Resection of recurrent pulmonary metastases in patients with soft-tissue sarcomas

Survival benefit and prognostic factors useful for patient selection have not been previously analyzed for patients with recurrent pulmonary metastases from soft-tissue sarcomas. Twenty-nine patients in our study had two or more resections of pulmonary metastases from 1976 to 1983. There were no operative deaths and three complications for 40 operations (7.5%). Factors predictive of increased survival following the second resection of pulmonary metastases were resectability and a disease-free interval of greater than six months from the first thoracotomy to the second recurrence in the lung. The tumor doubling time of the first recurrence and the presence of three or fewer nodules on full-lung tomography before the first thoracotomy, which were predictors of survival following initial resection, also predicted survival following subsequent resections. Overall median survival following the second resection was 14.5 months (22% overall three-year survival). The postresection actuarial survival curves for patients undergoing 1, 2, or 3 or more resections were not significantly different. Our findings demonstrate that patients undergoing repeated resections of pulmonary metastases from soft-tissue sarcomas can achieve prolonged survival.     

The management of locally recurrent soft-tissue sarcoma.

Thirty-eight patients with locally recurrent soft-tissue sarcomas of various histologic types and grades but with no evidence of distant metastases were studied. Twenty-five patients had more than one local recurrence. Most primary lesions had been initially treated by simple or "wide local" excision with removal of little or no surrounding normal tissue. The most common site for recurrence was the extremity. Sixteen patients received preoperative intra-arterial Adriamycin (30 mg/day X three days) and radiation therapy (3500 R over ten days) followed by wide resection of the recurrence and the previous operative field. Tumor-free margins were confirmed microscopically. There were no subsequent local recurrences in this group. In five patients, no preoperative therapy was used, and the resection was incomplete because of proximity to vital structures. In these patients, postoperative radiation therapy and chemotherapy could not prevent continued local tumor progression. Amputation for control of local recurrence was necessary in only three patients. the remaining patients underwent either resection alone or resection in combination with postoperative radiation and/or chemotherapy. Life-table analysis of these 38 patients shows an unexpectedly high predicted five-year survival of 76% (87% for patients whose local recurrence could be completely resected). This high salvage rate clearly justifies aggressive treatment of patients with local recurrences alone and warrants attempts to salvage functional extremities.     

Standardization of selection criteria for percutaneous image-guided cryoablation of recurrent soft-tissue sarcomas

PurposePercutaneous image-guided cryoablation has not been validated for local management of recurrence of soft tissue sarcoma (STS) of the trunk or limbs. This study aims to identify selection criteria for cryoablation in order to standardize indications of this treatment.Patients and methodsBetween 2000 and 2010, 46 patients (57 tumors) presenting local recurrences of STS of the trunk or limbs and treated following standards of care were selected from our institutional database. Eligibility for cryoablation was assessed by two radiologists according to predefined criteria: maximal diameter size of the tumor ≤ 10 cm, distance to skin >5 mm, distance to neurovascular structures 3 mm at least, absence of articular involvement and planned cryoablation covering the entire lesion volume. Characteristics and outcomes were compared.ResultsThere was nearly perfect agreement for all criteria (k coefficient ranging from 0.83 to 0.98) between both readers. A subgroup of 13 patients was identified as eligible for cryoablation. Locations to the trunk, pelvic girdle or shoulder were significantly more present in the cryoablation group (P = 0.002). In this group, tumors were mainly located deeply (P = 0.002) with great axes ≤ 5 cm (P = 0.044). High local tumor aggressiveness (P = 0.016) and differentiated myxoid liposarcoma or myxofibrosarcoma (P = 0.007) were more frequent in the eligible group.ConclusionBased on these criteria, two groups of patients with local relapse of STS can be identified. These results may improve the standardization of selection of patients who could be candidates for cryoablation.     

Wound complications of adjuvant radiation therapy in patients with soft-tissue sarcomas.

Adjuvant radiation therapy by the brachytherapy technique has been suggested by us to diminish local recurrence following resection of extremity and superficial truncal soft-tissue sarcoma. However, loading of the catheters with radioactive sources on the first through the fifth postoperative days results in a 48% significant wound-complication rate. Our previous animal experiments would suggest that delay of application of radiation to one week after wounding is accompanied by significant improvement in wound-breaking strength, new H3 hydroxyproline accumulation, and improved force-tension curves. As part of our ongoing prospective randomized trial of the effects of brachytherapy on local control, one change was made: the catheters were loaded five or more days after operation. Wound complications were then reviewed in 50 patients following this single change in brachytherapy delivery. Of the 21 patients receiving brachytherapy, 14% had significant wound complications; 10% of the 29 patients who did not receive radiation had wound complications of similar severity. This decrease in wound complications represents a major improvement over our prior experience and suggests that the timing of radioactive source loading in the postoperative period is a major factor in radiation-induced wound-healing delay.     

Definitive surgical management for soft-tissue sarcomas

The surgical management of soft-tissue sarcomas, a seemingly heterogeneous group of malignant tumours, depends on the circumstances (e.g., untreated primary tumour, inadequately resected primary tumour, local recurrence, metastasis) and site. The basic steps in managing a primary tumour include using the correct method to establish a diagnosis, obtaining adequate tumour-free resection margins and giving consideration to adjuvant radiotherapy or chemotherapy, or both. Local recurrences and metastatic lesions require a multidisciplinary approach. The relative rarity of this group of sarcomas and the low survival rate associated with them make it mandatory that such patients be treated in centres able to provide specialized care from the beginning.     

Preoperative chemotherapy for soft-tissue sarcomas of the extremities.

Forty-six patients with extremity soft-tissue sarcomas were treated with a mean of 4.4 cycles of preoperative adriamycin-based combination chemotherapy, followed by definitive local surgery and radiotherapy. All tumors were larger than 5 cm and of histologic type having significant risk of metastasis. Eighteen patients (40%) had an objective clinical response to the chemotherapy, while 27 patients (60%) did not respond. Patients with tumors responsive to chemotherapy had significantly improved overall survival (median 60 + months versus 32.7 months; p = 0.02), continuous disease-free survival (median 60 + months versus 15.1 months; p = 0.04), and distant metastasis-free survival (median 60+ months versus 28.5 months; p = 0.006) compared to the nonresponding patients. Tumor response to preoperative chemotherapy provides strong prognostic information and identifies a subgroup of patients most likely to benefit from chemotherapy.     

Retroperitoneal soft-tissue sarcomas: prognosis and treatment of primary and recurrent disease

Soft-tissue sarcomas of the retroperitoneum constitute a heterogeneous group of tumors with varying histology, potential for complete resection, and propensity for recurrent disease-making the development of effective treatment difficult and challenging. A retrospective review of 23 patients with retroperitoneal sarcomas from 1985 through 1998 was performed to assess the biological behavior and clinical outcomes and to identify factors that may influence prognosis and optimize treatment strategy. Liposarcomas were the most common pathology (61%); 79 per cent of these were of low grade. Leiomyosarcomas were the next most common pathology (30%); 43 per cent of these were of low grade. Low-grade sarcomas overall accounted for 62 per cent of the total group. Low-grade tumors independent of histologic type exhibited good prognosis for long-term survival with a median survival of 44 months. In contrast, intermediate- or high-grade tumors were associated with a median survival of only 9 months (P < 0.02). On the other hand, tumor histologic type independent of grade did not have a significant survival difference. Complete tumor resection was possible in 21 of 23 patients, which gives an overall resectability rate of 91 per cent. Eight patients (36%) remain disease-free after initial surgical treatment. However, local recurrence was common; this occurred in 11 of 22 patients (50%). Local recurrence, however, did not preclude long-term survival. Surgical resection of recurrent disease was done in nine patients with a median survival of 91 months (range 24-150 months). Three patients had as many as three operations for recurrent disease. With subsequent recurrences there was a decrease in interval from approximately 4 years to 2 years, and 33 per cent of these patients developed tumor dedifferentiation to high grade. An aggressive surgical approach with reoperation can produce prolonged survival in patients with low-grade retroperitoneal sarcoma.     

Long-term follow-up of patients with clubfeet treated with extensive soft-tissue release

BACKGROUND: Although long-term follow-up studies have shown favorable results, in terms of foot function, after treatment of idiopathic clubfoot with serial manipulations and casts, we know of no long-term follow-up studies of patients in whom clubfoot was treated with an extensive surgical soft-tissue release. METHODS: Forty-five patients (seventy-three feet) in whom idiopathic clubfoot was treated with either a posterior release and plantar fasciotomy (eight patients) or an extensive combined posterior, medial, and lateral release (thirty-seven patients) were followed for a mean of thirty years. Patients were evaluated with detailed examination of the lower extremities, a radiographic evaluation that included grading of osteoarthritis, and three independent quality-of-life questionnaires, including the Short Form-36 Medical Outcomes Study. RESULTS: At the time of follow-up, the majority of patients in both treatment groups had significant limitation of foot function, which was consistent across the three independent quality-of-life questionnaires. No significant difference between groups was noted with regard to the results of the quality-of-life measures, the range of motion of the ankle or the position of the heel, or the radiographic findings. Six patients who had been treated with only one surgical procedure had better ranges of motion of the ankle and subtalar joints (p < 0.004) than those who had had multiple surgical procedures. CONCLUSIONS: Many patients with clubfoot treated with an extensive soft-tissue release have poor long-term foot function. We found a correlation between the extent of the soft-tissue release and the degree of functional impairment. Repeated soft-tissue releases can result in a stiff, painful, and arthritic foot and significantly impaired quality of life.     

Preoperative versus postoperative radiation therapy for soft-tissue sarcomas

In this article, we report results from a retrospective consecutive series of 117 patients with soft-tissue sarcomas treated with adjuvant radiation and surgical resection at 2 associated institutions. Fifty-nine patients received preoperative radiation; 58 patients received postoperative radiation. Mean clinical follow-ups were 6.1 years and 8.4 years, respectively. Nineteen (32.2%) of 59 patients in the preoperative group and 17 (29.3%) of 58 patients in the postoperative group had wound complications (P = .89). Three (5.1%) of 59 sarcomas in the preoperative group and 7 (12.1%) of 58 sarcomas in the postoperative group recurred locally (P = .19). Improved local disease control and other potential advantages of using preoperative radiation make this a preferred adjuvant treatment.     

The management of soft-tissue sarcomas of the extremities.

Of fifty-four patients with a soft-tissue sarcoma of an extremity, having a projected five-year survival rate of 62 per cent, forty-six treated by an "adequate" surgical procedure (either radical local resection or ablation at an appropriate level, depending on defined circumstances) had a local recurrence rate of 2 per cent. In the other eight patients, whose surgical procedures were not adequate for one reason or another, the local recurrence rate was 100 per cent. The combined recurrence rate after both the adequate and the inadequate procedures was 16.7 per cent. The recurrences were noted prior to thirty months post-operatively and the metastases, prior to sixty months. Histogenesis of the sarcoma, one or more recurrences after previous operations, and treatment by an immediate definitive procedure at the time of biopsy and diagnosis by frozen section had no significant relationship to the rates of local recurrence or metastasis. Adequate radical local resection controlled these sarcomas as well as ablative surgery in terms of local recurrence and metastasis. The significant factors affecting local recurrence that were identified in this study were the location of the sarcoma and the adequacy of the surgical procedure.     

Vascular soft-tissue sarcomas. An analysis of tumor-related mortality.

Between 1982 and 1990, 69 adult patients were admitted to Memorial Sloan-Kettering Cancer Center with a diagnosis of angiosarcoma, lymphangiosarcoma, or malignant hemangiopericytoma. The existing literature regarding sarcomas focuses on individual histologic conditions or site-specific activity and includes pediatric patients, which makes estimates of survival difficult. We describe the clinical course of all vascular sarcomas, the survival without distant recurrence of patients with vascular sarcomas, and the overall survival of patients with vascular sarcomas. Using Cox's stepwise regression model, histologic characteristics of the tumors, tumor grade, tumor size, and other factors were assessed to determine their prognostic significance. Noncurative treatment and the presence of metastases were the only two factors influencing survival. Tumor grade approached significance. Disease recurrence was common among curatively treated patients (37% of such patients), and more than half of these recurrences involved distant sites. The survival of these patients depends on complete surgical resection and is independent of individual histologic characteristics of the tumor.     

Early lymphatic spread of osteogenic and soft-tissue sarcomas.

Records of 374 patients referred to the National Cancer Institute with a diagnosis of sarcoma over a 24-year period were reviewed to study the incidence of lymph node involvement in this disease. One hundred and thirteen patients had operations involving the draining nodal area and evaluation of these nodes for tumor. Only three patients (2.6%) had evidence of sarcoma metastatic to draining lymph nodes. Prophylactic removal or radiotherapy of draining lymph node areas in most adults with sarcomas does not appear to be worthwhile. A comprehensive analysis of the literature is presented.     

Prospective study of cardiomyopathy induced by adjuvant doxorubicin therapy in patients with soft-tissue sarcomas

Since a combination of surgery and adjuvant high-dose doxorubicin therapy can prolong survival in patients with extremity sarcomas, but at the expense of significant cardiomyopathic changes, we prospectively studied the differences in cardiotoxicity in 118 patients with sarcomas treated with high- vs low-dose doxorubicin therapy following surgery. Cardiac function, as assessed by left ventricular ejection fraction (EF), was determined by standard radionuclide angiography during rest and exercise. No patients in this study developed congestive heart failure. While both regimens produced net decreases in EF during rest and exercise, the high-dose doxorubicin regimen resulted in significantly greater declines in EF than the low-dose protocol. Of patients with normal baseline values, a greater percentage of patients receiving the high-dose regimen developed an abnormal EF than did those receiving the low-dose regimen, even after separating younger from older individuals. Thus, treatment-induced cardiomyopathy appears to be a significant clinical problem after both high- and low-dose doxorubicin therapy. The use of the low-dose regimen decreases the magnitude of the cardiomyopathic changes.