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3428 Isolated limb perfusion (ILP) with melphalan and tumour necrosis factor a (TNFa) for locally advanced soft tissue tumours of the extremities
Abstracts
S697
from this database we extracted data concerning primitive and recurrent retroperitoneal sarcomas observed from 2006 to 2011. This series was stratified according to hospital case volumes into three subgroups: patients treated at a comprehensive cancer center (Istituto di Candiolo − IRCCS − Turin), at a tertiary care academic hospital (City of Health and Science − CHS − University Hospital of Turin) and at secondary care regional hospitals. A complete dataset for 138 patients was collected. Results: 75% were primitive sarcomas, and 17,4% metastatic at first observation. The were 17 observed histotypes, the most common being liposarcomas, followed by leiomyosarcomas. Tumour diameter was not reported in half of the examined cases; in the other half, tumours >10 cm were observed in 75% of cases. Tumour grading was not available in 42% of cases: where reported, 61% of tumors were grade G3. A preoperative biopsy was performed in 20% of cases. Surgical margins were not considered in the pathological report in 55% of cases: where this data was available, none or marginally involved margins (R0 or R1) were observed in 72% of cases. Overall survival curves are clearly influenced by the quality of the first surgical treatment. Even though in the CHS University Hospital group primitive cases prevailed and in the IRCCS group recurrent sarcomas were most frequently treated, survival curves were not significantly different, apparently reflecting a lower quality of surgical care in the CHS academic hospital. This may be the consequence of the single surgeon caseload, as in the University hospital RPS are treated by several surgical departments by non dedicated surgeons while in the comprehensive cancer center RPS are treated by a dedicated surgical team. Conclusions: Adherence to guidelines is very poor outside reference or tertiary care centres, where pre-operatory biopsy is rarely performed, cancer integrity is hardly respected and surgical margins quality is not reported. The analysis of the different variables and of the overall survival curves according to the series stratification shows that surgeon’s activity volume, multidisciplinary approach and adherence to surgical and pathologic guidelines can significantly impact on treatment outcomes. No conflict of interest. 3428 POSTER Isolated limb perfusion (ILP) with melphalan and tumour necrosis factor a (TNFa) for locally advanced soft tissue tumours of the extremities H. Smith1 , J. Cartwright1 , M. Wilkinson1 , A. Hayes1 . 1 Royal Marsden Hospital, Department of Academic Surgery, London, United Kingdom Background: ILP is indicated in advanced in-transit melanoma (ITM) and in soft tissue sarcomas (STS) that are incompatible with limb-conserving surgery. We present the outcomes of a large single institution series for a range of pathologies. Materials and Methods: Patients undergoing ILP for any indication from 01/01/05 to 31/12/14 were identified from a prospectively maintained database. Data regarding pathology, operative characteristics, and outcomes were collected. Those undergoing ILP for ITM were grouped into low volume or bulky disease (deposits >2cm diameter). Results: 148 perfusions were attempted (9 upper limb, 139 lower limb). Five perfusions were unsuccessful either due to inadequate flow rates or excessive leakage from the isolated circuit (3 femoral, 2 iliac). Eight cases were lost to follow up before treatment response could be assessed. 70% of ILPs were for irresectable ITM and 27% for STS. Only 4 patients with sarcoma had ILP as induction therapy prior to a planned surgical resection. The remainder had ILP alone as palliation for irresectable sarcomas. Four perfusions were for squamous cell carcinoma (3) and metastatic colorectal cancer (1). The response rates following ILP are shown in the table.
ITM All Low-volume Bulky STS Other
Successful perfusions
Overall response
Complete response
Partial response
Stable disease
Progressive disease
100 73 27 39 4
76.7% 74.0% 84.6% 59.5% 100%
42.4% 37.8% 53.8% 21.6% 25%
34.3% 35.2% 30.8% 37.8% 75%
10.1% 10.0% 11.5% 18.9% 0%
8.1% 11.0% 0% 18.9% 0%
There was no significant difference in overall response between the low volume and bulky disease in those patients with ITM (p = 0.35). Regional toxicity following ILP was low with only 7 grade III (5.6%), 1 grade IV (0.8%) and 1 grade V (0.8%) reactions. In the ITM cohort, the limb salvage rate was 96% (4/100) compared to 64% (14/39) in the STS cohort. Amputations were due to disease progression in 3 and 12 cases, respectively. The remainder were due to regional toxicity (in the ITM cohort) or unrelated complications (femoral fracture due to bony
metastases and haemorrhage following trauma to the tumour in the STS cohort). The 2-year local progression free survival in these cohorts was 29.9% and 15.6%, respectively. The median time to progression was 11 months in both cohorts. In the ITM cohort, 47 patients developed metastases with 44 diseasespecific deaths. The 2-year overall survival was 44.5% with a median survival of 21 months. In the STS cohort, 15 patients developed metastases with 11 disease-specific deaths. The 2-year overall survival was 67.5% and a median survival was not reached. Conclusions: TNF based ILP is an effective palliative treatment for both ITM and STS. It is of particular value as limb salvage in ITM as most patients will go on to develop metastases. For STS amputation may still be necessary as the response rate is lower and fewer patients develop distant disease. No conflict of interest. 3429 The surgical management of elastofibromas
POSTER
H. Smith1 , J. Hannay1 , K. Thway2 , M. Smith1 , D. Strauss1 , A. Hayes1 . 1 Royal Marsden Hospital, Department of Academic Surgery, London, United Kingdom; 2 Royal Marsden Hospital, Department of Histopathology, London, United Kingdom Background: Elastofibromas are rare pseudo-tumours with a very characteristic presentation. They almost always occur at the inferior pole of the scapula, deep to the serratus anterior muscle and cause a ‘clunk’ on abduction/adduction of the shoulder. Due to their size and site of origin, they may often be mistaken for soft tissue sarcomas. We present the management of elastofibromas at a single institution. Material and Methods: All patients with a diagnosis of elastofibroma made from January 1995 to January 2015 were identified from a prospectively maintained histopathology database. Associated electronic patient records, imaging and histopathology reports were retrieved and reviewed. Results: A total of 37 patients were diagnosed with elastofibroma during this period. The median age at presentation was 66 years (43−93 yrs). Females were more commonly affected than males with a M:F ratio of 1:1.6. All tumours occurred in the characteristic subscapular position. A contralateral subclinical lesion was found in six cases (15.8%). The median maximum tumour size was 8.2cm (range 2−12cm). All patients were aware of a mass, with a median duration of symptoms of 6 months (1−60mths). A further 22 patients experienced ‘clunking’ and 15 experienced pain. The diagnosis of elastofibroma was suspected by the referring clinician in 10 cases (26.3%). In all other cases, the working diagnosis was that of a soft tissue sarcoma (73.7%). Diagnostic work-up included some form of imaging in 31 patients with the most common modalities being MRI (59.5%), CT (29.8%) and ultrasound (10.8%). No imaging was performed in 6 patients. Diagnostic percutaneous biopsies were obtained in all but one patient (97.4%), who presented with bilateral lesions and proceeded directly to surgery with a clinical diagnosis. Eighteen patients (48.6%) were managed non-operatively. The remaining 19 underwent marginal excisions due to significant symptoms. Four of these patients had bilateral lesions, all of whom underwent further excision of the contralateral lesion when it became symptomatic at a median of 29 months after the initial surgery. The median length of hospital stay was 3 days (2−9days). Peri-operative morbidity was generally low with 2 patients developing haematomas (10.5%) and 5 patients developing seromas (26.3%). At a median follow-up of 52.5 months (2–234 months), none of the patients that were managed operatively had developed a recurrence. Conclusions: The diagnosis of elastofibroma may be alluded to by its characteristic presentation and confirmed by percutaneous biopsy. Once the differential diagnosis of soft tissue sarcoma has been excluded, these lesions can be safely managed conservatively. Operative management, in the form of a marginal excision, should be reserved for those with significant symptoms. No conflict of interest. 3430 POSTER Clinical outcomes in 21 patients with gastrointestinal stromal tumor (GIST) treated in phase I trials: The NCCHE Experience Y. Nagatani1 , K. Shitara1 , H. Bando1 , W. Okamoto1 , T. Kojima1 , T. Yoshino1 , T. Nishida2 , T. Doi1 . 1 National Cancer Center Hospital East, Department of GI Oncology, Chiba, Japan; 2 National Cancer Center Hospital East, Department of Surgery, Chiba, Japan Background: Prognosis of patients with GIST after failure of standard therapies is poor with reported median PFS of 0.9 months with the
S697
from this database we extracted data concerning primitive and recurrent retroperitoneal sarcomas observed from 2006 to 2011. This series was stratified according to hospital case volumes into three subgroups: patients treated at a comprehensive cancer center (Istituto di Candiolo − IRCCS − Turin), at a tertiary care academic hospital (City of Health and Science − CHS − University Hospital of Turin) and at secondary care regional hospitals. A complete dataset for 138 patients was collected. Results: 75% were primitive sarcomas, and 17,4% metastatic at first observation. The were 17 observed histotypes, the most common being liposarcomas, followed by leiomyosarcomas. Tumour diameter was not reported in half of the examined cases; in the other half, tumours >10 cm were observed in 75% of cases. Tumour grading was not available in 42% of cases: where reported, 61% of tumors were grade G3. A preoperative biopsy was performed in 20% of cases. Surgical margins were not considered in the pathological report in 55% of cases: where this data was available, none or marginally involved margins (R0 or R1) were observed in 72% of cases. Overall survival curves are clearly influenced by the quality of the first surgical treatment. Even though in the CHS University Hospital group primitive cases prevailed and in the IRCCS group recurrent sarcomas were most frequently treated, survival curves were not significantly different, apparently reflecting a lower quality of surgical care in the CHS academic hospital. This may be the consequence of the single surgeon caseload, as in the University hospital RPS are treated by several surgical departments by non dedicated surgeons while in the comprehensive cancer center RPS are treated by a dedicated surgical team. Conclusions: Adherence to guidelines is very poor outside reference or tertiary care centres, where pre-operatory biopsy is rarely performed, cancer integrity is hardly respected and surgical margins quality is not reported. The analysis of the different variables and of the overall survival curves according to the series stratification shows that surgeon’s activity volume, multidisciplinary approach and adherence to surgical and pathologic guidelines can significantly impact on treatment outcomes. No conflict of interest. 3428 POSTER Isolated limb perfusion (ILP) with melphalan and tumour necrosis factor a (TNFa) for locally advanced soft tissue tumours of the extremities H. Smith1 , J. Cartwright1 , M. Wilkinson1 , A. Hayes1 . 1 Royal Marsden Hospital, Department of Academic Surgery, London, United Kingdom Background: ILP is indicated in advanced in-transit melanoma (ITM) and in soft tissue sarcomas (STS) that are incompatible with limb-conserving surgery. We present the outcomes of a large single institution series for a range of pathologies. Materials and Methods: Patients undergoing ILP for any indication from 01/01/05 to 31/12/14 were identified from a prospectively maintained database. Data regarding pathology, operative characteristics, and outcomes were collected. Those undergoing ILP for ITM were grouped into low volume or bulky disease (deposits >2cm diameter). Results: 148 perfusions were attempted (9 upper limb, 139 lower limb). Five perfusions were unsuccessful either due to inadequate flow rates or excessive leakage from the isolated circuit (3 femoral, 2 iliac). Eight cases were lost to follow up before treatment response could be assessed. 70% of ILPs were for irresectable ITM and 27% for STS. Only 4 patients with sarcoma had ILP as induction therapy prior to a planned surgical resection. The remainder had ILP alone as palliation for irresectable sarcomas. Four perfusions were for squamous cell carcinoma (3) and metastatic colorectal cancer (1). The response rates following ILP are shown in the table.
ITM All Low-volume Bulky STS Other
Successful perfusions
Overall response
Complete response
Partial response
Stable disease
Progressive disease
100 73 27 39 4
76.7% 74.0% 84.6% 59.5% 100%
42.4% 37.8% 53.8% 21.6% 25%
34.3% 35.2% 30.8% 37.8% 75%
10.1% 10.0% 11.5% 18.9% 0%
8.1% 11.0% 0% 18.9% 0%
There was no significant difference in overall response between the low volume and bulky disease in those patients with ITM (p = 0.35). Regional toxicity following ILP was low with only 7 grade III (5.6%), 1 grade IV (0.8%) and 1 grade V (0.8%) reactions. In the ITM cohort, the limb salvage rate was 96% (4/100) compared to 64% (14/39) in the STS cohort. Amputations were due to disease progression in 3 and 12 cases, respectively. The remainder were due to regional toxicity (in the ITM cohort) or unrelated complications (femoral fracture due to bony
metastases and haemorrhage following trauma to the tumour in the STS cohort). The 2-year local progression free survival in these cohorts was 29.9% and 15.6%, respectively. The median time to progression was 11 months in both cohorts. In the ITM cohort, 47 patients developed metastases with 44 diseasespecific deaths. The 2-year overall survival was 44.5% with a median survival of 21 months. In the STS cohort, 15 patients developed metastases with 11 disease-specific deaths. The 2-year overall survival was 67.5% and a median survival was not reached. Conclusions: TNF based ILP is an effective palliative treatment for both ITM and STS. It is of particular value as limb salvage in ITM as most patients will go on to develop metastases. For STS amputation may still be necessary as the response rate is lower and fewer patients develop distant disease. No conflict of interest. 3429 The surgical management of elastofibromas
POSTER
H. Smith1 , J. Hannay1 , K. Thway2 , M. Smith1 , D. Strauss1 , A. Hayes1 . 1 Royal Marsden Hospital, Department of Academic Surgery, London, United Kingdom; 2 Royal Marsden Hospital, Department of Histopathology, London, United Kingdom Background: Elastofibromas are rare pseudo-tumours with a very characteristic presentation. They almost always occur at the inferior pole of the scapula, deep to the serratus anterior muscle and cause a ‘clunk’ on abduction/adduction of the shoulder. Due to their size and site of origin, they may often be mistaken for soft tissue sarcomas. We present the management of elastofibromas at a single institution. Material and Methods: All patients with a diagnosis of elastofibroma made from January 1995 to January 2015 were identified from a prospectively maintained histopathology database. Associated electronic patient records, imaging and histopathology reports were retrieved and reviewed. Results: A total of 37 patients were diagnosed with elastofibroma during this period. The median age at presentation was 66 years (43−93 yrs). Females were more commonly affected than males with a M:F ratio of 1:1.6. All tumours occurred in the characteristic subscapular position. A contralateral subclinical lesion was found in six cases (15.8%). The median maximum tumour size was 8.2cm (range 2−12cm). All patients were aware of a mass, with a median duration of symptoms of 6 months (1−60mths). A further 22 patients experienced ‘clunking’ and 15 experienced pain. The diagnosis of elastofibroma was suspected by the referring clinician in 10 cases (26.3%). In all other cases, the working diagnosis was that of a soft tissue sarcoma (73.7%). Diagnostic work-up included some form of imaging in 31 patients with the most common modalities being MRI (59.5%), CT (29.8%) and ultrasound (10.8%). No imaging was performed in 6 patients. Diagnostic percutaneous biopsies were obtained in all but one patient (97.4%), who presented with bilateral lesions and proceeded directly to surgery with a clinical diagnosis. Eighteen patients (48.6%) were managed non-operatively. The remaining 19 underwent marginal excisions due to significant symptoms. Four of these patients had bilateral lesions, all of whom underwent further excision of the contralateral lesion when it became symptomatic at a median of 29 months after the initial surgery. The median length of hospital stay was 3 days (2−9days). Peri-operative morbidity was generally low with 2 patients developing haematomas (10.5%) and 5 patients developing seromas (26.3%). At a median follow-up of 52.5 months (2–234 months), none of the patients that were managed operatively had developed a recurrence. Conclusions: The diagnosis of elastofibroma may be alluded to by its characteristic presentation and confirmed by percutaneous biopsy. Once the differential diagnosis of soft tissue sarcoma has been excluded, these lesions can be safely managed conservatively. Operative management, in the form of a marginal excision, should be reserved for those with significant symptoms. No conflict of interest. 3430 POSTER Clinical outcomes in 21 patients with gastrointestinal stromal tumor (GIST) treated in phase I trials: The NCCHE Experience Y. Nagatani1 , K. Shitara1 , H. Bando1 , W. Okamoto1 , T. Kojima1 , T. Yoshino1 , T. Nishida2 , T. Doi1 . 1 National Cancer Center Hospital East, Department of GI Oncology, Chiba, Japan; 2 National Cancer Center Hospital East, Department of Surgery, Chiba, Japan Background: Prognosis of patients with GIST after failure of standard therapies is poor with reported median PFS of 0.9 months with the