Combined modality management of local and disseminated adult soft tissue sarcomas: A review of 257 cases seen over 10 years at the Christie Hospital & Holt Radium Institute, Manchester

Abstract

Summary Over a 10 year period, between 1974-1984, 257 adult cases of tissue sarcoma have been evaluated in the Department of Medical Oncology, Christie Hospital, Manchester. At registration locally advanced or metastatic diseases was present in 162 (63%). The male/female ratio was 1.5:1 and median age 54 years (range 14-85). The commonest sites were lower limb (33%), visceral (21%), trunk (13%), retroperitoneum (12%) and upper limb (10%). Leiomyosarcoma (27%), liposarcoma (14%) malignant fibrous histiocytoma (10%) and neuro plus fibrosarcomas (15%) were the most frequent histological subtypes. A high proportion of uterine sarcomas (17%) is a point of distinction from many other series. Histological grade was specified in 72% of cases and the distribution (Grade 1-27%; 11-6%; 111-67%) reflected a referral bias towards advanced disease. Local resection of the primary tumour was performed in 76% of cases.In many instances this only amounted to 'shelling out' and true compartmental excisions were rare. Amputation was performed in 31% of patients with limb sarcomas. Ninety-eight patients (38%) had experienced one or more local recurrences prior to referral and the overall local recurrence rate was 56%. Suitable patients (78%) received chemotherapy, 50% entering multicentre trials in collaboration with the EORTC. The commonest regime used in patients with advanced disease was CYVADIC which produced an overall response rate of 37%. Ifosfamide, used as a single agent in 16 patients, induced 3CR and 5PR for an overall response rate of 50%.When used in combination with MTX and VADIC, there was no difference in response rate, but numbers in these pilot studies were small. Seventeen high risk patients received adjuvant chemotherapy with VAC, but the results (11 relapses) were disappointing. An EORTC trial, comparing adjuvant CYVADIC chemotherapy with control has acrrued 307 patients, 49 of these from the Christie Hospital.Preliminary results within this centre -13/25 relapses in the control arm, 5/23 in the chemotherapy armsuggest an advantage for chemotherapy but the data are statistically not significant. Post-operative radical radiotherapy after resection of the primary tumour or local recurrence was performed in 51 patients, with local control in 65% of cases, although metastases developed in 41%. At the time of analysis (1st April 1984) 98 (38%) were alive, of whom 72 showed no evidence of disease and 52 had never relapsed. Malignant disease was the cause of death in 92%. Overall survival was not influenced by sex, but patients less than 40 years of age fared significantly better (P<0.001). Survival was better for patients with sarcomas of the extremities and trunk than for visceral tumours, whereas those in the head, neck, thorax and peritoneum did significantly worse (P<0.001). As shown in many other series, histological grade had a highly significant influence on survival (P<0.001), in favour of low grade (I) tumours, whereas histological subtype was unimportant (P=0.22). Although the incidence of local recurrence ...

Sarcomas in north west England: III Survival

“…overall had a slightly better 5-year survival rate than males (36% vs 32%), the difference was reversed for bone tumour patients (51% vs 32%) but neither difference was statistically significant. Better survival in female soft tissue sarcoma patients has been noted by R66ser et al (1988), Ueda et al (1988) and El-Jabbour et al (1990), but no difference was apparent in other series (Bramwell et al, 1985;Collin et al, 1987). The most consistent finding in these analyses was the better prognosis for younger patients as reported by other investigators (Bramwell et al, 1985;Collin et al, 1987;ElJabbour et al, 1990).…”

“…histological grade, size, depth, degree of necrosis etc. (Trojani et al, 1984;Rooser et al, 1988;Ueda et al, 1988;Mandard et al, 1989) [ion or on various treatment modalities (Markhede et al, 1982;Bramwell et al, 1985;Suit et al, 1985). In addition, most of tl in sarcoma patients is difficult to assess reliably these observations have been made on hospital-based or on of the rarity of such tumours, their differing toposelected sub-sets of population-based series.…”

“…Most published data on survival in sarcomas relates to selected patients referred to specialist treatment centres (Markhede et al, 1982;Bramwell et al, 1985;Collin et al, 1987;Stotter et al, 1990;El-Jabbour et al, 1990). Survival data from other, more broadly-based groups, have not relied upon centrally reviewed histological diagnoses for all the cases included (Tucker & Fraumeni, 1982;Fraumeni & Boice, 1982).…”

Prognostic factors for survival in soft tissue sarcoma

“…In this study, size was an independent prognostic factor in the superficial STS but not in either the overall group or the deep STS. As expected, due to the surgical problems and, probably, the nature of such tumours, survival was poor for patients with retroperitoneal disease (Bramwell et al, 1985;Collin et al, 1987;Markhede et al, 1982;Tsujimoto et al, 1988). Since retroperitoneal STS tend to be larger at presentation it is difficult to separate size from site as an independent prognostic factor.…”

“…Heise et al (1986) found a higher recurrence-free survival in patients presenting with mass as compared with other symptoms. The wide range of duration of symptoms has been shown by others (Bramwell et al, 1985;Ueda et al, 1988) and probably relates to the fact that many patients ignore any swelling not accompanied by pain. In our series there was an association of symptoms with site and they did not prove to be of prognostic significance.…”