close collaboration between the surgeon and the pathologist.

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.

The effect of an unplanned excision of a soft-tissue sarcoma on prognosis

We investigated whether our policy of routine re-excision of the tumour bed after an unplanned excision of a soft-tissue sarcoma was justified. Between April 1982 and December 2005, 2201 patients were referred to our hospital with the diagnosis of soft-tissue sarcoma, of whom 402 (18%) had undergone an unplanned excision elsewhere. A total of 363 (16.5%) were included in this study. Each patient was routinely restaged and the original histology was reviewed. Re-excision was undertaken in 316 (87%). We analysed the patient, tumour and treatment factors in relation to local control, metastasis and overall survival. Residual tumour was found in 188 patients (59%). There was thus no residual disease in 128 patients of whom 10% (13) went on to develop a local recurrence. In 149 patients (47%), the re-excision specimen contained residual tumour, but it had been widely excised. Local recurrence occurred in 30 of these patients (20%). In 39 patients (12%), residual tumour was present in a marginal resection specimen. Of these, 46% (18) developed a local recurrence. A final positive margin in a high-grade tumour had a 60% risk of local recurrence even with post-operative radiotherapy. Metastases developed in 24% (86). The overall survival was 77% at five years. Survival was related to the grade of the tumour and the finding of residual tumour at the time of re-excision. We concluded that our policy of routine re-excision after unplanned excision of soft-tissue sarcoma was justified in view of the high risk of finding residual tumour.

Resection of soft tissue sarcoma of the lower limb after evaluation of vascular invasion with intraoperative intravascular ultrasonography

Background

This study investigated the value of intravascular ultrasonography (IVUS) in the intraoperative assessment of vascular invasion of soft tissue sarcoma.

Methods

In a 4-year interval, of 337 patients with soft tissue sarcoma, 20 patients with tumours of the lower limb in close relation to the neurovascular bundle underwent intraoperative IVUS (20 MHz). Intraoperative findings were correlated with preoperative imaging, histopathological appearance of the resection specimen and patient outcome.

Results

Intraoperative IVUS was technically successful in all 20 patients. It correctly predicted vascular involvement (true positive) in ten of 11 patients who required resection of major vessels. There was one false-negative and one false-positive result. With magnetic resonance imaging, there were ten true-positive and three false-positive scans, and one false-negative diagnosis. IVUS improved the assessment of vascular involvement in four of the 20 patients. Histopathological examination confirmed complete resection (R0) in 18 patients. Mean survival was 37 months, and no local recurrence was observed in these patients.

Conclusion

Vascular infiltration by soft tissue sarcoma can be visualized accurately by IVUS. This may improve intraoperative decisions about vessel resection.

Preoperative Isolated Limb Infusion of Doxorubicin and External Irradiation for Limb-Threatening Soft Tissue Sarcomas

BACKGROUND

At present, limb-sparing surgery is the most appropriate and acceptable treatment option for soft tissue sarcomas of the extremities. To increase the number of limb-sparing resections in the treatment of locally advanced soft tissue sarcomas of the extremities, preoperative radiotherapy and/or chemotherapy are often used. Isolated limb perfusion of cytostatic agents is an effective alternative option but technically complex. Isolated limb infusion, essentially a low-flow isolated limb perfusion without oxygenation via a percutaneous catheter, had been developed as a simple alternative.

OBJECTIVE

The objective of this study was to achieve limb-sparing surgery in patients with locally advanced soft tissue sarcomas of the extremities that would otherwise have required an amputation or a functionally mutilating surgery by performing preoperative isolated limb infusion with doxorubicin and external beam irradiation to obtain local control and make limb-sparing surgery feasible.

METHODS

A total of 40 patients with locally advanced soft tissue sarcomas of the extremities were evaluated between 2002 and 2005. Tumors were located in the lower limb in 28 patients (70%) and in the upper limb in 12 patients (30%). All of these patients were felt to be unresectable and were referred because amputation was considered the only available treatment option. They underwent preoperative isolated limb infusion with doxorubicin (0.7 and 1.4 mg/kg for the upper and lower limbs, respectively). Preoperative external beam radiotherapy started within 3-7 days after isolated limb infusion was administered. The total dose was 35 Gy in ten fractions. After 3-7 weeks, surgery was performed aiming at limb preservation.

RESULTS

Tumor response was seen in 85% of patients, rendering these large sarcomas resectable in most cases. The mean values of pretreatment tumor volume and post-treatment volume were 2797 cm(3) and 1781 cm(3), respectively, with a significant p value of 0.0001. Histologic response was seen in 80% of patients. At a median followup of 15 months (range = 5-35), limb salvage was achieved in 82.5%. Procedure-related complications were limited and easily managed.

CONCLUSION

Isolated limb infusion with doxorubicin is a simple and safe method of regional chemotherapy. The addition of preoperative external beam irradiation helped to increase the rate of limb salvage in patients with large and/or high-grade soft tissue sarcomas of the extremities.

Isolated Limb Perfusion With Melphalan and Tumor Necrosis Factor α for Advanced Melanoma and Soft-Tissue Sarcoma

BACKGROUND

Isolated limb perfusion (ILP) with melphalan is used in the treatment of advanced in-transit melanoma but has no real efficacy for irresectable soft tissue sarcomas arising in the extremities. The addition of tumor necrosis factor (TNF)-alpha may increase response rates for bulky melanoma and for sarcoma, but the potential for major systemic toxicity has limited its use.

METHODS

Between October 2000 and April 2004, 49 ILPs were performed with melphalan and TNF-alpha. All procedures were performed with continuous leakage monitoring and regional hyperthermia.

RESULTS

Forty-nine ILPs were performed for melanoma (n = 30), sarcoma (n = 16), or other tumors (n = 3). The most common indications were widespread in-transit disease for melanoma (n = 29) and irresectable primary disease for sarcoma (n = 9). Complete and partial responses for melanoma were 40% and 37%, and for sarcoma they were 20% and 33%. At a median follow-up of 14 months, 66% of melanoma patients who responded had not experienced local progression, compared with only 37% of sarcoma patients. Progression-free survival was significantly less for patients with sarcoma than melanoma (P = .0476). Four of 16 patients with sarcoma subsequently required amputation for progressive disease.

CONCLUSIONS

ILP with melphalan and TNF-alpha is a valuable treatment for advanced in-transit melanoma. Significant response rates were also seen in irresectable sarcoma, although the duration of response was limited.

Les sarcomes des tissus mous : bonnes pratiques médicales pour une prise en charge optimale

The soft tissue sarcomas are a rare pathology and patient management complex. Good clinical practice should be delineated by rigorous recommendations. In case of suspicion of a sarcoma, precise assessment imagery must be carried out with a biopsy to allow the preparation of the surgical procedure. The surgical procedure should be extensive and complete to enable a macroscopic and microscopic resection. The adjuvant treatment could involve radiotherapy and chemotherapy whose indications should be specified within a multidisciplinary team. Unfortunately, recent studies showed no optimal management for majority of patients treated for sarcomas.

Chirurgie des sarcomes des tissus mous des membres et de la paroi du tronc

For this review of surgery in soft tissue sarcoma, we reviewed literature and added our personal experience. In front of a soft tissue tumour, the major objective is to think it could be a sarcoma. Diagnosis actually is made by core needle biopsies, but sometimes a surgical biopsy is needed. Surgical resection is better defined since ten years and distinguishes resection R0 (in sano), R1 (microscopic residual disease) and R2 (macroscopic residual disease). Quality of resection is determined collegially by confrontation of surgical and pathological reports according recommendations of the French Sarcoma Group (FSG). The risk of local recurrence depends on resection-type and tumour grade. With the help of the surgical classification from FSG, local prognosis is better understood and treatment can be adapted to individual tumours. In experienced hands, local recurrence can be pushed down to near 10 against 20% formerly. Severe complications after sarcoma surgery occur in 14% of cases. Functional outcome studies have benefited from new scoring systems, which complete each other. Isolated limb perfusion is a method that could save limbs in some desperate situations.

CONCLUSION

Due to rarity and treatment specifications, soft tissue sarcoma should be treated in specialised centres.

Limb salvage with isolated perfusion for soft tissue sarcoma: could less TNF-α be better?

BACKGROUND

The optimal dose of TNF-alpha delivered by isolated limb perfusion (ILP) in patients with locally advanced soft tissue sarcoma is still unknown.

PATIENTS AND METHODS

Randomised phase II trial comparing hyperthermic ILP (38-40 degrees ) with melphalan and one of the four assigned doses of TNF-alpha: 0.5 mg, 1 mg, 2 mg, and 3/4 mg upper/lower limb. The main end point was objective tumour response on MRI. Secondary end points were histological response, rate of amputation and toxicity. Resection of the remnant tumour was performed 2-3 months after ILP. The sample size was calculated assuming a linear increase of 10% in the objective response rates between each dose level group.

RESULTS

One hundred patients (25 per arm) were included. Thirteen per cent of patients had a systemic leakage with a cardiac toxicity in six patients correlated with high doses of TNF-alpha. Objective tumour responses were: 68%, 56%, 72% and 64% in the 0.5 mg, 1 mg, 2 mg and 3 or 4 mg arms, respectively (NS). Sixteen per cent of patients were not operated, 71% had a conservative surgery and 13% were amputated with no difference between the groups. With a median follow-up of 24 months, the 2 year overall and disease-free survival rates (95% CI) were 82% (73% to 89%) and 49% (39% to 59%), respectively.

CONCLUSION

At the range of TNF-alpha doses tested, there was no dose effect detected for the objective tumour response, but systemic toxicity was significantly correlated with higher TNF-alpha doses. Efficacy and safety of low-dose TNF-alpha could greatly facilitate ILP procedures in the near future.

Conformity to clinical practice guidelines, multidisciplinary management and outcome of treatment for soft tissue sarcomas

BACKGROUND

The primary management of adult soft tissue sarcomas (STS) is characterized by heterogeneity across centers. Several studies suggest that it is improved when coordinated by specialized sarcoma centers.

PATIENTS AND METHODS

This study, comparing STS patients of the Rhône-Alpes region treated within and outside the cancer network, retrospectively assesses the conformity of medical practice with 'evidence-based medicine' (EBM) reported under the clinical practice guidelines (CPGs) of the French Federation of Cancer Centers. Institutional records of 100 new STS patients seen between 1999 and 2001 in the regional comprehensive cancer center and Lyon University hospital were analyzed retrospectively (50/300 new files randomly selected in each institution). Medical decisions were checked for conformity with CPGs.

RESULTS

Median age was 58 years (range 18-88) and median tumor size was 9 cm (range 1-26). The most common primary sites were extremities, viscera or trunk. The most frequent histology was leiomyosarcoma (21%) or liposarcoma (12%). Only 7% of cases were reviewed by formal multidisciplinary committee before biopsy (with 42% pre-surgery biopsies only). The first surgical resection was R0, R1 and R2 in 26, 29 and 45% of cases, respectively. Conformity to CPGs was rated 52, 81, 94 and 95% for initial surgery, radiation therapy, chemotherapy and follow-up, respectively. At multivariate analysis, pre-surgery multidisciplinary discussion, management in reference center and management within cancer network independently predicted conformity to CPGs.

CONCLUSIONS

Conformity with EBM was similar to previous reports. Elaboration of treatment strategy within a formal multidisciplinary staff and treatment within a cancer network are both important prognostic factors for optimal clinical care.

Buttock Soft Tissue Sarcoma: Clinical Features, Treatment, and Prognosis

BACKGROUND

Primary buttock soft tissue sarcomas in adults are common entities that have been infrequently reported (three clinical series and isolated case reports). We present our experience of buttock sarcomas to better characterize and define the natural history of this condition.

METHODS

Buttock tumors occurring in adults (>16 years) between January 1990 and January 2002 were identified from the Royal Marsden Hospital's Sarcoma Unit prospective database.

RESULTS

Seventy-three buttock sarcomas were evaluated and treated at the Royal Marsden Hospital during this period. Liposarcoma (n = 19), leiomyosarcoma (n = 13), and synovial sarcoma (n = 9) were the most frequent histological types. There were 8 T1 and 61 T2 tumors, and size was not available in 4 patients. Most tumors (n = 64) were located deep to the deep fascia. There were 15 grade 1, 20 grade 2, and 37 grade 3 tumors, and grade was not available in 1 patient. There were 29 tumors contained within the gluteus maximus. Wide excision was performed in 50 patients. Local recurrence and distant metastasis occurred in 15 and 35 patients with a median time of 18 and 8 months, respectively. The rate of local recurrence at 2 years was 20.9% (SE, 6.8%). The 2-year overall and disease-free survival rates were 64.1% (SE, 6.7%) and 48.5% (SE, 6.4%), respectively.

CONCLUSIONS

Buttock sarcomas present special surgical difficulties because of proximity of the sciatic nerve and the ability of tumors at this site to extend into the pelvis and perineum. Size and grade of the tumor were independent predictors for disease-free and overall survival.

TNFalpha-based isolated perfusion for limb-threatening soft tissue sarcomas: state of the art and future trends

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.

Amputation for soft-tissue sarcoma

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

Major amputation for soft-tissue sarcoma

BACKGROUND

Advances in oncological practice have reduced the number of major amputations performed for soft-tissue sarcoma, but this remains a valuable, if infrequent, option for both curative and palliative indications.

METHODS

A review of patients and case-notes was carried out from the prospective sarcoma database at the Royal Marsden Hospital.

RESULTS

Over a 10-year interval, 40 major amputations (18 forequarter, 17 hindquarter and five through hip) were performed, predominantly for disease recurring after previous limb-conserving surgery (31 of 40). A wide variety of soft-tissue sarcoma subtypes was seen; they were often large (more than 10 cm; 18 of 40) or multifocal (six), usually high grade (25), and frequently proximal or involving neurovascular structures such that limb salvage was precluded. Median range age of the patients was 59 (17-87) years. The operative 30-day mortality rate was zero. Hospital stay was a median of 10.5 days for forequarter amputation, and 19 days for hindquarter and through-hip amputation. Local recurrence occurred in ten patients, six of whom had concurrent distant metastases. Twenty-seven patients were alive (20 disease free) at a median follow-up of 12 months, nine of whom were alive without evidence of disease beyond 2 years. Ten patients died after a median of 7.5 months; three survived more than 2 years.

CONCLUSION

Major amputation is a useful procedure in carefully selected patients with soft-tissue sarcoma.

[Free-flap reconstruction of locally advanced soft tissue sarcomas]

STUDY AIM

The aim of this retrospective study was to assess the advantages of free-lap reconstruction in locally advanced soft tissue sarcomas.

PATIENTS AND METHOD

From October 1997 to October 2000, among 256 procedures for sarcomas, 25 were associated with free-lap reconstruction. There were 16 women and nine men (mean age: 45 years). The tumor was located on inferior limbs (n = 15), superior limbs (n = 3) and trunk (n = 7), had a mean size of 12, 10 and 12 cm respectively, and was multifocal (n = 6), or recurrent (n = 10). Ten patients received a neoadjuvant chemotherapy. Tumoral excision was associated with a complementary procedure in 10 patients. Reconstruction was performed with free-laps of the latissimus dorsi (n = 21) and transverse rectus abdominis myocutaneous (TRAM) (n = 4). Early postoperative radiotherapy was associated in 15 patients.

RESULTS

Median duration of the procedure was 6.5 hours. There were no postoperative deaths. Two free-laps necrotized and another free-lap was constructed. Tumoral excision was Ro (n = 20), R1 (n = 4) and R2 (n = 1). With a median follow-up of 20 months, there were no local recurrences in patients Ro. Ten patients developed pulmonary metastases and five of them died.

CONCLUSION

With free-lap reconstruction, tumoral excision was larger, amputation of the limb was avoided in 14 patients, and early postoperative radiotherapy was possible in 15 patients. Multidisciplinary management and collaboration of the oncologist and plastic surgeon are associated with a better prognosis of locally advanced soft tissue sarcomas.