CA Cancer J Clin 200454:94109

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• CA Cancer J Clin 20045494109

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STS Sites

• Extremity (59),
• Trunk (19),
• Retroperitoneum (15),
• Head and neck (9)

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STS - Histologies

• Malignant fibrous histiocytoma (28)
• Leiomyosarcoma (12)
• Liposarcoma (15)
• Synovial sarcoma (10)
• Malignant peripheral nerve sheath tumors (6)
• Rhabdomyosarcoma (childhood)

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STS Risk Factors

• Radiation Therapy
• Herbicides
• Phenoxyacetic acid
• Wood preservatives
• Chlorophenols
• Chronic lymphedema
• Lymphangiosarcoma
• Stewart-Treves syndrome

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STS Work-up

• Chest X Rays
• All patients
• CT of the Chest (contrast enhanced)
• If primary tumor size gt 5 cm
• CT of the Abdomen / Pelvis
• If liposarcoma of the extremity
• MRI (contrast enhanced)
• Sarcomas of the extremity
• Differentiation between malignancy a benign
• T1 weighted contrast MRI can assess intratumoral
  necrosis

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Biopsy techniques

• FNA aspiration
• Acceptable if experienced cytopathologist
  available
• Limited information about tumor grade
• Method of choice for recurrences
• Accuracy ranges from 60-96

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Biopsy techniques

• Core needle biopsy
• Safe, accurate and economical
• More tissue
• Cytogenetics
• Electron microscopy
• Flow cytometry
• Accuracy93

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Biopsy techniques

• Incisional biopsy
• If FNA or Core biopsies are non diagnostic
• Incision wound in longitudinal access
• Performed by the same surgeon that is going to
  treat de patient
• Excisional biopsy
• For small (lt 3 cm), superficial tumors
• No advantage over other biopsy techniques

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Grade

• Metastatic potential by grade
• Low-Grade 5-10
• Intermediate-Grade 25-30
• High-Grade 50-60

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Size

• T1 - lt 5 cm (5-survival 84)
• T2 - gt 5 cm
• 5-10 cm (5-year survival 70)
• 10-15 cm (5-year survival 50)
• gt 15 cm (5-year survival 33)

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Treatment for T lt 5 cm

• Wide surgical resection
• 2 cm margin (free-of-disease)
• Include the biopsy site in the en-bloc resection
• Limb-sparing procedures if possible

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Radiation therapy

• Following limb-sparing procedures
• Local control 78-91
• High-Grade tumors
• Local control 70 (no RT) and 98 (RT)
• Local control 66 (no BT) and 89 (BT)
• No difference with RT in Low-Grade tumors
• No benefit of RT in High-Grade tumors lt5 cm

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Radiation therapy

• Margins
• 5-7 cm
• Dose
• Preoperative 5000 cGy en 25 fractions
• Wound complications 35
• Postoperative 6000-7000 cGy
• Wound complications 17

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Brachytherapy

• Advantages
• 5-6 days of therapy instead of weeks
• Less radiation scatter in critical anatomic sites
• Less expensive (in the US)
• Can be used in recurrences
• Disadvantages
• Hospitalization and bed rest

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Prognostic factors for poor long-term functional
outcome after radiation therapy

• Large tumors
• Large doses of RT (gt 63 Gy)
• Long radiation fields (gt 35 cm)
• Poor radiation technique
• Neural sacrifice
• Postoperative fractures
• Wound complications

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Systemic Therapy

• Response rate gt 20
• Doxorubicin
• Dacarbazine
• Ifosfamide

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Postoperative chemotherapy

• Doxorubicin-based adjuvant chemotherapy
• 1568 patients (14 trials)
• 4 increase in OS (p0.12)
• 7 increase in OS in extremity sarcomas (p0.029)
• Tierney JF. Adjuvant chemotherapy for localised
  resectable soft-tissue sarcoma of adults
  meta-analysis of individual data. Sarcoma
  Metaanalysis Collaboration. Lancet
  199735016471654.

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Preoperative chemotherapy

• Induction chemotherapy yields complete response
  in 6-9 of patients
• Patients with gt 95 tumor necrosis have 11
  10-year OS vs 23
• Patients with CR have 71 10-year survival rate
  vs 55 with no CR
• Chemotherapy does not appear to increase the rate
  of limb-sparing procedures

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Surveillance strategies

• First 2 years
• HP q3months
• CXR q6months
• Imaging of tumor site q6months
• 2-5 years
• HP q6months
• CXR q12months
• Imaging of tumor site q12months
• gt 5 years
• HP and CXR q12months

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Surveillance of Abdominal Sarcomas

• First 2 years
• HP q3months
• CXR q6months
• CT of abdomen / pelvis q3months
• 2-5 years
• HP q6months
• CT of abdomen / pelvis q6months
• CXR q12months
• gt 5 years
• HP and CXR q12months

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Retroperitoneal sarcomas

• 15 of STS
• Tend to recurr locally
• Worse prognosis
• 5-year survival 40-50
• Prognostic factors
• Margin positive resection
• Large tumor at presentation
• Unresectability
• High-grade

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GIST

• Require 2-4 cm margin
• C-Kit positive (CD 117) are candidates for
  Imatinib with 54 response rate in the metastatic
  setting

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Recurrent sarcomas

• Local recurrence
• Aggressive resection
• Pulmonary metastasis resection
• 15-40 LT survival in completely resected tumors
• Palliative Chemotherapy

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Puntos 0 10 20 30
40 50 60 70 80 90
100
lt 5 cm 5-10 cm
gt 10 cm
Superficial Profundo
Sup Inf Tórax Abdomen

Extremidades Tronco
Cabeza y cuello

MFH Leio Sinovio
Fibro Lipo
Otro MPNT

Edad 15 20 30 40 50
60 70 80 90
Total Puntos 0 20 40 60 80 100 120
140 160 180 200 220 240 260 280 300 320
Bajo Grado 0.04 0.06
0.1 0.15 0.2 0.3 0.4 0.5 0.6 0.7
0.8 0.88
Alto grado 0.04 0.06 .1 .15 .2
.3 .4 .5 .6 .7 .8 .88 .9
.95
Probabilidad de muerte por sarcoma a 12 años
Kattan MW, Leung DH, Brennan MF, Postoperative
nomogram for 12-year sarcoma-specific death. J
Clin Oncol. 2002 Feb 120(3)791-6
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Puntos 0 10 20 30
40 50 60 70 80 90
100
lt 5 cm 5-10 cm
gt 10 cm
Superficial Profundo
Sup Inf Tórax Abdomen

Extremidades Tronco
Cabeza y cuello

MFH Leio Sinovio
Fibro Lipo
Otro MPNT

Edad 15 20 30 40 50
60 70 80 90
Total Puntos 0 20 40 60 80 100 120
140 160 180 200 220 240 260 280 300 320
Bajo Grado 0.04 0.06
0.1 0.15 0.2 0.3 0.4 0.5 0.6 0.7
0.8 0.88
Alto grado 0.04 0.06 .1 .15 .2
.3 .4 .5 .6 .7 .8 .88 .9
.95
Probabilidad de muerte por sarcoma a 12 años
Kattan MW, Leung DH, Brennan MF, Postoperative
nomogram for 12-year sarcoma-specific death. J
Clin Oncol. 2002 Feb 120(3)791-6
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Ejemplo

• 56 años,
• Liposarcoma de extremidades inferiores,
• 6 cm, superficial,
• grado alto

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Puntos 0 10 20 30
40 50 60 70 80 90
100
lt 5 cm 5-10 cm
gt 10 cm
Superficial Profundo
Sup Inf Tórax Abdomen

Extremidades Tronco
Cabeza y cuello

MFH Leio Sinovio
Fibro Lipo
Otro MPNT

Edad 15 20 30 40 50
60 70 80 90
Total Puntos 0 20 40 60 80 100 120
140 160 180 200 220 240 260 280 300 320
Bajo Grado 12 años 0.04 0.06
0.1 0.15 0.2 0.3 0.4 0.5 0.6 0.7 0.8
0.88
Alto grado 0.04 0.06 .1 .15 .2
.3 .4 .5 .6 .7 .8 .88 .9
.95
Kattan MW, Leung DH, Brennan MF, Postoperative
nomogram for 12-year sarcoma-specific death. J
Clin Oncol. 2002 Feb 120(3)791-6
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Suma 0 7 30 3942
118
Puntos 0 10 20 30
40 50 60 70 80 90
100
lt 5 cm 5-10 cm
gt 10 cm
Superficial Profundo
Sup Inf Tórax Abdomen

Extremidades Tronco
Cabeza y cuello

MFH Leio Sinovio
Fibro Lipo
Otro MPNT

Edad 15 20 30 40 50
60 70 80 90
118
Total Puntos 0 20 40 60 80 100 120
140 160 180 200 220 240 260 280 300 320
Bajo Grado 12 años 0.04 0.06
0.1 0.15 0.2 0.3 0.4 0.5 0.6 0.7 0.8
0.88
Probabilidad de fallecer por sarcoma 23
Alto grado 0.04 0.06 .1 .15 .2
.3 .4 .5 .6 .7 .8 .88 .9
.95
Kattan MW, Leung DH, Brennan MF, Postoperative
nomogram for 12-year sarcoma-specific death. J
Clin Oncol. 2002 Feb 120(3)791-6
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• Cormier JN, Pollock RE. Soft Tissue Sarcomas. CA
  Cancer J Clin 20045494109

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• Postoperative nomogram for 12-year
  sarcoma-specific death based on 2,163 patients
  treated at Memorial Sloan-Kettering Cancer
  Center. Abbreviations Fibro indicates
  fibrosarcoma Lipo, liposarcoma
  Leiomyo,leiomyosarcoma MFH, malignant fibrous
  histiocytoma MPNT, malignantperipheral-nerve
  tumor GR, grade SSD, sarcoma-specific death.