Extremity Soft Tissue Sarcoma Patients Research Articles

Optical Surface-guided Radiation Therapy for Upper and Lower Limb Sarcomas: An Analysis of Setup Errors and Clinical Target Volume-To-Planning Target Volume Margins

PurposeTo assess the clinical benefits of surface-guided radiotherapy (SGRT) in terms of setup error, positioning time, and clinical target volume-to-planning target volume (CTV-PTV) margin in extremity soft tissue sarcoma (STS). Methods and MaterialsFifty consecutive patients treated with radiotherapy were retrospectively selected. Treatment setup was performed with either laser-based imaging only (control group), or with laser-based and daily optical surface-based imaging (SGRT group). Pre-treatment cone beam computed tomography images were acquired daily for the first 3 – 5 fractions and weekly thereafter, with the frequency adjusted as necessary. Translational and rotational errors were collected. CTV-PTV margin was calculated using the formula, 2.5Σ + 0.7σ. ResultsEach group consisted of 10 and 15 upper and lower limb STSs, respectively. For patients with upper limb sarcomas, the translation errors were (1.64 ± 1.34) mm, (1.10 ± 1.50) mm, and (1.24 ± 1.45) mm in SGRT group, and (1.48 ± 3.16) mm, (2.84 ± 2.85) mm, and (3.14 ± 3.29) mm in control group in the left-right (LR), supero-inferior (SI), and antero-posterior (AP) directions, respectively. Correspondingly, for patients with lower limb sarcomas, the translation errors were (1.21 ± 1.65) mm, (1.39 ± 1.71) mm, and (1.48 ± 2.10) mm in SGRT group, and (1.81 ± 2.60) mm, (2.93 ± 3.28) mm, and (3.53 ± 3.75) mm in control group, respectively. The calculated CTV-PTV margins of SGRT group and control group were 5.0 mm, 3.8 mm, 4.1 mm vs. 5.9 mm, 9.1 mm, 10.1 mm for upper limb sarcomas; and 4.2 mm, 4.7 mm, 5.2 mm vs. 6.3 mm, 9.6 mm, 11.4 mm for lower limb sarcomas in the LR, SI, and AP directions, respectively. ConclusionDaily optical surface guidance can effectively improve the setup accuracy of extremity STS patients, and safely reduce the required CTV-PTV margins.

When to ditch the ladder and take the elevator: The Anderson SArcoma Risk of Complications (A-SARC) score to guide reconstructive decision-making in extremity soft tissue sarcoma patients.

The reconstructive ladder relies mostly on defect size and depth to determine reconstructive technique, however, in actuality, many more variables ultimately inform reconstructive decision making, especially regarding extremity soft tissue sarcoma (eSTS) defects. The purpose of this study was to describe eSTS patients who will most optimally benefit from an advanced method of reconstruction (defined as a pedicled regional flap or free flap) and to create a simple risk assessment scale that can be employed in clinical practice. A single-institution retrospective cohort study examined patients undergoing resection of soft tissue sarcoma affecting the upper or lower extremities between 2016 and 2021. We categorized patients who required a pedicled or free flap as having had advanced reconstruction, and all other techniques were considered simple reconstruction. A regression was used to create a risk scale to guide reconstructive decision-making. The following variables were identified as independent predictors of complications and used to create our risk scale: lower extremity tumor location, preoperative radiotherapy, tumor bed excision, male sex, hypertension, and tumor volume. Intermediate and high-risk patients reconstructed using simple techniques had significantly greater overall complication rates compared to those reconstructed with advanced techniques. Major complications were significantly greater in low-risk patients reconstructed with advanced techniques. To minimize postoperative wound complications, low-risk patients should receive simple methods of reconstruction, whereas high-risk patients should be reconstructed using advanced techniques.

Oncology

The February 2024 Oncology Roundup360 looks at: Does primary tumour resection improve survival for patients with sarcomas of the pelvis with metastasis at diagnosis?; Proximal femur replacements for an oncologic indication offer a durable endoprosthetic reconstruction option: a 40-year experience; The importance of awaiting biopsy results in solitary pathological proximal femoral fractures: do we need to biopsy solitary pathological fractures?; Effect of radiotherapy on local recurrence, distant metastasis, and overall survival in 1,200 extremity soft-tissue sarcoma patients; What to choose in bone tumour resections? Patient-specific instrumentation versus surgical navigation; Optimal timing of re-excision in synovial sarcoma patients: immediate intervention versus waiting for local recurrence; Survival differences of patients with resected extraskeletal osteosarcoma receiving two different (neo) adjuvant chemotherapy regimens; Solitary versus multiple bone metastases in the appendicular skeleton: should the surgical treatment be different?.

Management of tumor volume changes during preoperative radiotherapy for extremity soft tissue sarcoma: a new strategy of adaptive radiotherapy.

Using adaptive radiotherapy (ART), to determine objective clinical criteria that identify extremity soft tissue sarcoma (ESTS) patients requiring adaptation of their preoperative radiotherapy (RT) plan. We included 17 patients with a lower extremity ESTS treated between 2019 and 2021 with preoperative RT, using helicoidal intensity-modulated RT (IMRT) tomotherapy, before surgical resection. We collected clinical, tumor parameters and treatment data. Repositioning was ascertained by daily Megavoltage computed tomography (MVCT) imaging. Using the PreciseART technology we retrospectively manually delineated at least one MVCT for each patient per week and recorded volume and dosimetric parameters. A greater than 5% change between target volume and planned target volume (PTV) dosimetric coverage from the initial planning CT scan to at least one MVCT was defined as clinically significant. All 17 patients experienced significant tumor volume changes during treatment; 7 tumors grew (41%) and 10 shrank (59%). Three patients (18%), all undifferentiated pleomorphic sarcomas (UPS) with increased volume changes, experienced significant reductions in tumor dose coverage. Seven patients required a plan adaptation, as determined by practical criteria applied in our departmental practice. Among these patients, only one ultimately experienced a significant change in PTV coverage. Three patients had a PTV decrease of coverage. Among them, 2 did not receive plan adaptation according our criteria. None of the patients with decreased tumor volumes had reduced target volume coverage. Monitoring volume variations by estimating gross tumor volume (GTV) on MVCT, in addition to axial and sagittal linear tumor dimensions, appeared to be most effective for detecting reductions in PTV coverage throughout treatment. Variations in ESTS volume are evident during preoperative RT, but significant dosimetric variations are rare. Specific attention should be paid to grade 2-3 UPSs during the first 2 weeks of treatment. In the absence of dedicated software in routine clinical practice, monitoring of tumor volume changes by estimating GTV may represent a useful strategy for identifying patients whose treatment needs to be replanned.

(Cost-)effectiveness of an individualised risk prediction tool (PERSARC) on patient’s knowledge and decisional conflict among soft-tissue sarcomas patients: protocol for a parallel cluster randomised trial (the VALUE-PERSARC study)

IntroductionCurrent treatment decision-making in high-grade soft-tissue sarcoma (STS) care is not informed by individualised risks for different treatment options and patients’ preferences. Risk prediction tools may provide patients and professionals...

Effect of radiotherapy on local recurrence, distant metastasis and overall survival in 1200 extremity soft tissue sarcoma patients. Retrospective analysis using IPTW-adjusted models

Background and purposeNeoadjuvant (NRTX) and adjuvant radiotherapy (ARTX) reduce local recurrence (LR) risk in extremity soft tissue sarcoma (eSTS), yet their impact on distant metastasis (DM) and overall survival (OS) is less well defined. This study aimed at analysing the influence of NRTX/ARTX on all three endpoints using a retrospective, multicentre eSTS cohort. Materials and methods1200 patients (mean age: 60.7 ± 16.8 years; 44.4 % females) were retrospectively included, treated with limb sparing surgery and curative intent for localised, high grade (G2/3) eSTS. 194 (16.2 %), 790 (65.8 %), and 216 (18.0 %) patients had received NRTX, ARTX and no RTX, respectively. For the resulting three groups (no RTX vs. NRTX, no RTX vs. ARTX, NRTX vs. ARTX) Fine&Gray models for LR and DM, and Cox-regression models for OS were calculated, with IPTW-modelling adjusting for imbalances between groups. ResultsIn the IPTW-adjusted analysis, NRTX was associated with lower LR-risk in comparison to no RTX (SHR [subhazard ratio]: 0.236; p = 0.003), whilst no impact on DM-risk (p = 0.576) or OS (p = 1.000) was found. IPTW-weighted analysis for no RTX vs. ARTX revealed a significant positive association between ARTX and lower LR-risk (SHR: 0.479, p = 0.003), but again no impact on DM-risk (p = 0.363) or OS (p = 0.534). IPTW-weighted model for NRTX vs. ARTX showed significantly lower LR-risk for NRTX (SHR for ARTX: 3.433; p = 0.003) but no difference regarding DM-risk (p = 1.000) or OS (p = 0.639). ConclusionNRTX and ARTX are associated with lower LR-risk, but do not seem to affect DM-risk or OS. NRTX may be favoured over ARTX as our results indicate better local control rates.

Amputation surgery associated with shortened survival in patients with localized soft tissue sarcoma

BackgroundThe objectives of this study were to clarify whether localized extremity soft tissue sarcoma (STS) patients who underwent amputation surgery experienced worsened survival and to identify those patients for whom amputation surgery worsened survival. MethodsUsing the Surveillance, Epidemiology, and End Results database, we identified 8897 patients with localized extremity STS between 1983 and 2016. Of these 6431 patients, 733 patients underwent amputation surgery (Amputation group), and 5698 underwent limb-sparing surgery (Limb-sparing group). ResultsAfter adjusting for patient background by propensity score matching, a total of 1346 patients were included. Patients in the Amputation group showed worsened survival (cancer-specific survival (CSS): hazard ratio (HR) = 1.42, 95% confidence interval (CI) 1.15–1.75, overall survival (OS): HR = 1.41, 95%CI 1.20–1.65). In subclass analysis, patients with high-grade STS, spindle cell sarcoma and liposarcoma in the Amputation group showed shortened survival (high-grade–CSS: HR = 1.44, 95%CI 1.16–1.77, OS: HR = 1.38, 95%CI 1.18–1.62; spindle cell sarcoma–CSS: HR = 4.75, 95%CI 1.56–14.4, OS: HR = 2.32, 95%CI 1.45–3.70; liposarcoma–CSS: HR = 2.91, 95%CI 1.54–5.50, OS: HR = 2.32, 95%CI 1.45–3.70). ConclusionsSurvival was shortened in localized extremity STS patients who received amputation surgery.

Extremity Soft Tissue Sarcoma: A Multi-Institutional Validation of Prognostic Nomograms.

Prognostic nomograms for patients with resected extremity soft tissue sarcoma (STS) include the Sarculator and Memorial Sloan Kettering (MSKCC) nomograms. We sought to validate these two nomograms within a large, modern, multi-institutional cohort of resected primary extremity STS patients. Resected primary extremity STS patients from 2000 to 2017 were identified across nine high-volume U.S. institutions. Predicted 5- and 10-year overall survival (OS) and distant metastases cumulative incidence (DMCI), and 4-, 8-, and 12-year disease-specific survival (DSS) were calculated with Sarculator and MSKCC nomograms, respectively. Predicted survival probabilities stratified in quintiles were compared in calibration plots to observed survival assessed by Kaplan-Meier estimates. Cumulative incidence was estimated for DMCI. Harrell's concordance index (C-index) assessed discriminative ability of nomograms. A total of 1326 patients underwent resection of primary extremity STS. Common histologies included: undifferentiated pleomorphic sarcoma (35%), fibrosarcoma (13%), and leiomyosarcoma (9%). Median tumor size was 8.0 cm (IQR 4.5-13.0). Tumor grade distribution was: Grade 1 (13%), Grade 2 (9%), Grade 3 (78%). Median OS was 172 months, with estimated 5- and 10-year OS of 70% and 58%. C-indices for 5- and 10-year OS (Sarculator) were 0.72 (95% CI 0.70-0.75) and 0.73 (95% CI 0.70-0.75), and 0.72 (95% CI 0.69-0.75) for 5- and 10-year DMCI. C-indices for 4-, 8-, and 12-year DSS (MSKCC) were 0.71 (95% CI 0.68-0.75). Calibration plots showed good prognostication across all outcomes. Sarculator and MSKCC nomograms demonstrated good prognostic ability for survival and recurrence outcomes in a modern, multi-institutional validation cohort of resected primary extremity STS patients. External validation of these nomograms supports their ongoing incorporation into clinical practice.

Refining the Approach to Patients with Primary Soft Tissue Sarcoma of the Extremities and Trunk Wall: Outcome Improvement Over Time at a Single Institution.

The improved outcome of extremity soft tissue sarcoma patients surgically treated until 2007 at the authors' institution was previously reported. This study updates the analysis at a later follow-up and extends the patients'cohort to assess changes in outcomes over time for extremity and superficial trunk soft tissue sarcoma (ESTSTS) treated at a single referral center. All consecutive patients with primary localized adult-type ESTSTSsurgically treated at the authors' institution between 1987 and 2017 wereincluded and divided into group 1 (1987-2002) and group 2 (2003-2017) according to primary surgery year. Crude cumulative incidence (CCI) of sarcoma-specific mortality (SSM), local recurrence (LR), and distant metastases (DM)were calculated in a competing-risks framework. DM-free survival (DMFS) and post-DM survivalwere also assessed. The study identified 2382 patients. The median follow-up was 104 months (range, 63-127 months), and the post-DM follow-up was 76 months (range, 37-126 months). Since 2003, an increased adoption of preoperative treatments was observed: the use ofchemotherapy, radiotherapy and combined chemoradiotherapy went from 10.5% to 23.7%, from 1.7% to 17.8%, and from 1% to 11.8%respectively. This change in treatment strategies was associated to an improvementin CCI-SSM (27.8% vs 19.5%; P < 0.001), CCI-LR (14.1 vs 7.5%; P < 0.001), DMFS (57.9% vs 65.8%; P = 0.004), and post-DM (12.2% vs 20.1%; P = 0.012), but not in CCI-DM. Increased adoption of preoperative treatments and greater availability of medical agents in the recent years were associated to better outcomes. New treatments are eagerly awaited for further improvement of outcome for ESTSTS patients because no major changes have been observed since 2003.

Measuring functional outcome in upper extremity soft-tissue sarcoma: Validation of the Toronto extremity salvage score and the QuickDASH patient-reported outcome instruments

Interest in functional outcome (FO) and health-related quality of life (HRQL) in extremity soft-tissue sarcoma (STS) patients has increased. The aim of this study was to validate two FO questionnaires for upper extremity STS patients: the Toronto Extremity Salvage Score (TESS) and short version of the Disability of Arm, Shoulder and Hand (QuickDASH), based on Finnish population data. A multi-center study was conducted at two academic sarcoma centers. Surgically treated upper extremity STS patients were invited to participate. Patients completed the TESS and the QuickDASH with HRQL questionnaires the 15D and the QLQ-C30. The scores were analyzed and compared. Fifty-five patients with a mean follow-up period of 4.7 years were included. Mean age was 63 years (standard deviation [SD] 14.6). The mean score for TESS was 88.5 (SD 15.1) and for QuickDASH 17.8 (SD 19.6). The QuickDASH had a statistically significantly better score coverage. A ceiling effect was noted, 27% and 20% for TESS and QuickDASH, respectively. The TESS and QuickDASH scores were strongly correlated (r= -0.89). The TESS score strongly correlated with the QLQ-C30 (r=0.79) and the 15D score (r=0.70). The QuickDASH score correlated strongly with the QLQ-C30 score (r=-0.71) and moderately with the 15D score (r= -0.56). The TESS score had a statistically significantly stronger correlation with the 15D score than QuickDASH (p<0.005). Both the TESS and the QuickDASH provide reliable scores for assessing FO in upper extremity STS patients. The QuickDASH has a better coverage, whereas TESS showed a stronger correlation to HRQL scores.

Prospective evaluation of intensity-modulated radiotherapy toxicity in extremity soft tissue sarcomas patients: A role for irradiated healthy soft tissue volume?

AimTo prospectively assess toxicities of curative-intent intensity-modulated conformal radiotherapy (IMRT) in patients with extremity soft tissue sarcomas (ESTS). MethodsData from 59 consecutive patients with ESTS between 2014 and 2019 were both retrospectively and prospectively analysed. Toxicity data were collected both by confidential mailed survey (39% completed) and medical charts, and graded according to CTCAE v5.0. Normal tissues dosimetric data (healthy soft tissue segment, joint and bone) were included. The healthy soft tissue segment was created by adding 5 cm on either side of the PTV on CT axial slices, the PTV and bone (and articulation if present) were then removed from the generated volume. ResultsIMRT was delivered post-operatively for nearly half of patients (n = 24, 41%), preoperatively for 18 (31%) and exclusively for 17 (28%; salvage: 13% or immediately inoperable: 15%). The median total dose delivered to the planned target volume (PTV) was 50.4 Gy (36–68 Gy) and 13 patients (22%) received a boost. With a median follow-up of 27 months (6–94 months), a total of 87 late effects were identified in 44/59 (75%) patients: 89% G1–2, and 11% G3–4. The main G1-2 toxicities were: functional limitation (36%), oedema (29%), gait disorders (20%), neurological disorders (20%) and chronic pain (32%). G3-4 toxicities were pain (n = 2), arterial stricture (n = 1) and a chronic wound requiring skin graft (n = 2). No bone fracture was observed. Quality of life was rated as good or very good in 70% patients who completed the survey. Larger (>3500 cm3) healthy soft tissue segment volume was associated with decreased late toxicities (p = 0.02). No other predictive factor of toxicity was identified. The 2-year rates of local control, overall survival and recurrence-free survival were 90%, 90% and 64%, respectively. ConclusionHealthy soft tissue segment volume influenced toxicity. Long-term prospective monitoring in a homogeneous population remains critical to assess the impact of IMRT induced chronic toxicity in ESTS patients. This should ideally lead to a validated normal tissue dose constraint (e.g.: healthy soft tissue segment volume > 3500 cm3) to recommend for practitioners to help reduce the late toxicity risk.

Simultaneous Integrated Boost During Postoperative Radiotherapy in Extremity Soft Tissue Sarcoma

Intensity modulated radiotherapy (IMRT) has allowed the use of simultaneous integrated boost (SIB) volumes. We compared the outcomes of extremity soft tissue sarcoma (eSTS) patients treated with postoperative RT with either a sequential or integrated boost. We retrospectively reviewed a prospectively maintained institutional database of eSTS patients. All patients underwent assessment by both a surgical and radiation oncologist and surgical resection prior to definitive treatment. The majority underwent preoperative radiation followed by surgery as that was the preferred option. When chosen, postoperative RT consisted of either a 2 phase plan with 50 Gy in 25 fractions followed by 16 Gy in 8 fraction boost (total 66 Gy in 33 fractions) to a reduced volume or a single phase delivering 56 Gy in 33 fractions to the larger volume and 66 Gy in 33 fractions (SIB) to the reduced volume. The change from 3D-conformal RT (3DCRT) to IMRT facilitated the use of SIB. Functional outcomes were collected using Toronto Extremity Salvage Score (TESS) and Musculoskeletal Society Score (MSTS). Multivariable logistic regression was used to compare major wound healing complications (MWC) between the two groups. Cumulative incidence of local recurrence considering death as a competing risk was calculated. T-test was used to compare functional outcomes at each follow up time between the groups. Between January 2001 and December 2017, 112 patients were treated with surgery and RT of whom 104 were treated with post-operative radiation for eSTS excluding patients with angiosarcoma and desmoid tumor. Median age of patients was 64 years (range 17-95). Median tumor size was 9 cm, 61% had high grade tumor, 32% had upper and 68% had lower eSTS. The margin status was negative in 66% and positive in 35%. The median follow-up was 45 months (range 3-194 months). There was no significant difference in MWC between the SIB group (18%) and the sequential boost group (16%) adjusting for lower vs upper extremities and tumor size, OR (95%CI) was 1.23 (0.39, 3.86), p = 0.72. The 5-year cumulative incidence of local recurrence was 3.6% and 2.2% for the sequential and SIB groups, respectively, p = 0.35. For the entire group the 5-year local recurrence (LR) was 3.4% (0-7.3), 5-yr metastasis-free rate was: 64.3% (55.-73.8) and 5-year OS: 68.7% (60.0-78.8). There was no difference in the functional outcome scores using TESS, MSTS87. Postoperative RT in eSTS resulted in excellent local control rates. No differences were found in local control and functional outcomes between sequential or simultaneous boost techniques, although the analysis was limited by the relatively small sample size.

Further validation of the Toronto extremity salvage score for lower extremity soft tissue sarcoma based on Finnish patients

The most widely used patient-reported outcome (PRO) measure for soft tissue sarcoma (STS) patients is the Toronto Extremity Salvage Score (TESS). The aim of the study was to validate and test the reliability of the TESS for patients with lower extremity STS based on Finnish population data. Patients were assessed using the TESS, the QLQ-C30 Function and Quality of life (QoL) modules, the 15D and the Musculoskeletal tumour Society (MSTS) score. The TESS was completed twice with a 2- to 4-week interval. The intraclass correlation coefficient (ICC) was used for test-retest reliability. Construct validity was tested for structural validity and convergent validity. Altogether 136 patients completed the TESS. A ceiling effect was noted as 21% of the patients scored maximum points. The ICC between first and second administration of the TESS was 0.96. The results of exploratory factor analysis together with high Cronbach's alpha (0.98) supported a unidimensional structure. The TESS correlated moderately with the MSTS score (rho = 0.59, p< 0.001) and strongly with the mobility dimension in the 15D HRQL instrument (rho = 0.76, p < 0.001) and the physical function in QLQ-C30 (rho = 0.83, p< 0.001). The TESS instrument is a comprehensive and reliable PRO measure. The TESS may be used as a validated single index score, for lower extremity STS patients for the measurement of a functional outcome. The TESS seems to reflect patients' HRQoL well after the treatment of lower extremity soft tissue sarcomas.

Patient\u2019s quality of life after surgery and radiotherapy for extremity soft tissue sarcoma - a retrospective single-center study over ten years

Background and objectivesThe purpose of this study is to analyze major complication rates and different aspects of health-related quality of life (HRQoL) in extremity soft tissue sarcoma (STS) patients treated with or without radio (chemo) therapy and surgery.MethodsWe performed a retrospective analysis of all patients who underwent Extremity STS excision from 2004 to 2014 (182 patients included). Patients’ data were collected from patients’ records. HRQoL was assessed by using EORTC QLQ-C30.ResultsA total of 182 patients underwent sarcoma resection. After neoadjuvant radiochemotherapy (RCT), the major-complication rate amounted to 28% (vs. 7%, no radiotherapy, p < 0.001). Major-complication rates after adjuvant radiotherapy (RT) occurred in 8% (vs. 7%, no radiotherapy, p = 0.265). Comparison QoL scores between treating with neoadjuvant RCT or without RT revealed significant worse scores with neoadjuvant RCT. Further stratification of disease control of these patients showed significant reduced scores in the group of disease-free patients with neoadjuvant RCT compared to irradiated disease-free patients.DiscussionTo date, there have only been a few investigations of QoL in STS. Retrospective study on quality of life have limitations, like a lack of baseline evaluation of QoL. Patient candidated to radiation therapy could have had worse QoL baseline due to more advanced disease. Disease status of the patients who answered the questionnaires could have been an influence of QoL and we could show reduced scores in the group of disease-free patients with neoadjuvant RCT, but not for the patients with recurrence or metastasis, so it is very hard to discriminate whether radiation therapy could really have an impact or not.ConclusionThis study might assist in further improving the understanding of QoL in STS patients and may animate for prospective studies examining the oncological therapies impact on HRQoL.

Changing odds of survival over time among patients undergoing surgical resection of extremity soft tissue sarcoma.

While survival after surgical treatment of extremity soft tissue sarcoma (STS) is traditionally reported as actuarial survival, conditional survival (CS) may be more clinically relevant as it accounts for time already survived. We compared actuarial survival and CS of STS patients. We analyzed 567 patients who underwent surgery for localized extremity STS. Actuarial survival was estimated using the Kaplan-Meier method. Cox proportional hazards model was used to evaluate factors associated with disease-specific survival. Five-year CS (CS5) estimates at "χ" year(s) after surgery were calculated as CS5 = S(χ + 5)/S(χ). Whereas actuarial survival decreased over time, CS5 increased. The postsurgical 1-, 3-, and 5-year CS5 values were 84.5%, 90.0%, and 93.8%, respectively, whereas the 6-, 8-, and 10-year actuarial survival rates were 82.0%, 79.4%, and 78.5%, respectively. The calculated CS5 exceeded actuarial survival especially in patients with risk factors such as large tumor size and Federation Nationale des Centers de Lutte Contre le Cancer (FNCLCC) grades 2 and 3 tumors. Patients with tumor size ≥5 cm had an actuarial survival of 73.9% at 10 years compared to a CS5 of 95.4% in patients alive at 5 years. Likewise, patients with FNCLCC grade 3 tumors had an actuarial survival of 71.1% at 10 years compared to a CS5 of 96.0% in patients alive at 5 years. Survival estimation by determination of CS can be dynamic and accurate especially in high-risk patients. CS can be useful for survival prediction and clinical decision making in extremity STS patients.

Extremity soft tissue sarcoma in the elderly: Are we overtreating or undertreating this potentially vulnerable patient population?

As the U.S. population ages, differences in oncologic outcomes among the elderly have been recognized. Our objective was to analyze the clinical, pathologic, and treatment outcomes for elderly soft tissue sarcoma (STS) patients, hypothesizing significant differences in the management and response to therapy. Using the National Cancer Database, we identified 33 859 patients with nonmetastatic extremity STS. We defined elderly as ≥74 years in age and compared patient and treatment variables between adult and elderly patients. Cox-proportional hazards analysis was used to determine predictors of overall survival (OS). We identified 8504 elderly patients. Significant differences in histologic subtype, grade, and facility type between elderly and nonelderly patients (P < 0.05) exist. Elderly patients were less likely to undergo R0 resection (P = 0.001) and had a higher 90-day mortality (P = 0.001). Surgical elderly patients experienced superior OS compared with nonsurgical patients (P = 0.001). Among elderly patients, younger age, and female sex, lower Charlson-Deyo score, lower grade, smaller tumors, surgical resection, negative surgical margins, and radiation therapy were associated with better OS. Key differences exist in elderly extremity STS patients, including a narrower benefit/risk ratio with surgical management. These data highlight that elderly patients represent a distinct cohort for whom more careful selection appears indicated.

Prognostic Factors in Extremity Soft Tissue Sarcoma Patients Treated with Preoperative Radiotherapy

Purpose: The purpose of the study was to investigate the prognostic factors and survival after preoperative radiotherapy in Extremity Soft Tissue Sarcomas (ESTS). Materials and Methods: In this retrospective study, all patients treated for an extremity sarcoma with pre-operative radiotherapy followed by surgery. Results: The mean follow-up for all 24 ESTS patients was 15.5 (range: 10-39 months). At last follow-up, 9 patients (37%) were alive, 15 patients (62%) had died of distant disease progression. Among the patients died, there were 15 with metastatic relapse (13 lung and 2 cranial metastasis), 5 with both local and metastatic recurrence. The median OS was 16 month. The 2-years actuarial OS rate and 3-years OS rate were 39% and 26%, respectively. The median RFS was 14(12.5-15.4) month. The 2-years and 3-years RFS rate was 71%.The median MFS was 12 months. The 2-years and 3-years MFS rate were 33%, 17%, respectively. The effects of age, sex, histopathologic type, tumor size, tumor localization, tumor grade, tumor depth, radiation doses and recestion margin on OS, RFS, MFS were not observed. In univariate and multivariate model, it was observed that recurrence decreased OS time significantly (p&lt;0.05). Conclusion: Recurrens and metastasis are strong and negative prognostic factor for survival in extremity soft tissue sarcoma patients.

Impact of Loco-regional Surgical Control on Survival of Extremity Soft Tissue Sarcoma among Patients of Hadhramout National Cancer Center

Background: Loco-regional surgery remains the mainstay therapy of extremity soft tissue sarcoma (ESTS) and provides the only chance of cure. Improvements of surgical technique, increased surgical experience, radiotherapy, adjuvant and neoadjuvant chemotherapy increased the survival. Aim of study: to evaluate the effect of the type of surgical intervention on the survival and quality of life of ESTS Patients. Methods: This is a prospective study to evaluate the impact of loco-regional surgical control on the survival among ESTS patients attended the National Cancer Center, Hadhramout -Yemen, between April 2010 and October 2018. Extremity soft tissue sarcoma patients were operated either by wide-local excision with safety margin or amputation or disarticulation. The study population consisted of 52 patients in which males and females represented (53.85%) and (46.15%) respectively. The three variable methods were compared using Chi-square test. Survival rate was analyzed by Kaplan-Meier test. Results: Fifty two patients, 12 patients in Group I (23, 1%), 10 patients in Group II (19.2%) and 30 patient’s in Group III (57.7%). The mean survival in patients underwent disarticulation was (77.5) months, while patients who had an amputation, the survival was (45.5) months, and in wide local resection patients was (59.9) months. The mean overall survival was (65.9) months, P value > (0.026) which was significant. Among the 3 different types of management, high overall survival rate was found in patients underwent disarticulation, while overall survival rate was also high in patient underwent wide local excision or compartmental resection in spite of functional limb preservation and good quality of life. The mean overall survival rate was low in patients who had limb amputation with loss of limb function. Conclusion: The wide local excision or compartmental resection mandates margin-negative, accepted post-operative local wound complication, associated with prolonged disease-free-survival and overall survival than other methods. Must be deal with improve patient overall survival, decrease local recurrence and obtained best Oncological outcome by preserve function with good quality of life for ESTS patients who underwent wide or compartmental resection or radical limb sparing surgery.

Substantial Volume Changes and Plan Adaptations During Preoperative Radiation Therapy in Extremity Soft Tissue Sarcoma Patients

PurposeMany authors suggest that extremity soft tissue sarcomas (ESTS) do not change significantly in size during preoperative radiation therapy (RT). This cone beam computed tomography study investigates the justification to deliver the entire course with 1 initial RT plan by observing anatomic changes during RT. Methods and MaterialsBetween 2015 and 2017, 99 patients with ESTS were treated with either curative (n = 80) or palliative intent (n = 19) with a regimen of at least 6 fractions. The clinical target volume to planning target volume margin was 1 cm. Action levels were assigned by radiation technicians. An extremity contour change of >1 cm and/or tumor size change >0.5 cm required a physician's action before the next fraction. ResultsA total of 982 cone beam computed tomography logfiles were studied. In 41 of 99 patients, the dose coverage of the initial treatment plan was fully satisfactory throughout the RT course. However, action levels were observed in 58 patients (59%). In 41 of these 58 patients, a contour increase of 5 to 23 mm was noted (29 tumor size increase only, 3 extremity contour increase, and 9 both). In 21 of 58 patients, a decrease of 5 to 33 mm was observed (20 tumor size decrease only and 1 tumor size decrease and extremity contour decrease). In 4 cases, contours initially increased and subsequently decreased. In 33 of 41 patients with increasing contours, the dose distribution adequately covered gross tumor volume because of the 1 cm planning target volume margin applied. For the remaining 8 patients (8%), the plan needed to be adapted. ConclusionsESTS volumes may change substantially during RT in 59% of all patients, leading to plan adaptations resulting from increased volumes in 8%. Daily critical observation of these patients is mandatory to avoid geographic misses because of increases in size and overdosing of normal tissues when masses shrink.

Impact of perioperative chemotherapy and radiotherapy in patients with primary extremity soft tissue sarcoma: retrospective analysis across major histological subtypes and major reference centres

BackgroundThe role of radiotherapy (RTx) and chemotherapy (CTx) in primary extremity soft tissue sarcoma (eSTS) patients is not precisely defined. MethodsAll consecutive primary eSTS patients treated within three European and one North American reference centres in a 20-year time span were included. The tendency to perform chemotherapy/radiotherapy (CTx/RTx) was explored using multivariable binary logistic models. Five and 10-year overall survival (OS) and crude cumulative incidence (CCI) of local recurrence (LR) and distant metastasis (DM) were estimated. Multivariable analyses of OS, CCI of LR and CCI of DM were performed. The effect of CTx administration was explored with a propensity score matching analysis. ResultsOverall, 3752 patients were included. Median follow-up was 79 months (interquartile range 44–119). Ten-year OS, CCI of LR and CCI of DM were 66.3% (64.3–68.2%), 8.2% (7.2–9.2%) and 28.2% (26.6–30.0%), respectively. Centre and histology significantly influenced administration of RTx/CTx. RTx was associated with a better local outcome, especially in myxoid liposarcoma, vascular sarcoma and myxofibrosarcoma, without being associated with survival. Chemotherapy was not an independent prognostic factor for OS in all patients (p = 0.73). In a propensity score–matched analysis, patients treated with CTx had longer survival although this difference did not reach statistical significance (p = 0.054). The use of perioperative CTx in patients with primary localised eSTS was not associated with worse survival after occurrence of DM. ConclusionSome histologies gain a greater benefit from perioperative RTx in terms of LR risk reduction. The trend towards a 5% survival benefit associated with CTx administration is consistent with the published literature, but definitive conclusions are awaited from ongoing randomised controlled trials. Perioperative CTx for primary eSTS does not hamper post-DM survival.