Local recurrence after surgery for soft tissue sarcoma. The Scandinavian Sarcoma Group experience

[Radiotherapy for soft tissue sarcomas: Technical evolution and impact on clinical benefit]

The standard treatment for extremity soft tissue sarcomas is based on the association of surgery and radiotherapy. This strategy allows local control improvement with the risk of increased toxicity. There is therefore a growing interest to identify those patients who will benefit from radiotherapy and those who will have the same local control with surgery alone. Furthermore, the development of toxicity has been correlated with the extension of the irradiated volume and the volume receiving high doses. Technological development as intensity modulated radiotherapy and image-guided radiotherapy allows limited irradiated volume improving the protection of the organs at risk leading to clinical benefit improvement. Moreover, efforts are being done to improve local control for the patients at high risk of local relapse. In this paper, we discuss all these mentioned aspects.

Extremity Soft Tissue Sarcoma: Tailoring Resection to Histologic Subtype

Soft tissue sarcomas comprise tumors originating from mesenchymal or connective tissue. Histologic grade is integral to prognosis. Because sarcoma management is multimodal, histologic subtype should inform optimum treatment. Appropriate biopsy and communication between surgeon and pathologist can help ensure a correct diagnosis. Treatment often involves surgical excision with wide margins and adjuvant radiotherapy. There is no consensus on what constitutes an adequate margin for histologic subtypes. An appreciation of how histology corresponds with tumor biology and surgical anatomic constraints is needed for management of this disease. Even with the surgical goal of wide resection being obtained, many patients do not outlive their disease.

Effectiveness of arthroscopic versus open surgical stabilisation for the management of traumatic anterior glenohumeral instability

Background  Anterior instability is a frequent complication following a traumatic glenohumeral dislocation. Frequently the underlying pathology associated with recurrent instability is a Bankart lesion. Surgical correction of Bankart lesions and other associated pathology is the key to successful treatment. Open surgical glenohumeral stabilisation has been advocated as the gold standard because of consistently low postoperative recurrent instability rates. However, arthroscopic glenohumeral stabilisation could challenge open surgical repair as the gold standard treatment for traumatic anterior glenohumeral instability. Objectives  Primary evidence that compared the effectiveness of arthroscopic versus open surgical glenohumeral stabilisation was systematically collated regarding best-practice management for adults with traumatic anterior glenohumeral instability. Search strategy  A systematic search was performed using 14 databases: MEDLINE, Cumulative Index of Nursing and Allied Health (CINAHL), Allied and Complementary Medicine Database (AMED), ISI Web of Science, Expanded Academic ASAP, Proquest Medical Library, Evidence Based Medicine Reviews, Physiotherapy Evidence Database, TRIP Database, PubMed, ISI Current Contents Connect, Proquest Digital Dissertations, Open Archives Initiative Search Engine, Australian Digital Thesis Program. Studies published between January 1984 and December 2004 were included in this review. No language restrictions were applied. Selection criteria  Eligible studies were those that compared the effectiveness of arthroscopic versus open surgical stabilisation for the management of traumatic anterior glenohumeral instability, which had more than 2 years of follow up and used recurrent instability and a functional shoulder questionnaire as primary outcomes. Studies that used non-anatomical open repair techniques, patient groups that were specifically 40 years or older, or had multidirectional instability or other concomitant shoulder pathology were excluded. Data collection and analysis  Two independent reviewers assessed the eligibility of each study for inclusion into the review, the study design used and its methodological quality. Where any disagreement occurred, consensus was reached by discussion with an independent researcher. Studies were assessed for homogeneity by considering populations, interventions and outcomes. Where heterogeneity was present, synthesis was undertaken in a narrative format; otherwise a meta-analysis was conducted. Results  Eleven studies were included in the review. Two were randomised controlled trials. Evidence comparing arthroscopic and open surgical glenohumeral stabilisation was of poor to fair methodological quality. Hence, the results of primary studies should be interpreted with caution. Observed clinical heterogeneity in populations and outcomes was highlighted and should be considered when interpreting the meta-analysis. Authors also used variable definitions of recurrent instability and a variety of outcome measures, which made it difficult to synthesise results. When comparable data were pooled, there were no significant differences (P > 0.05) between the arthroscopic and open groups with respect to recurrent instability rates, Rowe score, glenohumeral external rotation range and complication rates. Conclusions  Statistically, it appears that both surgical techniques are equally effective in managing traumatic anterior glenohumeral instability. In light of the methodological quality of the included studies, it is not possible to validate arthoscopic stabilisation to match open surgical stabilisation as the gold standard treatment. Further research using multicentred randomised controlled trials with sufficient power and instability-specific questionnaires with sound psychometric properties is recommended to build on current evidence. The choice of treatment should be based on multiple factors between the clinician and the patient.

Critical study of resection margins in adult soft-tissue sarcoma surgery

INTRODUCTION

Resection margins constitute a recognized risk factor for local recurrence, but their impact on survival is less clear.

HYPOTHESIS

Infiltrative proliferation and satellite nodules are prognostic factors for local and systemic aggressiveness.

TYPE OF STUDY

Retrospective cohort study.

PATIENTS AND METHODS

In 105 patients under curative treatment, resection quality was assessed on UICC criteria (R0/R1) and on a modified version (R0M/R1M) taking account of proliferation contours and satellite nodules for narrow margins (<1mm). Uni- and multi-variate analysis was performed, and Kaplan-Meier survival curves were compared on log-rank.

RESULTS

Mean 5-year local recurrence-free survival (LRFS) was 0.64 [0.52-0.76] after R1 surgery, 0.9 [0.85-0.95] after R0, 0.64 [0.519-0.751] after R1M and 0.92 [0.87-0.96] after R0M. Resection type according to R classification correlated with disease-free survival (DFS) (P=0.028), but not with metastasis-free survival (MFS) (P=0.156). Resection type according to RM classification correlated with DFS and MFS. Multivariate analysis disclosed correlations between LRFS rate and RM resection type (HR 6.77 [1.78-25.7], P=0.005), DFS rate and RM resection type (HR 2.83 [1.47-5.43], P=0.001) and grade (HR=3.17 [1.38-7.27], P=0.003), and MFS and grade (HR=3.96 [1.50-10.5], P=0.006).

DISCUSSION

The microscopic aspect of the proliferation contours and presence of satellite nodules were confirmed as prognostic factors for local and systemic aggressiveness. They impact both disease-free survival and metastasis-free survival in case of margins less than 1mm. Their systematic consideration may help identify patients with elevated systemic risk.

LEVEL OF EVIDENCE

IV.

Factors predicting local recurrence, metastasis, and survival in pediatric soft tissue sarcoma in extremities

BACKGROUND

Pediatric soft tissue sarcomas are rare and differ from those in adults regarding the spectrum of diagnoses and treatment. Sarcomas in extremities may have different prognoses from those located elsewhere.

QUESTIONS/PURPOSES

We sought risk factors predicting local recurrence, metastasis, and overall survival and asked whether radiation and chemotherapy influenced local recurrence, metastasis, and overall survival.

METHODS

We retrospectively reviewed all 98 patients aged 18 years or younger diagnosed with soft tissue sarcomas in extremities from 1990 to 2008. Age, tumor size, depth, location, bone or neurovascular involvement, histologic subtypes, unplanned excision, surgical margins, metastasis at diagnosis, and adjuvant treatments were reviewed for each patient. We determined the effect of each prognostic variable on local recurrence, metastasis, and overall survival.

RESULTS

Ninety-four patients underwent surgical excision and seven patients had local recurrence at a median time of 18.6 months. Radiation therapy reduced the rate of local recurrence. Fourteen patients had metastasis at diagnosis and seven patients later developed metastasis. The median time to metastasis was 20.9 months. Six patients died and the median time to death was 28.0 months. Metastasis at diagnosis was a predictive factor for death.

CONCLUSIONS

When limited to extremities, radiation therapy reduced the rate of local recurrence in pediatric soft tissue sarcomas. Metastases at diagnosis predict death.

Clinical significance of margin status in postoperative radiotherapy for extremity and truncal soft-tissue sarcoma

PURPOSE

To evaluate whether adjuvant radiotherapy (RT) in extremity and truncal soft-tissue sarcoma (STS) patients with microscopically positive or close margins after excision can achieve comparable local control to that of excision with negative margin plus RT.

METHODS AND MATERIALS

A total of 150 patients (111 extremity and 39 trunk cases) treated with conserving surgery and adjuvant RT was analyzed. All surgical margins were classified as being a negative margin or a positive or close margin based on pathologic margin width. RT was delivered with a shrinking-field technique in 150 patients (median, 63 Gy).

RESULTS

All patients were divided into two groups: (A) excision with negative margins plus RT (n = 56) and (B) excision with positive or close margins plus RT (n = 94). Overall, the 5-year local failure-free survival in all patients was 72.9%, and no significant differences were found between the two groups (Group A, 74.7%; Group B, 71.6%). High tumor grade was found to be a significant predictor of local failure. However, Group A was superior to Group B in distant metastasis-free survival (p = 0.02). No significant differences were shown in overall survival between the two groups.

CONCLUSIONS

In our series, margin status did not predict for LF when adjuvant RT was used. We believe that when adjuvant RT is used, re-resection may not be necessary for selected patients with positive or close pathologic margins in the management of extremity and truncal STS patients.

The prognostic significance of margin width for extremity and trunk sarcoma

BACKGROUND AND OBJECTIVES

To evaluate the significance of resection margin for soft tissue sarcoma (STS), we determined local recurrence-free interval (LRFI), distant metastases-free interval (DMFI), and overall survival (OS) for primary extremity and truncal STS with clear margins (> or =10 mm), close margins (1-9 mm), and positive margins (0 mm).

METHODS

Patients were evaluated via review of charts and tumor specimens.

RESULTS

Among 111 patients, tumors were predominantly high grade (86%), > or =5 cm (76%), and deep (81%). A minority of patients received adjuvant radiation (38%) and/or adjuvant chemotherapy (34%). Margin width was > or =10 mm (48%), 1-9 mm (40%), or 0 mm (12%). Margins > or =10 mm were less common for large (P = 0.009) or deep (P = 0.02) tumors. By multivariate analysis, independent factors for LRFI were tumor size (P = 0.04) and margin width (P = 0.03). Independent factors related to DMFI were tumor grade (P = 0.002), size (P = 0.007), and patient age (P = 0.02). Independent factors relating to OS were tumor grade (P = 0.001), size (P = 0.004), and depth (P = 0.03).

CONCLUSIONS

Margins > or =10 mm independently predicted longer LRFI and are optimal for extremity STS resection. Adjuvant radiotherapy should be considered for all STS resected with margins <10 mm, and margin width should be considered when reporting and interpreting LR outcomes for these patients.