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Is Repeat Pulmonary Metastasectomy Indicated for Soft Tissue Sarcoma?

ABSTRACT: BACKGROUND:Because recurrence is high after pulmonary metastasectomy (PM) for soft tissue sarcoma (STS), repeat PM is commonly performed. Our objective was to define the selection criteria for repeat PM among patients experiencing recurrence and to identify factors associated with survival. METHODS:We reviewed a prospectively maintained database of 539 patients undergoing PM for STS. Characteristics of the primary tumor, metastatic disease, treatment, and recurrence were examined. Multivariable Cox models were constructed to identify factors associated with the likelihood of operative selection after recurrence. Overall survival between patients with or without repeat PM was estimated using the Kaplan-Meier method, with prognostic factors identified using Cox models. Both analyses incorporated propensity score-matching weights. Factors associated with survival after repeat PM were assessed with multivariable Cox models among patients who underwent repeat PM. RESULTS:After initial PM, 63% of patients (n = 341) experienced pulmonary recurrence; 141 (41%) underwent repeat PM. Patients who were younger (p = 0.033) underwent minimally invasive resection at first PM (p = 0.041), had a longer disease-free interval after first PM (p = 0.009), were without extrapulmonary disease (p < 0.001), and had fewer nodules on recurrence (p < 0.001) were more likely to undergo repeat PM. Comparison between the repeat and non-repeat PM groups demonstrated an increased hazard of death among patients managed nonoperatively. Factors associated with an increased hazard of death after second PM included preoperative chemotherapy (p = 0.008) and R1/R2 metastasectomy (p < 0.001). CONCLUSIONS:Although operative selection occurs, when prognostic factors are controlled for, repeat PM for STS remains independently associated with prolonged overall survival.

SUBMITTER: Chudgar NP

PROVIDER: S-EPMC5696033 | biostudies-literature | 2017 Dec

REPOSITORIES: biostudies-literature

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Is Repeat Pulmonary Metastasectomy Indicated for Soft Tissue Sarcoma?

Chudgar Neel P NP Brennan Murray F MF Tan Kay See KS Munhoz Rodrigo R RR D'Angelo Sandra P SP Bains Manjit S MS Huang James J Park Bernard J BJ Adusumilli Prasad S PS Tap William D WD Jones David R DR

The Annals of thoracic surgery 20171102 6

<h4>Background</h4>Because recurrence is high after pulmonary metastasectomy (PM) for soft tissue sarcoma (STS), repeat PM is commonly performed. Our objective was to define the selection criteria for repeat PM among patients experiencing recurrence and to identify factors associated with survival.<h4>Methods</h4>We reviewed a prospectively maintained database of 539 patients undergoing PM for STS. Characteristics of the primary tumor, metastatic disease, treatment, and recurrence were examined. ...[more]

PMID: 29074153

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Project description:BackgroundMetastasectomy is performed on a select cohort of patients with advanced and/or recurrent bone and soft tissue sarcomas because of the potential for long term relapse free and overall survival associated with the procedure. However, the evidence supporting metastasectomy is difficult to summarize without a systematic examination of existing literature. The objective of this systematic review will be to examine survival among both adults and children with advanced and recurrent bone and STS who undergo metastasectomy.MethodsWe designed and registered a study protocol for a systematic review and meta-analysis. We will include data from survival studies (e.g., randomized trials, cohort studies, routine case registries, and case control) conducted in children and adults with advanced and recurrent bone and soft tissue sarcoma who undergo metastasectomy. The primary outcome will be overall survival. Secondary outcomes will be 30-day post-operative mortality, recurrence-free survival, time off systemic therapy, and patient-reported outcomes including quality of life end points where available. Literature searches will be performed in multiple electronic databases including Ovid MEDLINE ® (1946 to present), Ovid EMBASE (1974 to present), Web of Science, and Cochrane Library. Grey literature will be identified through searching references, conference abstracts, Papers First, and Google Scholar. Two investigators will independently screen all citations, full-text articles, and abstract data. Full-text articles selected for analysis will be assessed for quality and risk of bias. If feasible, we will conduct a random effects meta-analysis. Estimates will be stratified according to histology comparing survival based on organ of metastasectomy. Additional analysis will be conducted to explore the potential sources of heterogeneity according to various patient, disease, and treatment characteristics (e.g., metastasis status, age, disease burden, and concomitant interventions).DiscussionThis systematic review and meta-analysis will identify, evaluate, and integrate data on survival of metastasectomy of bone and soft tissue sarcoma by organ of metastasis. Our findings may have implications for clinicians, patients, and their families when considering selection for resection of oligometastatic disease in de novo, or recurrent bone and soft tissue sarcoma. Implications for future research will be identified to improve the outcomes of these complex patients.Systematic review registrationPROSPERO CRD42019126906.

Project description:Soft-tissue sarcoma (STS) represent a rare tumor entity, accounting for less than 1% of adult malignancies. The cornerstone of curative intent treatment is surgery with free margins, although the extent of the surgical approach has been subject to change in the last decades. Multimodal approaches usually including radiation therapy have replaced extensive surgical procedures in order to preserve functionality while maintaining adequate local control. However, the possibility to apply adequate radiation doses by external beam radiation therapy (EBRT) can be limited in some situation especially in case of directly adjacent organs at risk with low radiation tolerance. Application of at least a part of the total dose via intraoperative radiation therapy (IORT) with a single fraction during the surgical procedure may overcome those limitations, because radiosensitive structures can be moved out of the radiation field resulting in reduced toxicity while the enhanced biological effectivity of the high single dose improves local control. The current review summarizes rationale, techniques, oncological and functional outcomes including possible pitfalls and associated toxicities based on the published literature for IORT focusing on extremity and retroperitoneal STS. In extremity STS, combination of limb-sparing surgery, IORT and pre- or postoperative EBRT with moderate doses consistently achieved excellent local control rates at least comparable to approaches using EBRT alone but usually including patient cohorts with higher proportions of unfavourable prognostic factors. Further on, IORT containing approaches resulted in very high limb preservation rates and good functional outcome, probably related to the smaller high dose volume. In retroperitoneal STS, the combination of preoperative EBRT, surgery and IORT consistently achieved high local control rates which seem superior to surgery alone or surgery with EBRT at least with regard to local control and in some reports even to overall survival. Further on, preoperative EBRT in combination with IORT seems to be superior to the opposite combination with regard to local control and toxicity. No major differences in wound healing disturbances or postoperative complication rates can be observed with IORT compared to non-IORT containing approaches. Neuropathy of major nerves remains a dose limiting toxicity requiring dose restrictions or exclusion from target volume. Gastrointestinal structures and ureters should be excluded from the IORT area whenever possible and the IORT volume should be restricted to the available minimum. Nevertheless, IORT represents an ideal boosting method if combined with EBRT and properly executed by experiences users which should be further evaluated preferably in prospective randomized trials.

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Is Repeat Pulmonary Metastasectomy Indicated for Soft Tissue Sarcoma?

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Is Repeat Pulmonary Metastasectomy Indicated for Soft Tissue Sarcoma?

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