Outcome after Surgical Resections of (recurrent) Chest Wall Sarcomas Is it worthwhile? Chairmen, ladies and gentleman, I would like to thank the organising commitee for the opportunity to present our data on chest wall resections for sarcoma, here in Seattle. Michael Wouters Bert van Geel Lotte Nieuwenhuis Harm van Tinteren Cees Verhoef Houke Klomp Frits van Coevorden

Resections for Chest Wall Sarcoma Background Sarcomas 1 % of all malignancies in adults 10-15% arise in the chest wall best controlled by wide (full-thickness) chest wall resections neo-(adjuvant) radio- or chemotherapy Sarcomas account for approximately one percent of all malignancies in adults. Only 10 to 15 percent arise in the chest wall. It is generally advised to perform a wide full-thickness chest wall resection, with a skeletal reconstruction and soft tissue coverage. Surgical treatment may be proceded or followed by radio- or chemotherapy.

Resections for Chest Wall Sarcoma Background / Literature   Resections for Chest Wall Sarcoma Background / Literature Author (pub.year) Study period (years) Chest wall malignancies Chest wall sarcomas Recurrent sarcomas Pfannschmidt (’06) 18 25 Gross (’05) 32 55 17 Chang (’04) 10 113 27 unknown Walsh (’01) 51 11 Sabanathan (’97) 38 49 Incarbone (’97) 13 52 19 Chapelier (’94) 9 Burt (’92) 40 126 Gordon (’91) 149 Perry (’90) 28 4 King (’86) 20 71 Pairolero (’85) 8 90 36 12 Graeber (’82) 37 59 48 In the literature few data are available regarding the appropriate management of patients with locally recurrent sarcomas on the chest wall (see the collumn on the right in this table). Most series are heterogeneous, describing resections for sarcoma as well as carcinoma, without distinguishing primary, recurrent and metastastic disease.

Resections for Chest Wall Sarcoma Background / Literature   Resections for Chest Wall Sarcoma Background / Literature Author (pub.year) Study period (years) Chest wall malignancies Chest wall sarcomas Recurrent sarcomas Pfannschmidt (’06) 18 25 Gross (’05) 32 55 17 Chang (’04) 10 113 27 unknown Walsh (’01) 51 11 Sabanathan (’97) 38 49 Incarbone (’97) 13 52 19 Chapelier (’94) 9 Burt (’92) 40 126 Gordon (’91) 149 Perry (’90) 28 4 King (’86) 20 71 Pairolero (’85) 8 90 36 12 Graeber (’82) 37 59 48 To our knowledge the largest series of recurrent sarcomas reported is the one from Gross from the cancer centre in Sao Paolo, Brasil. Their series of 55 chest wall sarcomas contained 17 patients with a local recurrence on the chest wall.

Resections for Chest Wall sarcoma Objective To evaluate: - morbidity, mortality and (disease-free) survival - outcome for primary and recurrent sarcomas of the chest wall That’s why we decided to evaluate morbidity, mortality and disease-free survival of patients surgically treated for a chest wall sarcoma, ánd to compare outcome for primary and recurrent sarcomas of the chest wall.

Resections for Chest Wall sarcoma Methods retrospective study 2 tertiary referral centers in the Netherlands 1980 – 2006 any sarcoma involving: Ribs Sternum Costo-vertebral junction Vertebral body full-thickness Chest Wall resection We conducted a retrospective study in two tertiary referral centers in the Netherlands: the Netherlands Cancer Institute – Antoni van Leeuwenhoek hospital in Amsterdam and the Erasmus Medical Center – Daniel den Hoed hospital in Rotterdam. We identified patients surgically treated for a sarcoma of the Chest wall through the histopathologic results in file of the Pathology departments of these hospitals. The original patient files’ were retreived and only those patients with a full-thickness chest wall resection for a sarcoma involving ribs, sternum, costovertebral junction or vertebral body were selected.

Resections for Chest Wall sarcoma Full-thickness Chest Wall resection This picture shows a full thickness resection for sarcoma, including skin, a part of the latissimus dorsi, serratus muscle, intercostals as well as a partial rib resection.

Resection of Chest Wall sarcoma Patients In our study, we identified 133 patients meeting our inclusion criteria. 83 (62 percent) were treated for a primary sarcoma on the chest wall, 44 (33%) for a ‘local recurrence’. 6 patients were treated for metastases of a sarcoma on another part of the body. These patients were excluded from the study. median follow-up time: 74 months

Resections of Chest Wall sarcoma Results / Patient & Tumor characteristics PRIMARY RECURRENT Age 48 (13-81) 52 (23-75) Gender ( m – f ) 49 – 51% 45 –55 % Histology chondro/osteo liposarcoma fibrosarcoma pleiomorf leiomyosarcoma angiosarcoma other / NOS 36 (43%) 3 (4%) 11 (13%) 7 (8%) 4 (5%) 19 (23%) 13 (30%) 4 (9%) 8 (18%) 6 (14%) 2 (4%) 7 (16%) Tumor-grade low intermediate high unknown 16 (19%) 20 (24%) 31 (38%) 5 (11%) 18 (41%) 16 (36%) There were no significant differences in age, gender, co-morbidities, localization and median tumor-size of the sarcomas. Histologic types were very heterogeneous as you see in this table. The most occurring histologic subtypes were chondro- and osteosarcoma.There was no essential difference between the primary and the recurrent group.

Resections of Chest Wall sarcoma Results / Patient & Tumor characteristics PRIMARY RECURRENT Age 48 (13-81) 52 (23-75) Gender ( m – f ) 49 – 51% 45 –55 % Histology chondro/osteo liposarcoma fibrosarcoma pleiomorf leiomyosarcoma angiosarcoma other / NOS 36 (43%) 3 (4%) 11 (13%) 7 (8%) 4 (5%) 19 (23%) 13 (30%) 4 (9%) 8 (18%) 6 (14%) 2 (4%) 7 (16%) Tumor-grade low intermediate high unknown 16 (19%) 20 (24%) 31 (38%) 5 (11%) 18 (41%) 16 (36%) Also important is the similar number of high grade sarcomas in both groups.

Resections of Chest Wall sarcoma Results / Treatment characteristics PRIMARY RECURRENT Intention surgery curative palliative 81 (98%) 2 (2%) 43 (98%) 1 (2%) Neo-adj. Treatment none chemotherapy Radiotherapy 64 (77%) 17 (20%) 2 (3%) 41 (93%) 2 (5%) Skeletal resection ribs (mean number) sternum other 2.4 (0-10) 27 (32%) 16 (19%) 2.4 (0-7) 9 (20%) 10 (23%) Reconstruction mesh +/- omentum / myocutaneus flap 15 (18%) 68 (82%) 35 (80%) In the primary sarcoma group two patients, and in the recurrent group one patient had a palliative resection. In all other patients a full-thickness chest wall resection was performed with a curative intention. A minority of patients in the primary and recurrent group had pré-operative chemo or radiotherapy. A mean number of 2.4 ribs were resected in both groups. A reconstruction with any kind of mesh was performed in the majority of patients often covered by omentum or a myocutaneus flap.

Resections of Chest Wall sarcoma Results / Outcome / Morbidity PRIMARY RECURRENT Complications none bleeding infectious reconstr. failure pulm. / cardiac 66 (80%) 3 (4%) 6 (8%) 2 (2%) 9 (11%) 34 (77%) 0 (0%) 5 (11%) Re-operations number of patients 2 (5%) Hospital stay median (days) 9 12 In-hosp mortality In almost 80% of patients surgery was uneventful. Only 5% needed a re-operation, mostly for bleeding or failures of the reconstruction. Median hospital stay was 9 versus 12 days. There was no in-hospital or 30-day mortality in these groups.

Resections of Chest Wall sarcoma Results / Outcome PRIMARY RECURRENT Margins R0 R1 R2 66 (80%) 13 (16%) 3 (3%) 28 (64%) 10 (23%) 5 (11%) Recurrence no recurrence local recurrence distant recurrence 42 (51%) 20 (24%) 21 (25%) 11 (25%) 21 (48%) 12 (27%) Disease-free survival median (months) 36 18 Survival 125 55 There were more irradical resections in the recurrent than in the primary sarcoma group. This lead to a higher number of second local recurrences in this group; almost half of the patients, versus 24% in the primary sarcoma group. Therefore, disease-free survival is significantly less in the recurrent sarcoma group.

Resection of Chest Wall sarcoma Results / Outcome / DFS vs OS However, when we look at the survival curves, resection of both primary AND recurrent chest wall sarcoma translates into fair overall survival. The 5-year survival is 62% in the primary sarcoma group and 50% in the recurrent sarcoma group.

Resection of Chest Wall sarcoma Results / Outcome / Recurrences The distribution and type of recurrences in the primary and recurrent group is represented in this figure. It shows that 51% of patients in the primary group stayed disease-free during follow-up and only 25% of the recurrent group.

Resection of Chest Wall sarcoma Results / Outcome / Recurrences This difference is not due to a higher number of distant recurrences in the recurrent group, the contrary is true, the proportion of distant metastatic disease is similar.

Resection of Chest Wall sarcoma Results / Outcome / Recurrences In the group of patients operated for recurrent sarcoma, local re-recurrences occurred in 20 out of 44 patients. The contrast with the primary group in which 17 of 83 patients get a local recurrence, is considerable. Moreover, in patients with a second local recurrence in the recurrect group, MORE OFTEN a third chest wall resection was performed, namely in 12 of 20 patients against 5 of 17 in the primary sarcoma group.

Resections for Chest Wall Sarcoma Discussion Primary and Recurrent Chest Wall sarcomas have different recurrence patterns. This selection of locally recurrent Chest Wall sarcomas has less tendency to metastasize. To our opinion this difference in recurrence patterns can be explained by the biologic behaviour the tumors in the recurrent group have revealed. They are a selection of chest wall sarcomas that have shown to have less tendency to metastasize.

Resections for Chest Wall Sarcoma Conclusions Safe and effective procedure, even in locally recurrent sarcomas 5-year survival after resection of recurrent chest wall sarcomas is ‘worthwhile’! Recurrent chest wall sarcomas should be resected if technically possible. Therefore we may conclude that full-thickness chest wall resections are safe and effective procedures, even in locally recurrent sarcomas. 5-year survival is indeed worthwhile and not much less than in primary chest wall sarcomas. Thats why recurrent chest wall sarcomas without distant metastases should be resected if technically possible. THANK YOU FOR YOUR ATTENTION