Adherence to consensus-based diagnosis and treatment guidelines in adult soft-tissue sarcoma patients: a French prospective population-based study

Clinical and surgical effectiveness of the multi-disciplinary standardized management model in the treatment of retroperitoneal liposarcoma: Evidence-based clinical practice experience from Fudan Zhongshan

BACKGROUND

To assess the correlation between clinical outcomes and diagnostic accuracy of evaluations carried out by a preoperative multidisciplinary team versus standard surgical care for patients with retroperitoneal liposarcoma undergoing surgery.

METHODS

This comparative study was conducted retrospectively at a specialist assessment center within Zhongshan Hospital, Fudan University, China, between April 2011 and March 2021. Patients were assigned to a multidisciplinary team or nonmultidisciplinary team cohort based on referral to the multidisciplinary team. The primary outcome measured was long-term clinical prognosis, with other outcomes including diagnostic accuracy, 30-day reoperation, duration of stay, perioperative mortality, and medical complications. To mitigate selection bias, we conducted propensity-score matching. Uni- and multivariable Cox proportional hazard models were then used to evaluate the effect of multidisciplinary teams on postoperative survival. The previously specified questionnaire was used to measure the enhancement of awareness and treatment adherence facilitated by multidisciplinary team management. Data analysis was carried out between January 2023 and August 2023.

RESULTS

Of the 521 records that were screened, 139 patients were deemed eligible for inclusion and defined as the multidisciplinary team cohort. At the same time, 382 patients without multidisciplinary team management were also included during that period and defined as the nonmultidisciplinary team cohort. The multidisciplinary team cohort exhibited lower numbers of primary retroperitoneal liposarcoma but a higher tumor grade and a greater proportion of R2 resection. After propensity-score matching, the 1-, 3-, and 5-year overall survival rates were 89.5%, 70.5%, and 62.9%, respectively, in the multidisciplinary team cohort, and 77.1%, 49.8%, and 45.1% in the nonmultidisciplinary team cohort. The diagnostic consistency of the multidisciplinary team group was significantly superior to that of the nonmultidisciplinary cohort (92.5% vs 83.6%, P = .042). Although no significant links were shown with duration of stay (P = .232) and 30-day reoperation (P = .447), the multidisciplinary team participation was linked to a substantial decrease in perioperative mortality (P = .036) and postoperative complications (P = .002). Additionally, the multidisciplinary team group indicated stronger illness awareness and postoperative adherence among individuals with retroperitoneal liposarcoma.

CONCLUSION

The study's findings indicate that multidisciplinary team management could result in improved clinical outcomes, higher diagnostic accuracy, and reduced duration of postoperative stays, complications, and perioperative mortality. The intervention may also enhance disease awareness and postoperative compliance in retroperitoneal liposarcoma patients who undergo surgery. However, evidence quality was deemed low, and prospective studies with robust designs are required. Nonetheless, these results are worth considering.

Indicators of clinical performance in monitoring soft tissue sarcoma management: a population-based perspective

Background

Soft tissue sarcomas (STS) are rare malignancies which prognosis varies significantly by primary site, histological subtype, and tumor stage. Their low incidence, and the complexity of their clinico-pathological characteristics demand standardized, cancer-tailored diagnostics and therapies managed at high-volume, multidisciplinary care centers. This study evaluates the quality of STS management in north-east Italy (Veneto Region) through a list of ad hoc defined clinical indicators.

Methods

This population-based study concerns all incident cases of STS in 2018 (214 cases) recorded in the adult population censored by the Veneto's regional Cancer Registry. Based on the international literature, a multidisciplinary working group of experts identified a set of indicators for monitoring the quality of diagnostic, therapeutic, and end-of-life clinical interventions. The quality of care was assessed by comparing the reference thresholds with the indicators' values achieved in clinical practice.

Results

Diagnostic procedures showed poor adherence to the thresholds, with a low percentage of histological diagnoses validated by a second opinion. The indicators relating to the surgical treatment of superficial, small, low-grade STS, or of medium, high-grade STS of the head-neck, trunk, or limbs were consistent with the thresholds, while for intermediate, high-grade (large-sized, deep) and retroperitoneal STS they fell significantly below the thresholds.

Conclusion

A critical evaluation of the clinical indicators allowed to uncover the procedures needing corrective action. Monitoring clinical care indicators improves cancer care, confirms the importance of managing rare cancers at highly specialized, high-volume centers, and promotes the ethical sustainability of the healthcare system.

Survival Outcomes of Ewing Sarcoma and Rhabdomyosarcoma by High- versus Low-Volume Cancer Centres in British Columbia, Canada

Due to the rarity and complexity of treatment for Ewing sarcoma and rhabdomyosarcoma, studies demonstrate improved patient outcomes when managed by a multidisciplinary team at high-volume centres (HVCs). Our study explores the difference in outcomes of Ewing sarcoma and rhabdomyosarcoma patients based on the centre of initial consultation in British Columbia, Canada. This retrospective study assessed adults diagnosed with Ewing sarcoma and rhabdomyosarcoma between 1 January 2000 and 31 December 2020 undergoing curative intent therapy in one of five cancer centres across the province. Seventy-seven patients were included, 46 seen at HVCs and 31 at low-volume centres (LVCs). Patients at HVCs were younger (32.1 vs. 40.8 years, p = 0.020) and more likely to receive curative intent radiation (88% vs. 67%, p = 0.047). The time from diagnosis to first chemotherapy was 24 days shorter at HVCs (26 vs. 50 days, p = 0.120). There was no significant difference in overall survival by treatment centre (HR 0.850, 95% CI 0.448-1.614). Variations in care exist amongst patients treated at HVCs vs. LVCs, which may reflect differences in access to resources, clinical specialists, and varying practice patterns across centres. This study can be used to inform decisions regarding triaging and centralization of Ewing sarcoma and rhabdomyosarcoma patient treatment.

Mortality patterns of soft-tissue sarcomas worldwide up to 2018, with predictions for 2025

OBJECTIVE

The epidemiological evidence on soft-tissue sarcoma (STS) mortality is inconsistent in geographic and time coverage. This study provides mortality trends for STSs in selected countries worldwide over the last 2 decades, together with predicted figures for 2025.

METHODS

We extracted official numbers of certified deaths coded as C47 (i.e. malignant neoplasm of peripheral nerves and autonomic nervous system) and C49 (i.e. malignant neoplasm of other connective and soft tissue) according to the 10th Revision of the International Classification of Disease and population estimates from the WHO and the Pan American Health Organization databases. We computed age-standardized (world standard population) mortality rates (ASMRs). We used joinpoint regression analysis to identify significant changes in trends and to predict death numbers and rates for 2025.

RESULTS

The pattern emerging from the number of deaths and ASMRs up to 2018 shows an increase in most countries in both sexes. Around 2015 to 2018, ASMRs differed by 2.5-fold in both sexes with the highest rates being registered in Central-Eastern Europe, North America and Australia, while the lowest ones in Latin America, Japan, and Korea. In 2025, the number of STS deaths is predicted to increase in most countries and both sexes, and unfavourable rates are predicted in Central Europe in both sexes.

CONCLUSION

In addition to improvements in STSs registration, unfavourable mortality rates reported in this study reflect inadequate referral of patients with STSs to high-volume multidisciplinary centres, as well as insufficient advancements in STS prevention, diagnosis, and treatments.

Integrated Analysis of TME and Hypoxia Identifies a Classifier to Predict Prognosis and Therapeutic Biomarkers in Soft Tissue Sarcomas

Soft tissue sarcoma (STS) is one of the rarest but most aggressive cancer. It is important to note that intratumoral hypoxia and tumor microenvironment (TME) infiltration play a significant role in the growth and therapeutic resistance of STS. The goal of this study was therefore to determine whether linking hypoxia-related parameters to TME cells could provide a more accurate prediction of prognosis and therapeutic response. An analysis of 109 hypoxia-related genes and 64 TME cells was conducted in STS. Hypoxia-TME classifier was constructed based on 6 hypoxia prognostic genes and 8 TME cells. As a result, we evaluated the prognosis, tumor, and immune characteristics, as well as the effectiveness of therapies in Hypoxia-TME-defined subgroups. The Lowplus group showed a better prognosis and therapeutic response than any other subgroup. It is possible to unravel these differences based on immune-related molecules and somatic mutations in tumors. Further validation of Hypoxia-TME was done in an additional cohort of 225 STS patients. Additionally, we identified five key genes through differential analysis and RT-qPCR, namely, ACSM5, WNT7B, CA9, MMP13, and RAC3, which could be targeted for therapy. As a whole, the Hypoxia-TME classifier demonstrated a pretreatment predictive value for prognosis and therapeutic outcome, providing new approaches to therapy strategizing for patients.

Sarcoma European and Latin American Network (SELNET) Recommendations on Prioritization in Sarcoma Care During the COVID-19 Pandemic

Background

The COVID‐19 outbreak has resulted in collision between patients infected with SARS‐CoV‐2 and those with cancer on different fronts. Patients with cancer have been impacted by deferral, modification, and even cessation of therapy. Adaptive measures to minimize hospital exposure, following the precautionary principle, have been proposed for cancer care during COVID‐19 era. We present here a consensus on prioritizing recommendations across the continuum of sarcoma patient care.

Material and Methods

A total of 125 recommendations were proposed in soft‐tissue, bone, and visceral sarcoma care. Recommendations were assigned as higher or lower priority if they cannot or can be postponed at least 2–3 months, respectively. The consensus level for each recommendation was classified as “strongly recommended” (SR) if more than 90% of experts agreed, “recommended” (R) if 75%–90% of experts agreed and “no consensus” (NC) if fewer than 75% agreed. Sarcoma experts from 11 countries within the Sarcoma European‐Latin American Network (SELNET) consortium participated, including countries in the Americas and Europe. The European Society for Medical Oncology‐Magnitude of clinical benefit scale was applied to systemic‐treatment recommendations to support prioritization.

Results

There were 80 SRs, 35 Rs, and 10 NCs among the 125 recommendations issued and completed by 31 multidisciplinary sarcoma experts. The consensus was higher among the 75 higher‐priority recommendations (85%, 12%, and 3% for SR, R, and NC, respectively) than in the 50 lower‐priority recommendations (32%, 52%, and 16% for SR, R, and NC, respectively).

Conclusion

The consensus on 115 of 125 recommendations indicates a high‐level of convergence among experts. The SELNET consensus provides a tool for sarcoma multidisciplinary treatment committees during the COVID‐19 outbreak.

Implications for Practice

The Sarcoma European‐Latin American Network (SELNET) consensus on sarcoma prioritization care during the COVID‐19 era issued 125 pragmatical recommendations distributed as higher or lower priority to protect critical decisions on sarcoma care during the COVID‐19 pandemic. A multidisciplinary team from 11 countries reached consensus on 115 recommendations. The consensus was lower among lower‐priority recommendations, which shows reticence to postpone actions even in indolent tumors. The European Society for Medical Oncology‐Magnitude of Clinical Benefit scale was applied as support for prioritizing systemic treatment. Consensus on 115 of 125 recommendations indicates a high level of convergence among experts. The SELNET consensus provides a practice tool for guidance in the decisions of sarcoma multidisciplinary treatment committees during the COVID‐19 outbreak.

The COVID‐19 pandemic has caused deferral, modification, or cessation of treatment for patients with cancer. This article presents a consensus on prioritizing recommendations across the continuum of sarcoma patient care.

Incidence and time trends of sarcoma (2000-2013): results from the French network of cancer registries (FRANCIM)

BACKGROUND

The exhaustive collection of new sarcoma cases and their second histologic review offer a unique opportunity to study their incidence and time trends in France according to the major subtypes.

METHODS

Data were collected from population-based cancer registries covering 22% of the French population. Crude and world age-standardized incidence rates (ASR) were estimated according to anatomic, histological and genetic groups, age and sex over the 2010-2013 period.

RESULTS

Time trends in incidence were calculated by the annual percent change over the 2000-2013 period. During the most recent period (2010-2013), 3942 patients with sarcoma were included. The ASR of soft-tissue and bone sarcomas, and gastro-intestinal stromal tumors (GIST) were 2.1, 1.0 and 0.6, respectively. For the four most frequent histological subtypes (unclassified, leiomyosarcoma, GIST and liposarcoma), the ASR ranged from 0.4 to 0.7. ASRs were 1.9 for complex genomic and 1.3 for recurrent translocation sarcomas. The time-trend analysis showed a significant increase of sarcoma incidence rate between 2000 and 2005, which stabilized thereafter. Incidence rates increased for four histological subtypes (GIST, chondrosarcoma, myxofibrosarcoma, solitary fibrous tumors) and decreased for three (leiomyosarcomas, Kaposi sarcoma and fibrosarcoma).

CONCLUSION

To our knowledge, this study is the first to investigate sarcoma incidence based on a systematic pathological review of these cancers and on the updated sarcoma classifications. Due to the paucity of literature on sarcomas, future studies using data from population-based cancer registries should consider a standardized inclusion criterion presented in our study to better describe and compare data between countries.

Changes in Soft-Tissue Sarcoma Treatment Patterns over Time: A Population-Based Study in a Country with Universal and Centralized Healthcare

Background

The clinical care of soft-tissue sarcoma (STS) patients is largely multidisciplinary involving clinicians from surgical disciplines, medical oncology, and radiation oncology. It is not clear if treatment patterns for STS have changed over time. We present population-level data on changes in treatment patterns of patients diagnosed with STS of all stages in Ontario, Canada.

Methods

We performed a population-based cohort study using linked administrative databases in Ontario, Canada, of patients with STS between 2006 and 2015. Patients with the AJCC stage at the time of diagnosis were included. Patients were categorized into one of the seven treatment arms: single modality treatment (surgery, chemotherapy, or radiation therapy), bimodality therapy, or all three treatment modalities. Survival of STS patients of different stages is displayed with the Kaplan–Meier method.

Results

A total of 4696 patients were diagnosed with biopsy-proven sarcoma during the study period including 1915 patients with stage information available. Treatment patterns for patients with Stage 1 and 2 disease were similar enough to allow for grouping. The use of radiation therapy in Stage 1 and 2 patients increased by 15% over the study period. None of the 7 treatment regimens for Stage 3 patients changed appreciably during the study period. We observed that the use of chemotherapy for Stage 4 STS patients increased 36% during the study period. Overall patient survival was, as expected, highest in Stage 1 patients and lowest in Stage 4 patients.

Conclusion

This is the first population-level study reporting of 7 different STS treatment regimens in a country with universal and centralized healthcare. Radiation therapy for local disease control and chemotherapy for Stage 4 patients have recently become more utilized. Survival from STS is highly dependent on stage at presentation. Other population-based studies from other countries are needed to establish the current international treatment patterns.

Incidence, mortality, and survival trends of soft tissue and bone sarcoma in Switzerland between 1996 and 2015

BACKGROUND

Research on soft-tissue sarcoma (STS) and bone sarcoma (BS) is increasingly in the focus of physicians and pharmaceutical companies. Expanding knowledge has improved the management of sarcoma and possibly survival. Here we provide the first population-based data on time trends of incidence, mortality, and survival of STS and BS diagnosed in Switzerland between 1996 and 2015.

METHODS

We performed a retrospective registry study with data from the National Institute for Cancer Epidemiology and Registration (NICER) database in Switzerland between 1996 and 2015.

RESULTS

We identified 5384 STS patients and 940 BS patients. The three most common STS subtypes were undifferentiated/unclassified sarcoma (22.3%), liposarcoma (20.6%) and leiomyosarcoma (20.6%). Chondrosarcoma, osteosarcoma and Ewing sarcoma represented 40.4%, 27.0% and 15.2% of the BS group, respectively. The age-standardized incidence and mortality rates in 2011-2015 were 4.43 and 1.42 per 100,000 person-years for STS, and 0.91 and 0.42 for BS. Age-standardized incidence of STS in males was significantly higher during 1996-2000 than during 2001-2015; however, mortality rates did not change significantly over time. Five-year relative survival (RS) for STS improved significantly from 56.4% (95%CI 52.9-59.7 for 1996-2001) to 61.6% (95%CI 58.6-64.4 for 2011-2015) (p = 0.025). No improvement in 5-year RS for BS could be observed (RS 1996-2000: 69.6%, 95%CI 61.2-76.6; RS 2011-2015: 73.1%, 95%CI 66.6-78.6; p = 0.479).

CONCLUSION

Incidence rates of STS and BS have been stable since 2001. The longer RS in STS can be attributed to advances in sarcoma patient management.

Challenges of Clinical Management of Adolescent and Young Adults With Bone and Soft Tissue Sarcoma

Clinical management of adolescents and young adults with bone and soft tissue sarcomas is quite challenging, mainly because of different chemotherapy approaches adopted by pediatric and adult oncologists and tumor-associated factors related to this peculiar age group. Overcoming these barriers is essential for adolescent and young adult patients, whose survival and long-term physical effects are worse than their pediatric counterparts. Nowadays, constant efforts from international collaborations between pediatric and adult oncologists of sarcoma groups have optioned in converging toward a common therapeutic strategy, while improving quality of treatment, as well as research advances dedicated to this at-risk age group of patients with sarcomas.

Local and Metastatic Relapse Features in Patients After a Primary Soft Tissue Sarcoma: Advocating for a Better-Tailored Follow-Up

Background: No consensus exists on how to follow patients after complete remission of a primary Soft Tissue Sarcoma (STS). Studying relapse features could help tailor guidelines for follow-up.

Patients and Methods: Patients in complete remission after initial management of a localized STS at Institut Bergonié who presented a first local and/or metastatic relapse between January 1995 and July 2015 were eligible. Characteristics of relapse diagnosis were retrospectively collected.

Results: 359 patients met inclusion criteria. 197 and 187 patients presented a local relapse and a metastatic relapse, respectively. In group 1 (limbs/trunk wall) and 2 (trunk/gynecological/other location), local relapse was diagnosed on clinical symptoms in 89 and 44% of cases, first detected by the patient himself in 68.5 and 34% of cases, and outside a planned visit in 67 and 36% of cases, respectively. In patients with metastatic relapse, diagnosis was made during a planned visit in 63% of cases, and by imaging in 62% of cases. Median survival after relapse was not different whether the first local relapse was diagnosed clinically or by imaging (44 [95%CI: 28–69.8] vs. 57 months [95%CI: 33.9–84.5], p = 0.35) but was longer if diagnosis of metastatic relapse was made on planned chest-CT scan rather than chest X-ray (58 [95%CI: 35.5–103.9] vs. 25 months [95%CI: 16.5–32.6], p < 0.05).

Conclusion: Patient's education for regular clinical examination can be recommended for follow-up of local relapses after a primary STS of the limbs or superficial trunk. Modeling studies aiming at better understanding and predicting tumor biology to improve tailoring STS patients' follow-up are warranted.

ETIOSARC study : environmental aetiology of sarcomas from a French prospective multicentric population-based case-control study-study protocol

INTRODUCTION

Sarcomas are rare tumours of connective tissue. The exact overall incidence of sarcomas is unknown due to diagnostic difficulties and the various histological subtypes (over 80 subtypes). However, the apparent increasing incidence of sarcomas suggests environmental causes such as pesticides. Except for some specific factors (ie, ionising radiation, vinyl chloride, dioxin and genetic predispositions) the scientific knowledge on the aetiology of sarcomas is sparse and inconsistent. France is a particularly appropriate country to set up a study investigating the causes of sarcoma occurrence due to the French organisation in treatment and care of sarcoma patients, which is highly structured and revolved around national expert networks. The main objective of the ETIOlogy of SARcomas (ETIOSARC) project is to study the role of lifestyle, environmental and occupational factors in the occurrence of sarcomas among adults from a multicentric population-based case-control study.

METHODS AND ANALYSIS

Cases will be all incident patients (older than 18 years) prospectively identified in 15 districts of France covered by a general population-based cancer registry and/or a reference centre in sarcoma's patient care over a 3-year period with an inclusion start date ranging from February 2019 to January 2020 and histologically confirmed by a second review of the diagnosis. Two controls will be individually matched by sex, age (5 years group) and districts of residence and randomly selected from electoral rolls. A standardised questionnaire will be administered by a trained interviewer in order to gather information about occupational and residential history, demographic and socioeconomic characteristics and lifestyle factors. At the end of the interview, a saliva sample will be systematically proposed. This study will permit to validate or identify already suspected risk factors for sarcomas such as phenoxyherbicides, chlorophenol and to generate new hypothesis to increase our understanding about the genetic and environmental contributions in the carcinogenicity process.

ETHICS AND DISSEMINATION

The present study is promoted by the French National Institute of Health and Medical Research (identification number C17-03). This study received National French Ethic committee (CPP Sud Méditerrannée I) approval (identification number 18-31) and French Data Protection Authority (CNIL) approval (identification number 918171). Results of this study will be published in international peer-reviewed journals. Technical appendix, statistical code and dataset will be available in the Dryad repository when collection data are completed.

TRIAL REGISTRATION NUMBER

NCT03670927.

Conformity to Clinical Practice Guidelines at Initial Management in Adult Soft Tissue and Visceral Tumors since the Implementation of the NetSarc Network in Eastern France

BACKGROUND

Soft tissue sarcomas are rare and heterogenous tumors that are hard to diagnose. The aim of this study was to evaluate local practices and conformity to clinical practice guidelines (CPGs) for their initial diagnostic management.

MATERIALS AND METHODS

Patients were carriers of a soft tissue or visceral tumor, presented at a sarcoma tumor board (STB) between 2010 and 2016. Conformity to CPGs was evaluated using ten criteria designed for this purpose. Associations between different factors and conformity to composite criteria, reflecting the three main diagnostic steps (imaging, biopsy and histological report) were analyzed.

RESULTS

A total of 643 patients were included. A preoperative tumor imaging assessment and a biopsy were performed according to CPGs in 80.8% and 36.8% of the cases, respectively. When done, the first surgical resection was R0 in 30.3% of cases, R1 in 28.6%, and R2 in 10.9%. The rest of the operated patients with sarcoma had a second surgical excision (11.4%), an intraoperative fragmentation (4.3%), or margins were unknown (14.4%). Six of the ten quality criteria presented a conformity rate higher than 70%. Two criteria with a conformity rate lower than 20% were the most controversial: presentation at a STB before biopsy and freezing of a tumor fragment. A multivariate analysis revealed that the common predictor of nonconformity to composite criteria was the initial management in a nonexpert center.

CONCLUSION

Initial diagnostic management requires improvement, especially outside of specialized centers.

IMPLICATIONS FOR PRACTICE

This article supports the essential need to refer patients with soft tissue tumors to specialized centers to improve the management of sarcomas beginning at the diagnostic phase. Indeed, the reported data were very similar to those already described at the national level of the NetSarc network and indicate the necessity to keep raising awareness about this simple issue: early referral to reference centers will save lives.

Limbs and trunk soft tissue sarcoma systematic local and remote monitoring by MRI and thoraco-abdomino-pelvic scanner: A single-centre retrospective study

INTRODUCTION

Soft tissue sarcomas (STS) are rare malignant tumors that require management by an expert center. Monitoring modalities are not consensual. The objective of our study is to report systematic radiological monitoring data obtained by local MRI and by thoracic-abdominal-pelvic computed tomography (TAP CT).

MATERIAL AND METHODS

113 consecutive patients managed at "Centre Georges François Leclerc, Dijon", between 2008 and 2016, for an initially localized STS were included. Patient follow-up consisted of a local MRI and a TAP CT. Follow-up exams schedule was initially every 4 months during 2 years, followed by every 6 months during 3 years and finally every year during 5 years.

RESULTS

Median follow-up time was 37.2 months [min = 2.4 - max = 111.6]. After 5 years of surveillance, local recurrence (LR) rate was 8.8% and diagnosed by imaging in 60% of cases. No deep LR was clinically found. Median LR diagnosis time was 23.9 months [min = 2.0 - max = 52.4]. 50% of patients locally treated for their LR were alive without recurrence. Metastatic recurrence (MR) rate was 31%. 42.8% had extra-pulmonary involvement and 17.1% had exclusive extrathoracic metastases. The median time to diagnosis of MR was 17.4 months [min = 2.7- max = 77.2]. High-grade tumors relapsed more (20.4%) and earlier (all before the 5th year) than low grade.

CONCLUSION

Local MRI seems particularly suitable for monitoring deep tumors. In addition, the systematic monitoring by TAP CT highlighted a limited number of cases of exclusive extrathoracic metastases. The schedule of local and remote monitoring should primarily be adjusted to tumor grade.

Relevance of Reference Centers in Sarcoma Care and Quality Item Evaluation: Results from the Prospective Registry of the Spanish Group for Research in Sarcoma (GEIS)

BACKGROUND

Reference centers (RCs) are a key point for improving the survival of patients with soft-tissue sarcomas (STS). The aim of this study was to evaluate selected items in the management of patients with STS, comparing results between RC and local hospitals (LHs).

MATERIALS AND METHODS

Diagnostic and therapeutic data from patients diagnosed between January 2004 and December 2011 were collected. Correlation with outcome was performed.

RESULTS

A total of 622 sarcomas were analyzed, with a median follow-up of 40 months. Imaging of primary tumor preoperatively (yes vs. no) correlated with a higher probability of free surgical margins (77.4% versus 53.7%; p = .006). The provenance of the biopsy (RC vs. LH) significantly affected relapse-free survival (RFS; 3-year RFS 66% vs. 46%, respectively; p = .019). Likewise, 3-year RFS was significantly worse in cases with infiltrated (55.6%) or unknown (43.4%) microscopic surgical margins compared with free margins (63.6%; p < .001). Patients managed by RCs had a better 3-year overall survival compared with those managed by LHs (82% vs. 70.4%, respectively; p = .003). Perioperative chemotherapy in high-risk STS, more frequently administered in RCs than in LHs, resulted in significantly better 3-year RFS (66% vs. 44%; p = .011). In addition, patients with stage IV disease treated in RCs survived significantly longer compared with those in LHs (30.4 months vs. 18.5 months; p = .036).

CONCLUSION

Our series indicate that selected quality-of-care items were accomplished better by RCs over LHs, all with significant prognostic value in patients with STS. Early referral to an RC should be mandatory if the aim is to improve the survival of patients with STS.

IMPLICATIONS FOR PRACTICE

This prospective study in patients diagnosed with soft-tissue sarcoma shows the prognostic impact of reference centers in the management of these patients. The magnitude of this impact encompasses all steps of the process, from the initial management (performing diagnostic biopsy) to the advanced disease setting. This is the first prospective evidence showing improvement in outcomes of patients with metastatic disease when they are managed in centers with expertise. This study provides extra data supporting referral of patients with sarcoma to reference centers.

Higher complications after previous external beam radiation for extremity soft-tissue sarcoma in the surgical treatment of a local recurrence: a comparative retrospective study of one hundred and three patients

PURPOSE

The use of adjuvant radiation in the treatment of soft-tissue sarcoma (STS) is equivocal in selected cases. Our objective was to compare the short-term outcomes in patients operated on for a local recurrence who had radiation for the primary tumour to those who were spared radiation.

METHODS

This was a retrospective study of 103 patients treated for a local recurrence: 48 (47%) with previous radiation and 55 (53%) without. Our primary outcome criterion was to identify the differences in the local treatment provided. Secondary outcomes were the cumulative incidence of a surgical site infection/wound complication (SSI/WC), variables associated with SSI/WC, and local recurrence.

RESULTS

Amputation and the incidence of re-operation were significantly more frequent in patients who received previous radiation compared to patients without previous radiation (27% vs 9%, p = 0.02, for amputation; 26% vs 36% at 2 years for SSI/WC, p = 0.049). Multivariable regression models found previous radiation (p = 0.049), arteriopathy (p = 0.012), location at lower limb (p = 0.09), and use of a flap (0.0048) associated with the risk of SSI/WC.

CONCLUSIONS

Previous radiation is associated with an increased risk of amputation and reoperation for SSI/WC when treating a local recurrence. This information should be accounted for when deciding for the use of radiation.

The challenge of the management of adolescents and young adults with soft tissue sarcomas

Soft tissue sarcomas are relatively frequent in adolescents and young adults and their clinical management may be complex, partly due to tumor associated factors, but also because different approaches have been adopted by pediatric and adult medical oncologists dealing with the same disease. However, times are changing and in the last few years, management has tended to converge towards a common strategy. Continued and increased international collaboration between pediatric and adult sarcoma groups is of critical importance to improve the quality of treatment as well as research programs dedicated to young patients with soft tissue sarcomas.

Different quality of treatment in retroperitoneal sarcomas (RPS) according to hospital-case volume and surgeon-case volume: a retrospective regional analysis in Italy

Background

Retroperitoneal sarcomas (RPS) should be surgically managed in specialized sarcoma centers. However, it is not clearly demonstrated if clinical outcome is more influenced by Center Case Volume (CCV) or by Surgeon Case Volume (SCV). The aim of this study is to retrospectively explore the relationship between CCV and SCV and the quality of surgery in a wide region of Northern Italy.

Methods

We retrospectively collected data about patients M0 surgically treated for RPSs in 22 different hospitals from 2006 to 2011, dividing them in two hospital groups according to sarcoma clinical activity volume (HCV, high case volume or LCV, low case volume hospitals). The HCV group (> 100 sarcomas observed per year) included a Comprehensive Cancer Center (HVCCC) with a high sarcoma SCV (> 20 cases/year), and a Tertiary Academic Hospital (HVTCA) with multiple surgeon teams and a low sarcoma SCV (≤ 5 cases/year for each involved surgeon). All other hospitals were included in the LCV group (< 100 sarcomas observed per year).

Results

Data regarding 138 patients were collected. Patients coming from LCV hospitals (66) were excluded from the analysis as prognostic data were frequently not available. Among the 72 remaining cases of HCV hospitals 60% of cases had R0/R1 margins, with a more favorable distribution of R0/R1 versus R2 in HVCCC compared to HVTCA.

Conclusions

In HCV hospitals, sarcoma SCV may significantly influence RPS treatment quality. In low-volume centers surgical reports can often miss important prognostic issues and surgical quality is generally poor.

Presentation and outcome of frequent and rare sarcoma histologic subtypes: A study of 10,262 patients with localized visceral/soft tissue sarcoma managed in reference centers

BACKGROUND

The objective of this study was to describe characteristics at diagnosis and outcomes of adults with soft tissue sarcoma.

METHODS

The authors conducted a retrospective multicenter study of 12,262 patients who were treated between January 1980 and 31 December 2013 in French Sarcoma Group centers and enrolled in the "Conticabase." Diagnoses were systematically reviewed by expert pathologists, and entities were classified according to the 2013 World Health Organization classification. Diagnostic characteristics, treatments, and outcomes are described for the entire cohort, for the subgroup of patients with translocation-related sarcomas, and for 9 different histologic subtypes.

RESULTS

The results stressed the magnitude of heterogeneity among adult sarcomas. For example, compared with other sarcomas, translocation-related sarcomas (2143 tumors; 20.8%) were associated with a younger age at presentation (40.6 vs 60.0 years; P < .0001), a low rate of predisposing conditions (0.01% vs 22.3%; P < .0001), a higher rate of lymph node involvement (4.7% vs 1.3%; P < .0001), and a higher rate of synchronous metastasis (11.9% vs 6.7%; P < .001); and complete (R0) resection (41.6% vs 31.9%; P < .0001), receipt of (neo)adjuvant radiation therapy (62.6% vs 42.2%; P < .0001), and receipt of (neo)adjuvant chemotherapy (36.6% vs 22.3%; P < .0001) were significantly more frequent. Overall, translocation-related sarcomas were associated with a lower rate of local relapse (18.1% vs 26.0%; P < .0001) but a higher rate of metastatic relapse (42.0% vs 30.7%; P < .0001).

CONCLUSIONS

Collaborative efforts are urgently needed to better assess the natural history and management options for every histologic subtype of sarcoma. Cancer 2018;124:1179-87. © 2017 American Cancer Society.

Adherence to Guidelines for Adult (Non-GIST) Soft Tissue Sarcoma in the Netherlands: A Plea for Dedicated Sarcoma Centers

INTRODUCTION

Optimal management of soft tissue sarcoma (STS) remains a challenge. A nationwide survey assessed the quality of STS care in the Netherlands, thereby aiming to identify potentialities for improvement through more centralized disease management.

METHODS

From the Netherlands Cancer Registry (NCR), data were obtained on 3317 adult STS patients (excluding gastrointestinal stromal tumor, GIST) diagnosed in 2006-2011. Logistic regression models were employed to compare outcomes on selected clinical indicators reflecting prevailing STS guidelines between high-volume (≥10 resections annually) and low-volume (<10 resections) hospitals, between academic and general hospitals, and between sarcoma research centers and other hospitals, adjusted for case mix. Analyses were performed on imputed datasets (m = 50), generated through multiple imputations by chained equations.

RESULTS

Overall, 89% of patients underwent surgical resection. Resection status remained unknown in 24% (excluding those with metastasized disease), and grade was not documented for one-third of tumors. Microscopic residual disease was detected in 20% with an increased risk for older patients, larger and deeply located tumors, and those located in the (retro)peritoneum or upper extremity. Almost half of patients with an R1 resection received adjuvant radiotherapy. Following adjustment for case mix factors, patients treated in high-volume hospitals less often had macroscopic residual disease (R2 resection; adjusted odds ratio: 0.54). A strongly skewed distribution of surgical volumes was observed.

CONCLUSIONS

These survey results indicate a potential for improving Dutch STS care. More centralized sarcoma management should improve definitive pathology reporting on tumor characteristics, adherence to treatment guidelines and overall disease outcome.

Preliminary experience in laparoscopic resection of hepatic hydatidectocyst with the Da Vinci Surgical System (DVSS): a case report

Background

At present, Da Vinci robotic assisted hepatectomy has been routinely carried out in conditional units. But there is no report concerning the use of Da Vinci robots for hepatic hydatid cystectomy and experience on this aspect is seldom mentioned before. This study was to summarize the preliminary experience in laparoscopic resection of hepatic hydatidectocyst with the Da Vinci Surgical System (DVSS).

Case presentation

A 29-year-old female diagnosed as hepatic hydatid in the right anterior lobe of liver was treated with laparoscopic resection by the DVSS under general anesthesia. Appropriate disposal of tumor cell in vascular system and disinfection of surgical field with hypertonic saline were conducted. The hepatic hydatidectocyst was resected completely with an operation time of 130 min, an intraoperative blood loss of 200 ml and a length of hospital stay for five days. The vital signs of patient were stable and no cyst fluid allergy occurred after operation.

Conclusions

Our result showed that laparoscopic resection of hepatic hydatidectocyst by using the DVSS is safe and feasible on the basis of hospitals have rich experience in treatment of cystic echinococcosisliver, resection with DVSS and laparoscopic excision.

Soft tissue sarcomas in adolescents and young adults: a comparison with their paediatric and adult counterparts

Survival outcomes for adolescent and young adult patients with soft tissue sarcomas lag behind those of children diagnosed with histologically similar tumours. To help understand these differences in outcomes, we discuss the following issues with regard to the management of these patients with soft tissue sarcomas: delays in diagnosis, trial availability and participation, aspects of the organisation of care (with an emphasis on age-specific needs), national centralisation of sarcoma care, international consortia, and factors related to tumour biology. Improved understanding of the causes of the survival gap between adolescents and young adults with sarcomas will help drive new initiatives to improve final health outcomes in these populations. In this Review, we specifically focus on embryonal and alveolar rhabdomyosarcoma, synovial sarcoma, and adult soft tissue sarcomas diagnosed in adolescents and young adults, and discuss the age-specific needs of these patients.

[Surgery for soft-tissue sarcomas of the limbs and trunk wall]

Soft-tissue sarcoma of the limbs or the trunk wall determine a heterogeneous group of tumours that tends to receive a more individualized approach. The surgeon in charge with soft-tissue sarcoma has to be familiar with these tumours in order to deliver an adequate treatment. Most important is the initial diagnostic procedure, comprising imaging with MRI, a core needle biopsy, and in France, referral to a centre of expertise within the clinical network NETSARC. Prior to surgery, a multidisciplinary conference determines its moment and the extent of surgical resection within the frame of a multidisciplinary approach, and also plans reconstructive surgery, when needed. A standardized operative report summarizes items necessary to describe the resection quality (i.e. tumour seen, tumour infiltrated?). In multidisciplinary staff meetings, they are compared to margins measured by the pathologist on the operative specimen. Hence, resection quality is determined collegially and defined by resection type R (R0, R1, R2) as a qualitative result. The quality of resection directly determines the 5-year risk of local recurrence, estimated between 10 and 20% in specialized centres, with the objective to attain 10%. Early rehabilitation favours better functional outcome. The surgeon's experience with soft-tissue sarcoma, as part of a multidisciplinary treatment, is key in achieving the best adequacy between oncological resection and favourable functional outcome. In France, a specific university course for soft-tissue sarcoma will be set-up.

Soft tissue sarcoma in France in 2015: Epidemiology, classification and organization of clinical care

Four thousand new cases of soft tissue sarcomas are diagnosed each year in France, 23% of which are localized in the abdomen and pelvis; the treatment of non-metastatic tumor is based on wide surgical resection, the quality of which determines the long-term outcome. To ensure appropriate care, the European Society of Medical Oncology (ESMO) recommends that any patient with an unexplained soft tissue mass (of any size for deep lesions or of>5cm for superficial lesions) be referred to a specialized center with capacities for multidisciplinary team decision; appropriate imaging should be performed prior to treatment and a percutaneous image-guided needle biopsy should be routinely performed. In France, clinical and pathology networks (NetSarc and RRePS) currently offer patients a structured means to make a systematic diagnosis of soft tissue sarcoma and help to provide access to appropriate treatment in a specialized center.

Long-term recurrence of soft tissue sarcomas: prognostic factors and implications for prolonged follow-up

BACKGROUND

To the authors' knowledge, the incidence of late recurrence (> 5 years after initial management) is unknown and no prognostic factors for late events have been characterized in patients with soft tissue sarcomas.

METHODS

Follow-up data from patients with localized soft tissue sarcoma who were included in the French Sarcoma Group database from January 1990 to June 2005 were reviewed. The outcomes of interest were the cumulative probabilities of late (> 5 years) local and metastatic disease recurrence with death as a competing event. Estimations and 95% confidence intervals (95% CIs) were computed with the cumulative incidence function.

RESULTS

A total of 719 patients who were alive and event free > 5 years after their initial diagnosis were included in the current study. Sixty-seven patients (9.3%) developed a late local recurrence and 42 patients (5.8%) developed a late metastatic recurrence, respectively. On multivariate analysis, internal trunk location (hazard ratio [HR], 3.9; 95% CI, 2.2-6.7 [P < .001]) and tumor size > 100 mm (HR, 2.1; 95% CI, 1.1-4 [P = .035]) were the 2 factors found to be independently associated with an increased risk of late local recurrence. Grade > 1 (graded according to the French Federation of Cancer Centers Sarcoma Group) (HR, 4.7; 95% CI 1.1-21 [P = .04]) was the sole factor found to be independently associated with an increased risk of late metastatic recurrence.

CONCLUSIONS

Late recurrence of soft tissue sarcoma is relatively uncommon. However, the results of the current study emphasize the critical role of long-term follow-up to detect late local disease recurrence in patients with retroperitoneal or very large soft tissue sarcomas, and late metastatic recurrence in patients with high-grade disease. Conversely, the prolonged follow-up of patients with grade 1 disease is not needed.