Minimal Increase in Survival Throughout the Years in Patients with Soft Tissue Sarcoma with Synchronous Metastases: Results of a Population-Based Study

Ibero-American Consensus for the Management of Liver Metastases of Soft Tissue Sarcoma: Updated Review and Clinical Recommendations

Liver metastases from soft tissue sarcoma (STS) (excluding gastrointestinal stromal tumors) are rare and more commonly arise from retroperitoneal and intra-abdominal primary sites. Chemotherapy remains the mainstay of treatment for disseminated disease, but its effectiveness is limited and patients typically have a dismal prognosis with short survival. However, when metastases are confined to the liver (without pulmonary involvement), some patients may benefit from local techniques, either surgical or nonsurgical, that can provide long periods of disease-free survival. Due to the rarity of STS, especially with liver metastases, and the heterogeneity of histologies and biological behavior, there is a lack of standardized treatment guidelines and universally accepted criteria for this specific setting. To fill this gap, a multidisciplinary working group of experts in sarcoma and liver surgery reviewed the literature and available evidence and developed a set of clinical recommendations to be voted and discussed in the I Ibero-American Consensus on the Management of Metastatic Sarcoma, held at the III Spanish-Portuguese Update Meeting on the Treatment of Sarcomas in May 2024. Herein, the voting results of this meeting and the resulting consensus recommendations are presented, and their applicability, strengths, and limitations are discussed.

The Decline and Fall of the Current Chemotherapy Paradigm in Soft Tissue Sarcoma

BACKGROUND/OBJECTIVES

Despite conventional cytotoxic chemotherapy treatments, soft tissue sarcoma continues to remain a terminal diagnosis for most patients. Numerous chemotherapeutic agents have been trialed in soft tissue sarcoma, with marginal improvement in overall survival. Novel therapeutic approaches are needed to improve outcomes for this entity.

METHODS

the literature was reviewed, including a summary of pertinent adjuvant/neoadjuvant clinical trials and trials for metastatic disease.

RESULTS

Chemotherapeutic agent use in adjuvant/neoadjuvant trials provided limited if any evidence of the benefit of chemotherapy in this space. Despite multiple trials in the metastatic space, novel chemotherapeutic agents appear to have limited long-term benefits for the management of soft tissue sarcoma. Suggestions for further research, particularly with neoadjuvant clinical trials, were made.

CONCLUSIONS

Chemotherapy remains an inadequate treatment option for soft tissue sarcoma, and novel therapies are needed. The neoadjuvant space provides an excellent opportunity to study the effects of innovative treatments in soft tissue sarcoma.

A Novel Approach to Potentially Improving Soft-Tissue Sarcoma Survival: Prophylactic Lung Radiotherapy Inhibits Growth of Lung Metastases and Prolongs Survival in a Murine Soft-Tissue Sarcoma Model

BACKGROUND

 Circulating tumor cells and clusters (CTC) from soft-tissue sarcoma (STS) that become entrapped in the lung can form micro-metastases and lead to pulmonary metastatic disease. Many patients with localized high-risk STS later develop metastases. Radiation is effective at reducing local recurrence by eradicating microscopic infiltration and satellites in the reactive zone surrounding the primary tumor. Prophylactic lung irradiation for patients with high-risk STS is a novel concept to potentially reduce the appearance of macroscopic metastases and improve survival. A proof-of-principle study was performed based on a novel approach: prophylactic lung radiation after resection of the primary tumor to address microscopic pulmonary deposits from CTC.

METHODS

 Immunocompromised mice and luciferase-expressing human fibrosarcoma (HT-1080-Luc) cell lines were used. In phase 1, HT-1080-Luc cells were injected into the tail vein to simulate CTC for the development of pulmonary metastases. Whole-lung irradiation (WLI) was then performed in the treated mice prior to the appearance of macroscopic metastases. In phase 2, a flank tumor was established to simulate a primary STS, followed by a tail-vein injection of HT-1080-Luc cells. Treatment groups included surgical removal of the primary STS and hemithoracic irradiation (HTI). Body weight and bioluminescence data were obtained and the mice were euthanized on Day 31 (phase 1) and Day 15 (phase 2) or when they reached 20% weight loss.

RESULTS

 In phase 1, prophylactic WLI increased survival and decreased pulmonary metastases. In phase 2, prophylactic HTI (left lung) decreased pulmonary metastases compared to controls. Lung histology showed dramatically decreased growth and number of established metastases with HTI. Resection of the primary tumor did not affect the growth of metastases.

CONCLUSION

 Prophylactic WLI after resection of the primary tumor to inhibit the growth of pulmonary metastases from previously entrapped CTCs may be a promising approach to improve survival for patients with localized high-risk STS.

The Musculoskeletal Tumor Society Clinical Practice Guideline on the Management of Metastatic Humeral Disease

Management of Metastatic Humeral Disease is based on a systematic review of published studies surrounding the management of metastatic disease, multiple myeloma, and lymphoma limited to the humerus. This guideline contains seven action statements to assist orthopaedic surgeons, orthopaedic oncologists, physicians, and any other qualified healthcare professionals involved in the surgical management of metastatic disease of the humerus. It is also intended to serve as an information resource for decision makers, researchers, and developers of clinical practice guidelines. In addition to providing pragmatic practice recommendations, this guideline also highlights gaps in the literature and informs areas for future research and quality measure development. This guideline has been endorsed by the American Academy of Orthopaedic Surgeons.

Gene expression-based prediction of pazopanib efficacy in sarcoma

BACKGROUND

The multi-receptor tyrosine kinase inhibitor pazopanib is approved for the treatment of advanced soft-tissue sarcoma and has also shown activity in other sarcoma subtypes. However, its clinical efficacy is highly variable, and no reliable predictors exist to select patients who are likely to benefit from this drug.

PATIENTS AND METHODS

We analysed the molecular profiles and clinical outcomes of patients with pazopanib-treated sarcoma enrolled in a prospective observational study by the German Cancer Consortium, DKTK MASTER, that employs whole-genome/exome sequencing and transcriptome sequencing to inform the care of young adults with advanced cancer across histology and patients with rare cancers.

RESULTS

Among 109 patients with available whole-genome/exome sequencing data, there was no correlation between clinical parameters, specific genetic alterations or mutational signatures and clinical outcome. In contrast, the analysis of a subcohort of 62 patients who underwent molecular analysis before pazopanib treatment and had transcriptome sequencing data available showed that mRNA levels of NTRK3 (hazard ratio [HR] = 0.53, p = 0.021), IGF1R (HR = 1.82, p = 0.027) and KDR (HR = 0.50, p = 0.011) were independently associated with progression-free survival (PFS). Based on the expression of these multi-receptor tyrosine kinase genes, i.e. the features NTRK3-high, IGF1R-low and KDR-high, we developed a pazopanib efficacy predictor that stratified patients into three groups with significantly different PFS (p < 0.0001). Application of the pazopanib efficacy predictor to an independent cohort of patients with pazopanib-treated sarcoma from DKTK MASTER (n = 43) confirmed its potential to separate patient groups with significantly different PFS (p = 0.02), whereas no such association was observed in patients with sarcoma from DKTK MASTER (n = 97) or The Cancer Genome Atlas sarcoma cohort (n = 256) who were not treated with pazopanib.

CONCLUSION

A score based on the combined expression of NTRK3, IGF1R and KDR allows the identification of patients with sarcoma and with good, intermediate and poor outcome following pazopanib therapy and warrants prospective investigation as a predictive tool to optimise the use of this drug in the clinic.

Immunotherapy in soft tissue sarcoma: current evidence and future perspectives in a variegated family of different tumour

INTRODUCTION

In the last few years steps forward in the knowledge of the biology of soft tissue sarcomas (STS) has led to the development of new therapeutic strategies, including immunotherapy.

AREAS COVERED

This review outlines the recent findings on immunological features and provides a synopsis of the results of clinical trials with different immunotherapy approaches in STS, discussing criticisms and how the efficacy of immunotherapy could be improved.

EXPERT OPINION

The heterogeneity of STS has limited generalized approaches of immunotherapy in the disease. Clinical decisions should encompass a comprehensive characterization of the tumour microenvironment (TME), marked by intra-histotype diversity. Profiling of immune cells, checkpoint molecules and antigen target/HLA expression is deemed to re-shape the classical histotype classification for a selection of the most appropriate immune-based treatment. In a synergistic view, tumour-directed treatments, designed on the genetic and epigenetic histotype make-up, should be monitored for their immunomodulant effect and applied to ensure or amplify immunotherapy response. In light of the dynamic nature of the TME, this immunomonitoring should be conducted at baseline and during treatment, for improved therapeutic decisions and rational sequence of treatment combination, pursuing an immunological marker approach by histotype guidance.

Primary Intracranial Leiomyosarcoma Secondary to Glioblastoma: Case Report and Literature Review

Background

Leiomyosarcoma is a highly malignant soft-tissue sarcoma with a poor prognosis. In recent years, treatment for leiomyosarcoma has not shown much progress. Primary intracranial leiomyosarcoma (PILMS) is a much rarer type of neoplasm, which occurs more frequently in immunocompromised patients. PILMS cases reported in the literature are scarce and treatment strategy and prognosis are still under debate. In this study, a case of PILMS secondary to the total resection of giant cell glioblastoma is reported.

Case Description

A 38-year-old male was hospitalized with a three-month history of a temporal opisthotic bump. His medical history included a total resection of a tumor located in the right temporal lobe performed 4 years earlier. Pathological examination led to a diagnosis of giant cell glioblastoma, and the patient underwent postoperative chemotherapy with temozolomide for 6 weeks plus simultaneous radiotherapy with 63.66 Gary. Four years later, during regular follow-up, a preoperative MRI brain scan resulted in a well-defined signal pointing out two nodule-like features located at the right temporal lobe and subcutaneous soft tissue, respectively, and near the area where the previous giant cell glioblastoma was located. The mass was completely removed by a transtemporal approach and postoperative pathology revealed that the mass was a leiomyosarcoma. The patient underwent postoperative radiotherapy and no recurrence occurred until now.

Conclusions

To date, research on soft-tissue sarcoma, especially PILMS, has not made much progress, and a limited number of studies have provided few details on the management of PILMS. The treatment of choice for PILMS is aggressive multimodal treatment based on total tumor resection and radiotherapy. Moreover, systemic treatment with chemotherapy and targeted therapy, such as olaratumab, as well as further research still needs to be performed as many questions are left unanswered. To our knowledge, this is the first report on a case of PILMS secondary to glioblastoma, which might serve as a potential reference for clinicians and clinical studies.

Bone metastasis in extremity soft tissue sarcomas: risk factors and survival analysis using the SEER registry

INTRODUCTION

While lung is the most common site of metastasis, bone metastasis of soft tissue sarcoma is a part of the natural history affecting the prognosis of these patients. To date, no studies have analyzed the histologic subtypes more likely to metastasize to bone, the risk factors for bone metastasis at initial presentation, or the effect that bone metastasis has on the survival of these patients.

MATERIAL/METHODS

Patients were identified from the Surveillance, Epidemiology and End Results database with primary extremity STS between 2010 and 2015. Risk factors for early bone metastasis, survival based on different sites of metastasis, and prognostic factors of survival were analyzed.

RESULTS

Among 8,234 STS, 2.2% (n = 180) presented with skeletal metastasis. Bone metastasis was more likely when regional lymph nodes were involved (OR = 4.48, p = 0.008). Deep and moderate or high-grade sarcomas had 5-12-fold tendency to present with bone and lung metastasis (p = 0.046, 0.006, 0.030, respectively). The 5-year survival rate was 41.2% (26.9-54.9%) for isolated bone metastasis and 32.9% (21.2-45.1%) for patients with bone and lung metastasis. Resection of the primary sarcoma was the only significant predictor of survival (HR = 0.44, p = 0.021) for patients with bone metastasis.

CONCLUSION

High tumor grade, deep location to fascia and regional lymph node metastasis are significant risk factors for skeletal metastasis at diagnosis of an extremity STS. While neither systemic chemotherapy nor radiotherapy of the primary sarcoma has a significant influence on survival in the presence of bone metastasis, radical resection of the primary STS is associated with increased survival.