Limb-sparing surgery plus radiotherapy results in superior survival: an analysis of patients with high-grade, extremity soft-tissue sarcoma from the NCDB and SEER.

Stephen J Ramey,Lily Wang,Wei Zhao,Raphael Yechieli,Breelyn A Wilky,Felix M Chinea,Isildinha M Reis,Jonathan C Trent,Joyson Kodiyan,Vivek Patel,David Asher,Ty Subhawong

doi:10.1002/cam4.1625

Abstract

Small randomized trials have not shown an overall survival (OS) difference among local treatment modalities for patients with extremity soft‐tissue sarcomas (E‐STS) but were underpowered for OS. We examine the impact of local treatment modalities on OS and sarcoma mortality (SM) using two national registries. The National Cancer Database (NCDB) and the Surveillance, Epidemiology, and End Results (SEER) Program were analyzed separately to identify patients with stage II‐III, high‐grade E‐STS diagnosed between 2004 and 2013 and treated with (1) amputation alone, (2) limb‐sparing surgery (LSS) alone, (3) preoperative radiation therapy (RT) and LSS, or (4) LSS and postoperative RT. Multivariable analyses (MVAs) and 1:1 matched pair analyses (MPAs) examined treatment impacts on OS (both databases) and SM (SEER only). From the NCDB and SEER, 7828 and 2937 patients were included. On MVAs, amputation was associated with inferior OS and SM. Relative to LSS alone, both preoperative RT and LSS (HR, 0.70; 95% CI: 0.62‐0.78) and LSS and postoperative RT (HR, 0.69; 95% CI: 0.63‐0.75) improved OS in NCDB analyses with confirmation by SEER. Estimated median survivals from MPA utilizing NCDB data were 7.2 years with LSS alone (95% CI: 6.5‐8.9 years) vs 9.8 years (95% CI: 9.0‐11.2 years) with LSS and postoperative RT. A MPA comparing preoperative RT and LSS to LSS alone found median survivals of 8.9 years (95% CI: 7.9‐not estimable) and 6.6 years (95% CI: 5.4‐7.8 years). Optimal high‐grade E‐STS management includes LSS with preoperative or postoperative RT as evidenced by superior OS and SM.

Highlights

Extremity soft-tissue sarcoma (E-STS) is a rare malignancy accounting for 0.7% of cancer diagnoses in 2017.1 Limb- sparing surgery (LSS) combined with radiation therapy (RT) has become the preferred treatment regimen[2] for high-grade extremity soft-tissue sarcomas (E-S TS) since a randomized trial showed similar disease-free survival and overall survival (OS) to amputation.[3]
The Commission on Cancer (CoC)’s National Cancer Database (NCDB) and the hospitals participating in the CoC NCDB are the source of the de-identified data used ; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors
Our study found that adding RT to LSS was associated with increased OS and reduced sarcoma mortality (SM) in patients with high-g rade E-S TS

Summary

Introduction

Extremity soft-tissue sarcoma (E-STS) is a rare malignancy accounting for 0.7% of cancer diagnoses in 2017.1 Limb- sparing surgery (LSS) combined with radiation therapy (RT) has become the preferred treatment regimen[2] for high-grade E-S TS since a randomized trial showed similar disease-free survival and overall survival (OS) to amputation.[3] Subsequent trials have shown greater local control (LC) for high-g rade E- STS patients receiving LSS and RT. Two National Cancer Database (NCDB)[8,9] and two Surveillance, Epidemiology, and End Results (SEER) studies[10,11] indicated a survival benefit using RT in the treatment of high-g rade E-STS. A study from the National Oncology Database found significantly greater OS and cause-specific survival with preoperative RT.[18]

Objectives

Methods

Results

Discussion

Conclusion