Management Of Soft Tissue Sarcomas Research Articles

Trabectedin and Eribulin: Where Do They Fit in the Management of Soft Tissue Sarcoma?

Trabectedin and eribulin are two agents that have been recently approved for the treatment of specific soft tissue sarcoma subtypes. They have proved to be a much-needed line of additional treatment for patients with these rare tumors, but their activity remains admittedly modest in most cases. Further exploitation of these novel agents is likely to require a more granular understanding of the salient mechanisms of action. For example, if as some studies suggest, eribulin derives its benefit from restructuring of tumor vasculature to improve efficacy of subsequent lines of therapy, then patients may benefit from its use earlier in the treatment pathway. The sequencing of trabectedin with other agents is also worth examining. In a disease like myxoid liposarcoma, consideration should be given to using trabectedin before other salvage regimens like gemcitabine and docetaxel, given its tolerability and excellent efficacy against this sarcoma subtype. Also, to be further investigated is the use of trabectedin in sarcoma subtypes which were excluded from the phase III study, but in which activity has been documented in earlier trials and subsequent reports. Combinations of trabectedin with other agents, particularly doxorubicin, have been explored, but the data to date do not support the routine use of these regimens.

Surgical management of soft tissue sarcoma

Soft tissue sarcomas (STS) are a heterogeneous group of tumours and surgery is the principal treatment. The majority occur in the limbs and trunk wall and this article refers to management of these anatomical sites. STS is managed within a specialist multidisciplinary team and an individualized treatment plan is produced for each patient. Histological, anatomical and patient factors will all influence the strategy. In localized disease, the surgical aim is to achieve a wide excision with negative margin and preserve function. Radiotherapy may be indicated to reduce the risk of local recurrence and can be given pre- and/or post-operatively. Planned marginal excision combined with radiotherapy is an acceptable approach in order to preserve critical structures. Neo-adjuvant radiotherapy can reduce tumour burden and improve operability. However, amputation is sometimes the only treatment option. Reconstructive surgery may be required to achieve wound healing and restore function. The approach to management of local recurrence is much the same as for primary disease. Advanced disease is predominantly treated by systemic therapy but metastatectomy is utilized in some circumstances. Follow-up is required to monitor for recurrence, metastasis and complications of treatment.

American Brachytherapy Society consensus statement for soft tissue sarcoma brachytherapy

PurposeRadiation therapy represents an essential treatment option in the management of soft tissue sarcomas (STS). Brachytherapy represents an important subset of radiation therapy techniques used for STS, with evolving indications and applications. Therefore, the purpose of this guideline was to update clinicians regarding the data surrounding brachytherapy (BT) and provide recommendations for the utilization of BT in patients with STS. Methods and MaterialsMembers of the American Brachytherapy Society with expertise in STS, and STS BT in particular, created an updated guideline for the use of BT in STS based on a literature review and clinical experience. ResultsGuidelines are presented with respect to dose and fractionation and technical features to improve outcomes and potentially reduce the risk of toxicity. Brachytherapy as monotherapy can be considered in low-risk cases or in situations where re-irradiation is being considered. Brachytherapy boost can be considered in cases at higher risk of recurrence or where BT alone cannot adequately cover the target volume. To limit wound complications, the start of BT delivery should be delayed until final wound closure, or if after immediate reconstruction, started after postoperative Day 5. ConclusionsThe current guidelines have been created to provide clinicians with a review of the data supporting BT in the management of STS as well as providing indications and technique guidelines to ensure optimal patient selection and clinical outcomes.

An Update on Non-extremity Soft Tissue Sarcomas

The management of soft tissue sarcoma is challenging and varied. Centralisation of management in high volume specialist centres has revolutionised outcomes. Surgery remains the mainstay of treatment and is currently the only potentially curative therapy. Retroperitoneal soft tissue sarcoma presents a particular challenge to the surgical oncologist and the concept of extended resection to include surrounding expendable organs taken en bloc with the tumour has now largely been adopted. The use of neoadjuvant and adjuvant therapies for retroperitoneal soft tissue sarcoma is still to be established, although they are employed on a case-specific basis. Guidance on the management of retroperitoneal recurrences and distant metastatic disease is now recognised. The approach to soft tissue sarcoma of the head and neck, trunk and abdominal wall remains largely extrapolated from experience of the management of extremity soft tissue sarcoma. Secondary angiosarcoma of the breast is becoming increasingly more common and presents a particular therapeutic challenge. Continued international collaboration is essential to ensure evolution of the optimal management of this rare group of cancers.

Patient, tumour and treatment factors affect complication rates in soft tissue sarcoma flap reconstruction in a synergistic manner

IntroductionFlap reconstruction plays an essential role in the management of soft tissue sarcoma, facilitating wide resection while maximizing preservation of function. The addition of reconstruction increases the complexity of the surgery and identification of patients who are at high risk for post-operative complications is an important part of the preoperative assessment. This study examines predictors of complications in these patients. Methods294 patients undergoing flap reconstruction following sarcoma resection were evaluated. Data on patient, tumour and treatment variables as well as post-operative complications were collected. Bivariate and multivariate regression analysis was performed to identify independent predictors of complications. Analysis of synergistic interaction between key patient and tumour risk factors was subsequently performed. ResultsA history of cerebrovascular events or cardiac disease were found to be the strongest independent predictors of post-operative complications (OR 14.84, p = 0.003 and OR 5.71, p = 0.001, respectively). Further strong independent tumour and treatment-related predictors were high grade tumours (OR 1.91, p = 0.038) and the need for additional reconstructive procedures (OR 2.78, p = 0.001). Obesity had significant synergistic interaction with tumour resection diameter (RERI 1.1, SI 1.99, p = 0.02) and high tumour grade (RERI 0.86, SI 1.5, p = 0.01). Comorbidities showed significant synergistic interaction with large tumour resections (RERI 0.91, SI 1.83, p = 0.02). ConclusionPatient, tumour and treatment-related variables contribute to complications following flap reconstruction of sarcoma defects. This study highlights the importance of considering the combined effect of multiple risk factors when evaluating and counselling patients as significant synergistic interaction between variables can further increase the risk of complications.

The value of adaptive preoperative radiotherapy in management of soft tissue sarcoma

PurposeTo determine the value of preoperative adaptive radiotherapy (ART) for soft tissue sarcoma patients (STS) by modeling the dosimetric consequences of tumour volume changes (TVC) using different external beam radiotherapy techniques. Methods and materialsA subset of 22 STS patients from a recent trial (NCT00188175) underwent a repeat CT scan (CT2) prompted by TVC>1cm during IMRT; 14 tumours grew, 8 shrank. Conformal and conventional plans were modelled in addition to IMRT replicating original criteria from the initial planning dataset (CT1):95% PTV encompassed by 97% prescribed dose. CT1 RT parameters for all plans were applied to CT2 for dosimetric assessment of TVC. Co-registration of CT1 and CT2 permitted comparison of original and new contours. ResultsMean TVC was 45% for growing and 33% for the shrinking cohort with TVC prompting CT2 at a mean of 13 fractions. For growers, the lack of target coverage on CT2 was statistically significant but was adequate for shrinkers. ConclusionGTV expansion of >1cm during RT may result in target underdosage independent of RT technique. ART applied offline for TV increases >1cm is a practical adaptive strategy to ensure tumour coverage during RT. TV shrinkage may allow for normal tissue sparing, which should be investigated prospectively.

Management of soft-tissue sarcomas; treatment strategies, staging, and outcomes.

Soft-tissue sarcomas (STS) are a rare group of malignant tumors which can affect any age group. For the majority of patients who present with a localized STS, treatment involves a multidisciplinary team decision-making approach ultimately relying on surgical resection with or without adjuvant radiation for successful limb salvage. The goals of treatment are to provide the patient with a functional extremity without local tumor relapse. The purpose of this article is to review the treatment of extremity STS, with a focus on staging, treatment options, and outcomes.

Advances and controversies in the management of soft tissue sarcomas.

Intensive clinical research in the sarcoma field has provided insight into the histopathological diversity of soft tissue sarcomas (STS) and led to the introduction of many new agents that promise to play an important role in the management of patients with STS. While an increasing body of scientific data has advanced our knowledge of this complex family of mesenchymal diseases, several controversies remain to be resolved: Is doxorubicin-based therapy still the definitive standard first-line treatment for all patients with unresectable and/or metastatic STS of all subtypes? Is histology-driven therapy beyond gastrointestinal stromal tumors a reality or are we pursuing an unachievable objective? Are we making practical headway in the establishment of sarcoma reference centers? Is it clearly established which is the best parameter to evaluate the efficacy of a new agent in STS?

SEOM Clinical Guideline of management of soft-tissue sarcoma (2016).

Soft-tissue sarcomas are uncommon and heterogeneous tumors of mesenchymal origin. A soft-tissue mass that is increasing in size, greater than 5 cm, or located under deep fascia are criteria for suspicion of sarcoma. Diagnosis, treatment, and management should preferably be performed by a multidisciplinary team in reference centers. MRI and lung CT scan are mandatory for local and distant assessment. A biopsy indicating histological type and grade is needed previous to the treatment. Wide surgical resection with tumor-free tissue margin is the primary treatment for localized disease. Radiotherapy is indicated in large, deep, high-grade tumors, or after marginal resection not likely of being improved with reexcision. Neoadjuvant and adjuvant chemotherapy improve survival in selected cases, usually in high-grade sarcomas of the extremities. In the case of metastatic disease, patients with exclusive lung metastasis could be considered for surgery. First-line treatment with anthracyclines (or in combination with ifosfamide) is the treatment of choice. New drugs have shown activity in second-line therapy and in specific histological subtypes.

Systemic therapy for bone sarcomas

Bone sarcomas comprise less than 0.2% of all malignancies and are divided into several subtypes with varying sensitivities to systemic therapy. While the role of adjuvant chemotherapy in the management of soft-tissue sarcomas is controversial, perioperative chemotherapy has greatly improved the survival of nonmetastatic Ewing sarcoma and osteosarcoma. However, metastatic unresectable Ewing sarcoma and osteosarcoma are still associated with a poor prognosis. Giant cell tumor of bone and chordoma are refractory to conventional cytotoxic chemotherapy, but in recent years targeted therapy has been shown to be able to provide a degree of control of unresectable disease. Conventional chondrosarcoma remains refractory to systemic therapy, although the less common subtypes, dedifferentiated and mesenchymal chondrosarcomas, can be sensitive to chemotherapy but still have a poor prognosis.

Neoadjuvant Chemoradiation With Ifosfamide and Etoposide in the Management of Soft Tissue Sarcomas: A Single-Institution Review

Neoadjuvant Chemoradiation With Ifosfamide and Etoposide in the Management of Soft Tissue Sarcomas: A Single-Institution Review

Small AnimalReview

Introduction: Cisplatin beads are an alternative treatment modality to radiotherapy for the management of soft tissue sarcomas following surgery.

Tumor volume is a better predictor of post-operative wound complications compared to tumor size in soft tissue sarcomas of the proximal lower extremity.

BackgroundWide local excision with or without radiation therapy (RT) and chemotherapy is widely accepted as appropriate management for soft tissue sarcomas (STS) of the extremity. Although survival and local control rates are comparable to amputation, post-operative wound complications (WC) following limb salvage can result in significant morbidity for the patient. Certain risk factors such as location, pre-operative RT, and age have been shown to increase the risk of WCs. Somewhat surprisingly, size has not consistently been shown to impact WC rates. The goal of this study is to assess whether tumor volume, as opposed to the traditional measurement of the largest dimension in one plane, correlates with the development of post-operative WCs.MethodsBetween 2000 and 2013, 81 patients with STS of the proximal lower extremity, buttock and pelvis were retrospectively identified from our prospective database. We reviewed the impact of patient, tumor, and treatment variables on postoperative WC. Predictors for WC were evaluated using the Fisher exact test for univariate analysis and logistic regression for multivariate analysis. Tumor volume was determined using the medical image merge (MIM) ® software program (version 6.5.4, MIM Software, Cleveland, OH). Tumor size (diameter) was determined the historical way of measuring the widest dimension on the sagittal, coronal, and axial planes from the MRI scan at midplane.ResultsThe overall WC rate within 6 months of tumor resection was 32 %. WC were more likely to occur with larger tumor volumes (p = 0.015), although not with tumor diameters ≥10 cm (p = 0.55). Neither volume of subcutaneous fat (p = 0.34) or depth of the subcutaneous fat layer (p = 0.82) significantly impacted WC rates. Tumor proximity to skin surface also did not significantly impact WC risk (p = 0.73).ConclusionsIncrease in tumor volume led to a higher risk of post-operative WCs. Assessing tumor volume may allow clinicians to better counsel patients on their risk of post-operative WCs. Tumor volume, as opposed to size alone, should be considered in future sarcoma outcome studies.

The role of radiotherapy in the management of localized soft tissue sarcomas.

The combination of radiotherapy (RT) and function-preserving surgery is the most usual contemporary approach in the management of soft tissue sarcomas (STS). Pre- and postoperative RT result in similar local control rates, as shown by a landmark trial in extremity STS. In this review, the role of RT in the management of extremity STS will be discussed, but STS in other sites, including retroperitoneal STS, will also be addressed. The focus will consider various aspects of RT including strategies to reduce the volume of tissue being irradiated, dose, scheduling, and the possible of omission of RT in selected cases. Finally, technology advances through the use of intensity-modulated radiotherapy (IMRT), image-guided IMRT, intraoperative radiotherapy (IORT) and particle therapy will also be discussed.

SY10-6 - Radiotherapy for management of soft tissue sarcomas

SY10-6 - Radiotherapy for management of soft tissue sarcomas

Long-term Results of Intraoperative Radiation Therapy in the Management of Soft Tissue Sarcoma

Long-term Results of Intraoperative Radiation Therapy in the Management of Soft Tissue Sarcoma

Histology-Driven Therapy: The Importance of Diagnostic Accuracy in Guiding Systemic Therapy of Soft Tissue Tumors.

Soft tissue tumors (STTs) are rare mesenchymal neoplasms accounting for less than 1% of adult cancers. More than 50 different subtypes of STTs have been identified, with this number expected to grow as our understanding of the complex genetic landscape of these diseases improves. As the classification of soft tissue neoplasms continues to diversify, so does the approach to therapy. Accurate histopathologic diagnosis, utilizing the appropriate ancillary immunohistochemical and molecular diagnostic platforms, underpins the oncologic management of soft tissue sarcomas. As increasing numbers of reproducible genetic abnormalities in soft tissue neoplasms are defined, molecular genetic and molecular cytogenetic investigations have become a standard part of the ancillary diagnostic repertoire. However, other soft tissue neoplasms lack reproducible genetic abnormalities, and for these, traditional histology and immunohistochemistry remain the cornerstones for diagnosis. Here, we give an overview of histology-driven therapy in STTs, highlighting the critical role of accurate surgical pathology in guiding the systemic treatment of patients with these neoplasms, and the importance of close collaboration between the surgical pathologist and the oncologist. We also summarize what is considered standard practice in nonhistology- and histology-driven therapy.

Optically-tracked handheld fluorescence imaging platform for monitoring skin response in the management of soft tissue sarcoma.

Standard clinical management of extremity soft tissue sarcomas includes surgery with radiation therapy. Wound complications (WCs) arising from treatment may occur due to bacterial infection and tissue breakdown. The ability to detect changes in these parameters during treatment may lead to earlier interventions that mitigate WCs. We describe the use of a new system composed of an autofluorescence imaging device and an optical three-dimensional tracking system to detect and coregister the presence of bacteria with radiation doses. The imaging device visualized erythema using white light and detected bacterial autofluorescence using 405-nm excitation light. Its position was tracked relative to the patient using IR reflective spheres and registration to the computed tomography coordinates. Image coregistration software was developed to spatially overlay radiation treatment plans and dose distributions on the white light and autofluorescence images of the surgical site. We describe the technology, its use in the operating room, and standard operating procedures, as well as demonstrate technical feasibility and safety intraoperatively. This new clinical tool may help identify patients at greater risk of developing WCs and investigate correlations between radiation dose, skin response, and changes in bacterial load as biomarkers associated with WCs.

(i) Management of soft tissue sarcoma

Abstract Soft tissue sarcomas (STS) are rare malignant connective tissue tumours. A multi-disciplinary approach is required to manage such tumours. This article reviews the diagnosis and management of STSs.

Timelines for multidsiciplinary limb soft tissue sarcoma management.

e17549 Background: Treatment timelines are an important metric in health services delivery. In rare tumors such as limb soft tissue sarcomas (STS’s) expert multidisciplinary management is very indi...