1. 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

2. CASE STUDY -- 62 year old male with right posterior arm soft tissue mass

3. Close approximation to radial nerve
Close approximation to humerus

4. 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

5. Excision Negative margin
Innervated latissimus flap to restore function

6. 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

7. 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

8. How to contact us Scheduling Contact: Leslie Fischer
Telephone:
Fax:
Nursing
Darin Davidson
Telephone:

9. 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

10. 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

11. 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

12. High grade soft tissue sarcoma with areas of hemorrhage and necrosis

13. Management Local and systemic staging MRI of affected area Biopsy
CT chest
Mainstay of treatment is surgical resection
Adjuvants
Radiation therapy
Chemotherapy

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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)

20. Overall survival comparing preoperative and postoperative XRT, indicating slightly higher overall survival in the preoperative group.
O’Sullivan et al, Lancet, 2002

21. 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%

22. 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)

23. 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

24. Chemotherapy Role of chemotherapy Role in metastatic disease
Controversial for localized disease
Meta-analyses have shown slight survival advantage with chemotherapy

25. Meta-analysis of adjuvant chemotherapy in localized soft tissue sarcoma
Lancet , 1997

26. Hazard ratio of survival for meta-analysis of adjuvant chemotherapy in localized soft tissue sarcoma
Pervaiz et al, Cancer 2008

27. 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

28. 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

29. 47 year old male with well circumscribed mass; biopsy proven synovial sarcoma

30. Fibromatosis

31. 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