12. STAGE WISE MANAGEMENT
IA LG SX--FOLLOW UP
IB LG SX ONLY if margin adequate
SX –PORT if close/positive margin
IIA Resectable without functional loss SX—PORT
IIB,III Resectable without fuctional loss SX ---PORT
13.
14.
15. Synchronous Stage IV
Single organ ,limited tumor bulk,
amenable to complete resection
Disseminated
Primary tr mx
+Metastatectomy/SBRT +/- CT
+/-RT
Palliation + BSC
16. SURGERY
First intervention
Most effective treatment to ensure cure.
Function preservation
Adequate Oncologic clearance
22. PREOP RT PORT
Treatment volume smaller-No need to
cover operated field
Treatment volume larger
Reduce seeding during surgery More seeding
Tumor regression and better resectability
Decreased risk of recurrence
Less toxic More toxic
No hypoxia-Blood supply uninterrupted Hypoxia in tumor bed may adversely affect
oucome
Disadv-Poor wound healing
-No complete HPR
Adv-Complete HPR available
23. RADIOTHERAPY PLANNING
Positioning & Immobilisation
Planning CT Scan 3-5 mm cuts with iv contrast
Co register Preoperative MRI /CT
3DCRT/IMRT preferred
24. RADIOTHERAPY PLANNING
GTV –contour tumor in preop MRI –T1C
CTV
---Initial GTV + Margin to encompass microscopic
spread
---Surgical Scar/Drain sites/Surgical clips
---GTV to CTV Margin 3 cm longitudinally (RTOG)
1.5 cm laterally
26. Example Case
55-year-old male with a large high-grade round
cell liposarcoma in right distal thigh. Clinical
stage (AJCC 7th edition) IIIT2bN0M0G3.
The MRI of right distal thigh showed a large well
circumscribed heterogeneous, multiloculated mass
located within the posterior thigh.
The tumor measured 14.8 cm in craniocaudal
dimension, 7.8 cm in AP dimension, and 11.3 cm in
maximal medial-lateral dimension.
Simulation CT images were fused with those
from the diagnostic thigh MRI
124. Trials
Trial Results
Pisters et al 160 extremity & trunk Randomized
to BT/Obs
42–45 Gy over 4–6d)
BT-LC for high-grade lesions
(65–90%), but not for LG.
No difference in DSS /DM.
NCI
(Yang et al. 1998):
rct
140 ,extremity sarcoma, WLE.
LG to obs vs. PORT
HG post-opCT vs.
post-op chemo-RT.
RT = large field to 45 Gy → boost to
63 Gy.
RT increased LC for low-grade
(60% vs. 95%) and high-grade
(75% vs. 100%).
No difference in OS /DMFS
NCI
(Rosenberg et al.
1982):
43 , HG STS ,extremity
WLE + PORT vs. amputation alone.
RT = 45–50 Gy to compartment
with boost to 60–70 Gy.
No difference in LC, OS, or
DFS.
Chemo decreased LR and
increased DFS (60% vs. 90%)
and OS (75% vs. 95%).
125. Pre-op or Post-op RT
NCIC (O’Sullivan et al.
2002; Davis et al. 2005):
190 patients
with extremity STS
randomized pre-op RT (50
Gy) vs. post-op
RT (66 Gy). If +margins,
pre-op got 16 Gy boost..
No difference LC /DM /PFS
Preop-woundhealing
PORT-late fibrosis
Pollack et al. (1998): post-op RT
(60–66 Gy) Vs pre-op RT
(50 Gy) before excision or
reexcision.
.
No difference in LC
presenting with gross
disease, best LC with pre-
op RT (88% vs.
67%)
presenting after excision -
immediate reexcision and
post-op RT (LC 91% vs.
72%).
wound-healing --pre-op
126. IORT
Oertel et al. (2006): n=153
primary or recurrent
extremity STS
limb-sparing surgery + IORT
10–20 Gy → post-op EBRT
36–50 Gy.
Five-year OS 77%, DMFS
48%, and LC 78%. IORT
dose >15 Gy improved
LC, but EBRT <45 or 45
Gy not significant for LC.
Acute wound-healing
toxicity.-High
NCI
(Sindelar et al. 1993):
N=35 ,resectable
retroperitoneal STS
randomized to surgery +
IORT 20 Gy → post-op 35–40
Gy vs. surgery → post-op 50–
55 Gy.
No difference in 5-year
OS (35%), nonsignificant
increase in LC ,IORT
increased neuropathy if
>15 Gy.
Alektiar et al. (2000): primary or recurrent
retroperitoneal STS
surgery + IORT 12–15 Gy →
post-op EBRT 45–50 Gy.
5-year OS 55%, DMFS
80%, LC 62%, 10%
neuropathy
127. BENEFIT OF PORT
Enucleation-80% recurrence
WE with negative margin- 30%
WE with negative margin and PORT-5%
Adjuvant radiotherapy improves local control
without benefit in Overall survival
133. 34% of all STS
MC- liposarcoma (40%), leiomyosarcoma
(25%), malignant peripheral nerve sheath
tumour and fibrosarcoma
MC visceral STS -GIST, leiomyosarcoma and
desmoid tumour
134. Presentation
Asymptomatic mass
Pain
Gastrointestinal bleeding
Incomplete obstruction
Neurological symptoms due to invasion of
neurovascular structures
135. Imaging
CT-abdomen
Also allows evaluation of the liver, the most
common site of metastasis
Staging
No official staging system
The same grading system applies as for
extremity STS
136. Diagnosis
Laparotomy with open biopsy
CT guided biopsy has a limited role only
Only if:
- unresectable tumour
- doubtful diagnosis
- neoadjuvent chemotherapy considered
137. Treatment
Surgery -The mainstay of treatment
Chemotherapy principles are the same as for
extremity STS
Radiotherapy
-High morbidity and mortality due to
radiosensitivity of surrounding organs
-Intensity-modulated radiation showing
promising results
138.
139.
140. prognosis
Adverse factors for local recurrence:
+ margins
>50 years age
deep location
fibrosarcoma type including desmoid, malignant
peripheral nerve sheath tumors.
Adverse factors for distant metastasis:
high-grade (at 5 years, <10% for low-grade, 50% for high grade)
increasing size
deep location,
leiomyosarcoma or malignant peripheral nerve sheath
tumor
high Ki-67.
141. Follow up
H&P
CXR/CT Chest 3-6 mon x 2-3 yr
6monthly x 2yr
Annual
Baseline and periodic imaging of primary site
142. Recurrence
Local relaspse-Work up
Metastasis
Single organ &Limited tumor bulk-
Metastatectomy+/-CT/RT
Ablation
Isolated Node-Nodal dissection+/- RT/CT
Disseminated mets-Palliation
143. Survival
StageI extrimity 5-year LC 90–100%, OS 90%
II–III extremity ~5-year LC 90%, OS 80% for stage II,
60% for stage III.
For recurrence, amputation salvages
~75%
Stage IV EXTRIMITY Limited mets~5-year OS ~25%.
Disseminated ~5-year OS 10%
Retroperitoneal ~5-year LC 50%, DM
20–30%, OS 50%
144. Take home message
STS are hterogeneous neoplasms
Management of STS requires multidisciplinary
tumor boards and close collaboration between
specialists.
Surgery is the most important form of treatment
Radiotherapy helps to improve local control.
Chemotherapy can be utilised in selected situations
in adjuvant/Neoadjuvant treatment.