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1.
Taeger G  Ruchholtz S  Schütte J  Nast-Kolb D 《Der Unfallchirurg》2004,107(7):601-15; quiz 616-7
Soft tissue sarcomas (STS) represent a rare entity of all malignant tumors (1%). Thus, an in-depth understanding of multidisciplinary treatment strategies may not be sufficiently present at all operative units. Consecutively, optimal diagnostic and therapeutical pathways may not be applied. Magnetic resonance imaging (MRI) is the procedure of choice in diagnosing STS. Biopsies should be performed in specialized centers. Identification of cytogenetic factors has become more important for the typing and prognosis of STS. Management of STS should employ multimodal treatment concepts (Oncology, Radiotherapy, Surgical Oncology). The decision on whether radiotherapy, chemotherapy or another option is indicated should be taken by an interdisciplinary tumor board, which also determines the sequence of treatment in relation to resection. To obtain sufficient information from histopathologic examination of the resected tumor, a clear and distinct definition of critical margins and topography by the surgeon is essential. Following these concepts, optimal local tumor control associated with resections preserving function and limbs is achieved without impairment of overall prognosis. Tumor resection alone, without previous evaluation and where appropriate adopting multimodal treatment strategies, no longer meets modern standards. After primary treatment is complete, patients have to be enrolled in a standardized follow-up program.  相似文献   

2.
??Decision making of surgery type and resection extent in extremity soft tissue sarcomas CHEN Yong. Department of Gastric and Soft Tissue Surgery, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
Abstract Surgical resection remains the mainstay of treatment for extremity soft tissue sarcomas (STS). With the development of modern surgical technologies and theories, the surgical treatment of STS has been developed into a multidisciplinary model which mainly includes limb-sparing resection and functional reconstruction. Wide local excision with at least 1 cm of normal tissue around the tumor is the current surgical goal. Marginal resection combined with adjuvant therapy could be used in case of proximity to vital structures. Removal of neurovascular bundles or bony structures necessitates reconstruction in limb-sparing surgeries. Amputation should be taken into consideration when a non-functional residual limb will be left after massive resection of neurovascular bundles and surrounding soft tissue.  相似文献   

3.
Patients with high-risk soft tissue sarcomas (FNCLCC grades 2–3, >?5 cm and deep lying) are at a high risk of local recurrence or distant metastases despite optimal surgical tumor resection. Therefore, multimodal treatment should be considered for this difficult to treat patient group. Besides surgery, radiation therapy and chemotherapy, hyperthermia has become a valid, complementary treatment option within multimodal treatment concepts. Hyperthermia in this context means the selective heating of the tumor region to temperatures of 40–43?°C for 60 min by microwave radiation in addition to simultaneous chemotherapy or radiation therapy. A randomized phase III study demonstrated that the addition of hyperthermia to neoadjuvant chemotherapy improved tumor response and was associated with a minimal risk of early disease progression as compared to chemotherapy alone. The addition of hyperthermia to a multimodal treatment regimen for high-risk soft tissue sarcoma consisting of surgery, radiation therapy and chemotherapy, either in the neoadjuvant or adjuvant setting after incomplete or marginal tumor resection, significantly improved local progression-free and disease-free survival. Based on these results and due to the generally good tolerability of hyperthermia, this treatment method in combination with chemotherapy should be considered as a standard treatment option within multimodal treatment approaches for locally advanced high-risk soft tissue sarcoma.  相似文献   

4.
Formerly an exclusive business of surgery, gastrointestinal (GI) tumors are nowadays increasingly approached with multimodal strategies. Neoadjuvant concepts have had a particularly far-reaching impact on surgery and have contributed to improved survival. Modern pre-treatment staging and risk assessment provide the basis for decision on one of three general treatment concepts (1) Early cancers, confined to the mucosal/submucosal layers, are approached with primary surgery, without prior antineoplastic therapy. (2) Systemically metastasized tumors receive merely palliative treatment. (3) Locally advanced cancers are increasingly approached with neoadjuvant strategies. The benefit from these preoperative protocols is proven for diverse entities, but is evidently confined to a specific subgroup patients, i.e., the responders to neoadjuvant treatment. These are the ones benefiting most from subsequent surgical resection, which is required to ensure complete removal of the residual tumor tissue, as complete tumor regression occurs very rarely and cannot be proven without a specimen. The fact that responders will benefit and non-responders will not benefit or will even deteriorate during the neoadjuvant treatment makes early response prediction most demanding. An amazing new approach is the use of position emission tomography with fluro-desoxyglucose (FDG-PET) to assess the "metabolic response," which is possible as early as 14 days after initiation of the neoadjuvant protocol. This strategy offers the chance for modulating the surgical approach in accord i.e., with such metrobolic response termination of the protocol and proceeding to resection in the case of nonresponse.The future of GI cancer surgery is multimodal therapy in a response-based fashion and requires reponse-based trials for further evaluation.  相似文献   

5.
??Diagnosis and treatment of soft tissue sarcomas: hot and difficult problems WANG Ya-nong, CHEN Yong. Department of Gastric and Soft Tissue Surgery, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
Corresponding author: WANG Ya-nong, E-mail: wangyn1111@hotmail.com
Abstract Diagnosis and treatment of soft tissue sarcoma (STS) have evoked emphasis clinically with the incidence rate slightly increased recently. Despite various evidence-based medicine guidelines or strategies have been sponsored worldwide, misdiagnosis and mistreatment of STS, which would negatively impact further treatment and even patients' survival, are not uncommonly encountered. It's mandatory to obtain a histopathological diagnosis of STS by biopsy before definite treatment, but the importance of biopsy was underestimated and the methods of biopsy were not always rational. As to therapy, surgical resection remains the mainstay of treatment, but a multidisciplinary treatment model has been accepted due to the emerging evidences supporting the use of chemoradiotherapy and target therapies. The optimized individualized treatment should be performed for STS according to different subtypes.  相似文献   

6.
S Beller  P M Schlag 《Der Chirurg》2006,77(3):219-225
Before any palliative tumor resection, the morbidity and mortality risks must be carefully weighed against the continued prognosis (including quick and lasting relief of discomfort from the tumor) and alternative strategies such as bypass, chemotherapy, and radiotherapy. Multimodal concepts have seen considerable progress in recent years, and endoscopic and interventional methods have expanded the instrumentarium for palliative tumor therapy. Thus the value of palliative resection must be reassessed. The most important criteria and study results are described here, as they have resulted in increased interest in palliative tumor resection within a multimodal treatment for most gastrointestinal tumors. More studies are needed to learn how much can realistically be expected of these new approaches.  相似文献   

7.
Before any palliative tumor resection, the morbidity and mortality risks must be carefully weighed against the continued prognosis (including quick and lasting relief of discomfort from the tumor) and alternative strategies such as bypass, chemotherapy, and radiotherapy. Multimodal concepts have seen considerable progress in recent years, and endoscopic and interventional methods have expanded the instrumentarium for palliative tumor therapy. Thus the value of palliative resection must be reassessed. The most important criteria and study results are described here, as they have resulted in increased interest in palliative tumor resection within a multimodal treatment for most gastrointestinal tumors. More studies are needed to learn how much can realistically be expected of these new approaches.  相似文献   

8.
Background: Increased tumor neovascularity has been shown to correlate with poor prognosis in solid tumors. Methods: Microvessels were identified by factor VIII immunohistochemical staining. Analysis of microvessel counts, tumor characteristics, and resection details was performed on 119 primary, high-grade extremity soft tissue sarcomas (STS) and correlated with clinical outcome. Results: Tumor characteristics and resection details were analyzed and patient outcome was examined with respect to local recurrence, distant metastasis, and disease-specific survival. Factors found to be significant on univariate analysis for all outcome variables were positive microscopic margin and tumor size. A positive microscopic margin was found to be a significant risk factor for local recurrence (P=.03), distant metastasis (P=.006), and disease-specific survival (P=.004). A primary tumor greater than 10 cm in diameter was a poor prognostic factor for distant metastasis (P=.03) and disease-specific survival (P=.006) when compared to tumors smaller than 10 cm. Microvessel count did not correlate with survival nor did it predict distant metastasis or local recurrence. Histologic subtypes of STS that have a prominent vascular pattern as a diagnostic criterion (i.e., angiosarcoma, liposarcoma, hemangiopericytoma) form a subgroup of all STS. Neovascularity in these subtypes showed no relationship to clinical outcome. Conclusions: These data confirm the prognostic importance of microscopic margin and tumor size in high-grade extremity STS. Neovascularity measured by factor VIII staining had no prognostic significance in these mesenchymal tumors, in contradistinction to carcinomas. Alternatively, microvessel counts may not accurately represent the angiogenic capacity of STS. Therefore, patients with STS who are eligible for anti-angiogenesis clinical trials cannot be identified solely by microvessel count.Presented at the 50th Annual Cancer Symposium of The Society of Surgical Oncology, Chicago, Illinois, March 20–23, 1997.  相似文献   

9.
Summary. The increasing spectrum of therapeutic options for tumors of the gastrointestinal tract has resulted in a refinement of the pretherapeutic diagnostic strategies. The diagnostic approach in surgical institutions that are focused on primary surgical resection will therefore be much less sophisticated than in institutions who propose a selective therapeutic approach based on the pretherapeutic tumor stage and prognostic parameters. Pretherapeutic assessment of the depth of tumor infiltration, i. e. the T-category, is essential because most further diagnostic and therapeutic decisions are based on this information. This can today be achieved with a high degree of accuracy by endoscopy and endoscopic ultrasonography. Early T-stages (T1–2) are usually an indication for primary surgical resection and, after exclusion of distant metastases, no further diagnostic studies are required. In patients with locally advanced esophageal, gastric or rectum tumors (T3–4) multimodal therapeutic concepts should be considered. This usually requires additional diagnostic studies. None of the available diagnostic imaging modalities today allows satisfactory pretherapeutic assessment of lymph node metastases. The assumed nodular status should therefore currently not influence therapeutic decisions. Essential is, however, the assessment of distant metastases, since the documentation of distant tumor spread will change the therapeutic approach to a palliative situation. Detailed histologic and molecular-biologic assessment of tumor characteristics is growing in importance. This not only provides therapeutically relevant information regarding tumor grading, but opens the door towards a modern molecular diagnostic approach. It can be expected that in the near future a vast amount of relevant prognostic information can be obtained from endoscopic tumor biopsies, which may soon alter our therapeutic concepts.   相似文献   

10.
This article presents and summarizes different treatment options for rectal cancer. The aim of this article is an historical review of treating primary and recurrent rectal cancer, highlighting the development and advancement in surgical and multimodal therapy. Limitations, specifically regarding recurrent rectal cancer are discussed and reviewed. A R0 resection can almost always be achieved in primary rectal cancer. In recurrent rectal cancer a R0 resection with extended surgical resection can be achieved in up to 70?% of the cases. In addition, surgical therapy plays a crucial role in the case of metastatic disease but should be incorporated into a multimodal network. The analysis of tumor genetics and predictive parameters will lead to the emergence of new treatment concepts shifting the limits of the current gold standard. Oncological long-term survival and improving the quality of life are the main focal points.  相似文献   

11.

Background

Function-preserving treatment in patients with soft tissue sarcomas (STS) of the limbs is an interdisciplinary challenge.

Objective

Analysis of evidence on the status and type of radiotherapy (RT) within multimodal concepts.

Material and method

Compilation of current guidelines and publications on multimodal treatment, in particular on the role of preoperative and postoperative RT for STS of the limbs. Presentation and explanation of the role of modern and special RT techniques.

Results

Both preoperative and postoperative RT are recommended indications for patients with stage II and III STS. Furthermore, postoperative RT after incomplete resection has a clear recommendation. The use of both preoperative and postoperative RT correlates with an increase in local control but a positive influence on survival is most likely limited to the subgroup of patients with high-grade STS. In the long term preoperative RT shows less late toxicity but leads to more acute wound complications. Modern special techniques, such as imaging-guided magnetic resonance imaging (IG-MRI), intraoperative radiotherapy (IORT) and brachytherapy (BT) can significantly reduce side effects as well as reduce safety margins during irradiation planning.

Conclusion

In patients with STS of the limbs, preoperative and/or postoperative RT should be performed in stages II and III and after incomplete resection. The use of special techniques and modern target volume concepts leads to a reduction of side effects.
  相似文献   

12.
Background/Aims  Soft tissue sarcomas (STS) are rare tumors. General treatment is difficult while multimodality treatment strategies are more and more common. In these strategies, surgical resection of the primary tumor is essential to achieve local control of the tumor. In certain cases, complex resections (CR) including multivisceral and/or vascular resection are needed to achieve resection with tumor-free margins. In this study, we evaluated retrospectively the overall prognosis, morbidity, and mortality of patients treated for STS at our university hospital. Patients/Methods  Between 1992 and 2000, 24 of 154 patients with STS received multivisceral resection and four of 154 underwent vascular resection. To determine the influence of CR on overall prognosis, we compared n = 19 patients after CR with a matched control group after simple tumor resection (SR). To determine surgical morbidity and mortality the whole study group was used (n = 154, SR n = 126, CR n = 28). Results  The median follow up for all patients was 6.89 years (mean 5.64 years SD 4.3) with no difference between the groups (CR vs SR: 5.4 SD 4.8 vs 5.9 SD 3.9 years; p = 0.711). Patients receiving CR had a similar overall prognosis (mean survival 9.9 years), morbidity (10.7%) and mortality (0%) compared to patients with SR (mean survival 8.5 years; morbidity 10.3%; mortality 3.96%). Conclusions  Multivisceral resection and/or vascular resection with tumor-free margins can be achieved with the same overall prognosis, same morbidity and mortality as SR. This has to be taken into account when evaluating the treatment strategy in patients with STS.  相似文献   

13.
Rectal cancer with synchronous liver metastases includes a wide variety of clinical presentations. In patients with rectal cancer and synchronous liver metastases, treatment strategy depends on the site and the extent of rectal cancer, the extent of liver metastases and the presence of extra-hepatic disease. In the majority of patients, liver metastases are unresectable and in this setting, the primary goal of treatment strategy is to prolong survival and to preserve quality of life. Most of these patients are treated with systemic chemotherapy and local treatment including radiotherapy or surgical resection is indicated in patients presenting with symptoms or complications related to the primary tumor. In patients with resectable liver metastases, a curative approach to the disease including resection of rectal cancer and liver metastases should be proposed. In this setting, a large number of treatment options can be discussed especially regarding the use of preoperative treatments (radiotherapy, radiochemotherapy or chemotherapy) and the design of surgical strategy (simultaneous resection of rectal cancer and liver metastases or staged resection). Treatment strategy should aim at conciliating optimal treatment for all tumor sites. Accurate pretreatment workup contributes to identify the most advanced tumor site that should be treated first without compromising optimal treatment of the other site. None standard treatment approach can be define for all patients presenting with rectal cancer and synchronous liver metastases because this entity includes a wide variety of clinical presentation and a large number of treatment options are available. Treatment strategy should be discussed during multidisciplinary meeting at diagnosis.  相似文献   

14.
OBJECTIVE: To analyze treatment and survival of a large cohort of patients with retroperitoneal soft-tissue sarcomas (STS) treated and prospectively followed at a single institution. SUMMARY BACKGROUND DATA: Retroperitoneal STS are relatively uncommon and constitute a difficult management problem. Although surgical resection is often difficult or impossible, current chemotherapy is not effective and radiation is limited by toxicity to adjacent structures. Thus, complete surgical resection remains the most effective modality for selected primary and recurrent disease. METHODS: Five hundred patients with retroperitoneal STS were admitted and treated between July 1, 1982, and September 30, 1997, and prospectively followed. Patient, tumor, and treatment variables were analyzed for disease-specific and disease-free survival. Survival was determined with the Kaplan-Meier method. Statistical significance was evaluated using the logrank test for univariate influence and Cox model stepwise regression for multivariate influence. RESULTS: Two hundred seventy-eight patients (56%) had primary disease and 222 (44%) recurrent disease. Median follow-up was 28 months (range 1 to 172 months), 40 months for survivors. Median survival was 72 months for patients with primary disease, 28 months for those with local recurrence, and 10 months for those with metastasis. For patients with primary or locally recurrent tumors, unresectable disease, incomplete resection, and high-grade tumors significantly reduced survival time. CONCLUSIONS: In this study of patients with retroperitoneal STS, stage at presentation, high histologic grade, unresectable primary tumor, and positive gross margin are strongly associated with the tumor mortality rate. Patients approached with curative intent should undergo aggressive attempts at complete surgical resection. Incomplete resection should be undertaken only for symptom relief.  相似文献   

15.
Background  Isolated limb perfusion (TM-ILP) is an effective limb-sparing treatment for primarily nonresectable soft tissue sarcomas (STS). Surgical margins of STS after ILP were yet not systematically studied. Methods  In 47 patients with nonresectable STS, TM-ILP with subsequent tumor resection was performed. Surgical margins were systematically analyzed by light microscopy using the TNM and the Enneking classification. Furthermore, margins were analyzed for tumor regression in terms of improved resectability. Results were correlated with clinical and pathological parameters. Results  Of 47 STS, 44 were classified as high-grade (93.6%) with a median tumor size of 10.0 cm. Primary limb-salvage rate was 85.1%. According to TNM resection margins were complete in 70.2% (R0) and incomplete in 29.8% (R1 = 21.3%, R2 = 8.5%). According to Enneking, 27.7% intralesional, 42.6% marginal, 21.3% wide, 2.1% radical, and 6.4% unclassifiable margins were found. Prior surgery and/or radiotherapy significantly decreased margin quality. Ten patients with incomplete resection (three intralesional, seven marginal) had no viable tumor at the plane of dissection, which was designated as “improved margins.” Whereas those patients remained relapse free, five patients with viable tumor (not improved margins) at the resection margin had local recurrences. Poor margins were associated with local and distant recurrences and limited disease-specific survival. Conclusion  TM-ILP is effective for achieving limb salvage. Histopathology of surgical margins demonstrates cases with so-called “improved margins” after TM-ILP, which are related to a better outcome even in intralesionally resected tumors. Improvement of margins should be further evaluated as a potential relevant prognostic parameter.  相似文献   

16.
The majority of recommendations in the current S3 guideline on the diagnosis and treatment of gastric carcinoma are based on good clinical practice and lack supporting randomized studies. With the development of endoscopic resection and multimodal treatment concepts, pretherapeutic tumor staging has gained in importance. However, the accuracy of present imaging modalities is still limited with a tendency towards overstaging of locally advanced tumors. Extended lymph node dissection cannot be recommended in cases with advanced lymph node involvement. In cardiac cancer retroperitoneal lymphatic spread to the left renal vein is an early event and should thus not be classified as stage IV disease. In cases of intra-abdominal gastrectomy a pouch reconstruction should be considered in cases with a good overall prognosis. Subgroup analyses indicate a differential therapeutic effect of the established perioperative chemotherapy depending on the location of the primary tumor. There is also good evidence for an additional beneficial effect of radiotherapy in combination with chemotherapy.  相似文献   

17.
We report our experience about somatotrophinomas without clinical manifestation of acromegaly having radiological- and surgical-verified invasion of the cavernous sinus. We present the clinical, radiological and hormonal status of three patients affected by invasive GH-secreting pituitary adenomas without clinical signs and symptoms of acromegaly with elevation of serum IGF-1 from a series of 142 pituitary adenomas operated in our institute with the aid of intraoperative magnetic resonance imaging (MRI). Total tumor removal was possible in two of the three cases; the patients show normal hormonal status and no recurrence at long-term follow-up. In the third case, due to the different features of the tumor, complete resection was not possible and a multimodal treatment was performed that allowed regularization of the hormonal status and control of the residual tumor. GH-secreting adenomas without clinical manifestation of acromegaly are uncommon lesions. Total microsurgical excision can be curative. However, in case of partial removal, a tailored adjuvant treatment should be considered to preserve the quality of life of the patient and avoid regrowth of the lesion. In not resectable tumors, preoperative medical treatment with somatostatin analogues is always an option.  相似文献   

18.
The primary goals of multimodal, interdisciplinary treatment of bone metastases are to achieve mobility, pain relief, and improve quality of life. In cooperation with radiotherapists and oncologists, an individual therapy plan has to be designed. As bone metastases are a sign of a systemic spread of the disease, cure is not possible in nearly all cases. A singular bone metastasis of a renal cell carcinoma may be regarded as an exemption, where wide resection might cure the patient. The extent of the operation should be based on the 3S principle “save, short & simple”. The prognosis of survival should influence the treatment regime. If it is unclear whether a bone metastasis or a primary bone tumor is present, a biopsy is required.  相似文献   

19.
Soft tissue sarcomas (STS) represent a heterogenous group of malignant tumors arising in mesenchymal tissue and in the autonomal and peripheral nervous systems. Only 1% of all malignancies in adults are STS. Most of them are localized at the extremities, but they also occur in the abdomen and the thorax as well as at the abdominal and chest wall. They are usually surrounded by a pseudocapsule which contains tumor cells and they can exhibit a discontinuous growth pattern. Macroscopically undetectable branches might grow along given anatomical structures. Thus the whole sarcoma-related anatomic compartment should be judged as tumor-contaminated. The high rate of local failure is often caused by insufficiently extended primary resections. Lymph node metastases are rare. The main prognostic factors are histological grading, tumor size and surgical radicality. Diagnosis of STS is often made at a rather late state of tumor progression often too late for curative therapy. Early histological diagnosis is thus of great importance. The operation aims at the removal of the whole tumor bearing anatomic compartment. Even wide excisions of the sarcoma surrounded by 3 cm of tumor free tissue will lead to at least 60% local recurrencies. Excisions along the pseudocapsule (enucleation) will most likely leave parts of the tumor behind. Insufficient surgical radicality cannot be compensated for by adjuvant therapies. The resection should be carried out without compromises.  相似文献   

20.
Background: Soft tissue sarcomas (STS) of the extremities are rare. The purpose of this study was to identify prognostic risk factors associated with survival in patients with primary extremity and truncal STS.Methods: Patient, tumor, and pathologic data from 149 consecutive patients with localized primary STS of the extremities and trunk were analyzed using Kaplan-Meier and Cox regression techniques to identify univariate and multivariate risk factors. A subgroup analysis was performed to compare factors predictive of survival in patients who received treatment before (n=50) and after (n=99) treatment was standardized in 1988.Results: The 5-year survival rate was 76.5% with an average follow-up of 6 years. Local recurrence occurred in 23% of all patients, 40% before 1988 and 15% after 1988 (P<0.0001). Risk factors associated with survival included resection quality (R0 vs. R1;P<0.0001), era of operation (P=0.002), local recurrence (P<0.001), UICC stage (P<0.0001), tumor size (P<0.001), tumor depth (P=0.002), regional lymph nodes (P<0.0001), and histology (P<0.0001). Multivariate analysis revealed that tumor size, tumor depth, and resection quality were independent risk factors of survival.Conclusions: These results indicate that management of STS in a specialized institution improves overall survival. Resection quality is the most important risk factor of survival. Therefore, effort should be made during primary treatment of STS to achieve wide, tumor-free resection margins.  相似文献   

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