Management of Sarcomas
Soft Tissue Sarcomas:
A Multi-Disciplinary Strategy of
Care
Darin J. Davidson, MD, MHSc, FRCSC
Department of Orthopaedics and Sports Medicine
Assistant Professor, University of Washington School of Medicine
Orthopedic Oncologist, Seattle Cancer Care Alliance
October 25, 2014
Missoula, Montana
CASE STUDY
-- 62 year old male with right posterior arm
soft tissue mass
-Close approximation to radial nerve
-Close approximation to humerus
• Image guided needle biopsy- synovial sarcoma
• Neoadjuvant chemotherapy
– Pazopanib trial
• Neoadjuvant radiation therapy
– Planned positive margin on radial nerve and humerus
• No increased risk of local recurrence
• Preserve function
Excision
Negative margin
Innervated latissimus flap to restore function
Sarcoma: Multi-disciplinary Team
• Treatment decisions not made independently by
one specialty
• Essential to have multidisciplinary discussion
– Surgeon(s)
– Radiation oncologist
– Medical oncologist
– Radiologist
– Pathologist
All have input into management of every case
One modality may optimize management of another
SCCA: Multi-disciplinary Sarcoma Program
Medical
Oncology
Orthopaedic
Oncology
Radiation
Oncology
General
Surgery
Jones, Robin
Conrad, Ernest
‘Chappie’
Kane,
Gabrielle
Mann, Gary
Loggers,
Elizabeth
Davidson, Darin
Kim, Edward
Pillarisetty,
Venu
Pollack, Seth
Lindberg, Antoinette
Pathology
Radiology
Pediatrics
Plastic
Surgery
Hoch, Ben
Ha, Alice
Hawkins,
Doug
Neligan, Peter
How to contact us
•
Scheduling Contact: Leslie Fischer
Telephone:
206.288.2018
Fax:
206.288.6996
Email:
lfischer@seattlecca.org; pccsarcoma@seattlecca.org
•
Nursing
Telephone:
Email:
206.288.2018
sarcomarn@seattlecca.org
Darin Davidson
Telephone:
Email:
206.543.3690
djdavi@uw.edu
•
Soft Tissue Sarcoma
• Benign soft tissue masses much more common than
malignant masses
–Approximately 100:1
• Red flags for STS vs benign mass
–Large (>5cm)
–Deep to fascia
• Age, presence of symptoms, duration not contributory
Clinical Presentation And Assessment
• Usually painless mass
–Pain suggestive of neural origin, rapid growth
• History- NF, sarcoma associated syndromes (Li-Fraumeni,
Retinoblastoma)
• Key on physical exam
–Depth of lesion relative to fascia
Imaging
• MRI is preferred imaging modality
• Sarcoma suggested by signal intensity heterogeneity
– Imaging characteristics are not typical of particular
type of soft tissue sarcoma
– Fluid signal may be present in setting of necrosis or
hemorrhage
High grade soft tissue sarcoma with areas
of hemorrhage and necrosis
Management
• Local and systemic staging
–MRI of affected area
–Biopsy
–CT chest
• Mainstay of treatment is surgical resection
• Adjuvants
–Radiation therapy
–Chemotherapy
Indications for Biopsy
• Aggressive or malignant appearing bone or soft tissue
lesions
• Soft tissue mass- >5cm, deep to fascia or overlying bone or
neurovascular structures
• Except definitive imaging of benign mass (eg. lipoma)
• Unclear diagnosis in symptomatic patient
• Solitary bone lesion in a patient with a history of carcinoma
• Even if fractured!!
• Just need to confirm not sarcoma
Biopsy Principles
• An asymptomatic (latent) or symptomatic bone lesion (active)
that appears entirely benign on imaging does not need a
biopsy
• A soft tissue lesion that appears entirely benign on MRI
(lipoma, hemangioma) does not need a biopsy
• When in doubt, it is safer to do a biopsy
Biopsy Principles
• Extensile incision – longitudinal in extremities
• Tract needs to be excised
• Avoid developing planes
• Use involved compartment
• Do not expose neurovascular structures
• Meticulous hemostasis
• Release tourniquet prior to wound closure
• If using drain, bring out in line with incision
• For bone lesions, ok to biopsy soft tissue mass
• Frozen section
Importance of the Biopsy
• Whatever is exposed to the tumor is potentially
contaminated and must be excised at definitive treatment
• When biopsy principles aren’t followed
– Increased risk of
• Wrong diagnosis
• Altered treatment
• Altered outcome
• Complications
• Local recurrence of STS
Mankin et al, 1996
Noria et al, 1996
Surgical Resection
• Goal is complete resection of tumor with ‘adequate’
margin
–Definition of adequate margin controversial
–Use of preoperative radiation can affect extent of
margin required
• Marginal excision of STS- LR >30%
• Marginal excision of STS after neoadjuvant XRT- LR
<10%
• Consideration for preservation of vital (major nerves,
vessels, bone) structures to preserve function
Gerrand et al, JBJS-B 2001
Radiation Therapy
• Neoadjuvant XRT ‘sterilizes’ reactive zone surrounding
the tumor
–Allows for closer margin (still complete resection with
negative margin)
• Preserve critical structures and improve function
• Neoadjuvant XRT uses lower dose (50 Gy) compared to
postop (66 Gy)
–Decreased fibrosis, edema (Davis et al, JCO 2002)
–Decreased risk of radiation induced fracture
(Holt et al, JBJS-A 2005)
Overall survival comparing preoperative and postoperative
XRT, indicating slightly higher overall survival
in the preoperative group.
O’Sullivan et al, Lancet,
2002
Radiation Therapy
• The downside to neoadjuvant XRT
–Higher risk of wound healing complications, infection
–RCT of neoadjuvant vs adjuvant XRT (O’Sullivan et al,
Lancet 2002) comparing wound healing complications
requiring return to OR
• Neoadjuvant XRT 35%
• Adjuvant XRT 17%
Radiation Therapy
• Decision between neoadjuvant and adjuvant is balance of
risks
– Edema and fibrosis are not treatable and are disabling
– Radiation associated fracture can be difficult to treat
– Wound complications can be managed (may require
prolonged treatment, multiple procedures)
Local Control
• Goal of local treatment is local control
• Traditional predictors of local recurrence
– Grade, size, depth
• Competing risk model demonstrates margin status at
resection is the most important predictor of local control
(Biau et al, 2012)
– Multi-modal local treatment
Chemotherapy
• Role of chemotherapy
– Role in metastatic disease
– Controversial for localized disease
• Meta-analyses have shown slight survival
advantage with chemotherapy
Meta-analysis of adjuvant chemotherapy in
localized soft tissue sarcoma
Lancet , 1997
Hazard ratio of survival for meta-analysis of adjuvant
chemotherapy in localized soft tissue sarcoma
Pervaiz et al, Cancer
2008
Outcome
• Outcome best considered on basis of initial disease
–Localized disease
• Superficial, low grade ≈ 100% 5 year survival
• Deep, high grade ≈50% 5 year survival
–Metastatic disease at presentation (Ferguson et al,
Cancer 2010)
• Pulmonary mets- 8% 5 year survival
• Lymph node mets- 59% 5 year survival
Soft Tissue Sarcoma Pitfalls
• Soft tissue sarcoma grow quickly and are painful
– Synovial sarcoma known for slow growth
• Well circumscribed, smooth border of mass = benign and
infiltrative, irregular border = sarcoma
47 year old male with well circumscribed
mass; biopsy proven synovial sarcoma
Fibromatosis
Summary
• Benign soft tissue masses are far more common than
sarcoma, but beware
–Large mass
–Deep mass
• MRI is imaging modality of choice
• Biopsy principles essential
• Surgical resection is mainstay of treatment of localized soft
tissue sarcoma
–XRT- consider advantages and disadvantages to
preoperative vs postoperative
–Chemotherapy- slight survival advantage