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Long-Term Results of Postoperative 3-Dimensional High-Dose-Rate Brachytherapy for Soft-Tissue Sarcomas
Poster Viewing Abstracts S763
Volume 90 Number 1S Supplement 2014
3401 Long-Term Results of Postoperative 3-Dimensional High-Dose-Rate Brachytherapy for Soft-Tissue Sarcomas M. Kenjo, T. Kubo, S. Shimose, J. Fujimori, T. Nakashima, Y. Doi, T. Okabe, Y. Murakami, T. Kimura, Y. Kaneyasu, and Y. Nagata; Hiroshima University, Hiroshima, Japan Purpose/Objective(s): When malignant soft tissue sarcoma is located nearby major vessels or nerves, modified resection followed by brachytherapy is a reasonable choice for preserving leg or arm. The long term results and considerations about interstitial high dose rate brachytherapy (HDR-BT) for soft tissue sarcomas with 3-dimentional (3D) planning are shown on this paper. Materials/Methods: Twenty-six consecutive malignant soft tissue sarcoma patients received modified or marginal resection and treated with post-operative interstitial HDR-BT between 1995 and 2010 in single institution. Twentyone male and fifteen female patients were enrolled. Median age was 65 years (range 15-86). Primary tumor sites were located in femoral in 22 patients, fore arm in 5, lower led in 4 and others in 5. Eighteen patients were diagnosed as malignant histiocytoma, eight were as liposarcoma, and ten were as others. No patients had nodal or distant metastasis. Total resection was done with preserving nerve and vessels just attached to the tumor. Marginal evaluation of surgery were wide resection in 2 patients, marginal resection in 32 and intratumor resection were 2. Soft-tube applicators (median 10 catheters) were located enough to cover the tumor bed during surgery. Computed tomography based 3D planning was done for all cases with the reference of pre surgical magnetic resonance images. Clinical target volume (CTV) was defined to cover the tumor bed and surrounding areas bounded to critical structures Ir-192 high dose rate brachytherapy was initiated 7 to 12 days after surgery. Irradiation plan was made to cover the CTV by 100% isodose surface. Prescribed dose was 50 Gy per 10 fractions in one week. External irradiation or concurrent chemotherapy was not used. Follow up images were taken every 3 months up to 2 years, and twice a yare later. Results: All patients completed prescribed HDR-BT. Median follow up time was 40 months (range, 3-147). Overall survival rates at 3 and 5 years were 70% and 59%. Local control rate at 3 and 5 years were 90% and 90%. Four patients experienced local recurrence. All local recurrences were identified in patients who received marginal resection and occurred outside of CTV. All of them received additional resection. Thirteen patients (36%) developed distant metastases and 11 of them had the lesion in lung. Nine patients died of primary disease. Grade 3 acute and late complications were observed in 11% and 14%. Bone fracture or necrosis which needs local intervention occurred in 3 patients and severe nerve disorders were in 3. No grade 4 or 5 late adverse events were observed. Conclusions: Postoperative 3D HDR-BT following less invasive surgery is effective treatment for soft tissue sarcomas. As all local recurrences were occurred outside CTV, applicator placements and target volume settings are important for local control. Attention should be paid for bone and nerve late complications. Author Disclosure: M. Kenjo: None. T. Kubo: None. S. Shimose: None. J. Fujimori: None. T. Nakashima: None. Y. Doi: None. T. Okabe: None. Y. Murakami: None. T. Kimura: None. Y. Kaneyasu: None. Y. Nagata: None.
3402 Intraoperative Radiation Therapy (IORT) in the Management of Recurrent Extremity Soft-Tissue Sarcoma (STS) C.L. Tinkle, R.J. O’Donnell, V. Weinberg, and A.R. Gottschalk; University of California San Francisco, San Francisco, CA Purpose/Objective(s): To investigate the efficacy and morbidity of limbsparing surgery with IORT for patients with locally recurrent extremity STS. Materials/Methods: Twenty-six consecutively treated patients were identified in a single institution retrospective analysis of patients with locally recurrent extremity STS treated with IORT following salvage limbsparing resection from May 2000 to July 2011. Twenty patients (77%)
sustained a single recurrence, while 6 (23%) were multiply recurrent. Distant metastasis developed prior to re-resection and IORT in 5 patients (19%). Close (<2mm) or positive margins at IORT were found in 19 patients (73%). Fifteen patients (58%) received external beam radiation therapy (EBRT) prior to recurrence (median dose 6300 cGy), while 11 patients (42%) received EBRT following IORT (median dose 5220 cGy). The median IORT dose was 1500 cGy (range 1000-1800 cGy). Chemotherapy prior to recurrence was given to 6 patients (23%), while 14 patients (54%) received perioperative chemotherapy. The most common histologies were undifferentiated pleomorphic sarcoma and synovial sarcoma (27% and 19%, respectively), and most tumors were high grade (Coindre grade 2-3) (77%), deep in location (85%), and AJCC pathologic stage II or higher (77%). The Kaplan-Meier product limit method was used to estimate disease control and survival, subsets were compared using a log rank statistic, and toxicity was reported according to CTCAE v4.0 guidelines. Results: With a median duration of follow-up from surgery and IORT of 34.9 months (range 4 - 139 mos.), 10 patients developed a local recurrence all within 30 months of IORT with 4 subsequently undergoing amputation. The 5-year Kaplan-Meier estimates for local control (LC) were 58% (95% CI 36-75%); for amputation-free was 81% (95% CI 57-93%); for metastasis-free control (MFC) were 56% (95% CI 31-75%); for disease-free survival (DFS) were 35% (95% CI 17-54%); and for overall survival (OS) was 50% (95% CI 24-71%). Prior EBRT did not appear to influence disease control (LC, p Z 0.74; MFC, p Z 0.66) or survival (DFS, p Z 0.16; OS, p Z 0.58). Grade 3 or higher acute and late toxicities were reported for 6 (23%) and 8 (31%) patients, respectively. The frequency of both acute and late grade 3 or higher toxicities occurred equally between patients who received EBRT prior to or after IORT. Conclusions: IORT in combination with oncologic resection of recurrent extremity STS yields good rates of local control and limb-salvage with acceptable morbidity. Within the limitations of small subsets, these data suggest prior EBRT does not significantly influence disease control or toxicity. This technique offers a method of delivering focal therapy to achieve local control for the majority of patients who otherwise may require more radical surgical procedures. Author Disclosure: C.L. Tinkle: None. R.J. O’Donnell: None. V. Weinberg: None. A.R. Gottschalk: None.
3403 Outcomes of Patients With Synovial Sarcomas Treated With Multimodality Therapy: A Single-Institution Review A. Jacobson, C. Giraud, F. Hornicek, K. Raskin, J. Schwab, J. Mullen, D. Harmon, E. Choy, G. Nielsen, T. DeLaney, and Y. Chen; Massachusetts General Hospital, Boston, MA Purpose/Objective(s): Synovial sarcoma (SS) is a rare soft tissue sarcoma frequently found in young patients and most often found in the extremities. We assessed the impact of disease and treatment factors on patient outcome. Materials/Methods: Pathologically confirmed SS treated at our institution from 1978-2013 were retrospectively reviewed. Patients were re-staged according to AJCC 7th Edition. Kaplan-Meier and Cox proportional hazards models were used to assess overall survival (OS), disease specific survival, and local failure (LF) following definitive treatment of the primary tumor. Results: We identified 170 cases of SS presenting as follows: 58.2% male, 41.8% female; median age 36 (10-80); 52.8% biphasic and 37.7% monophasic histological subtypes; 64.7% in the lower extremity, 15.3% upper extremity/ shoulder, and 10% head and neck; 90.6% localized, 3% locally recurrent, and 6.5% metastatic. 165 patients (97%) underwent treatment of the primary tumor, of these 11 had oligometastatic disease. Most common stage at diagnosis was Stage IIB (70 patients, 41.2%) and Stage IIA (62 patients, 36.5%). Of the 159 patients presenting with non-metastatic disease, 91% received RT in addition to surgery. 15 (9%) were treated by surgery only with 7 amputations. RT was given pre-op in 68 (34 also had postop boost), and only postop in 46. The median follow-up time was 63 mo. (range 2-34 years). OS was 75.8% and 66.8%, local failure rate was 90.8% and 89.2%, end event-free survival (defined as survival without disease progression, local recurrence, or metastases) was
Volume 90 Number 1S Supplement 2014
3401 Long-Term Results of Postoperative 3-Dimensional High-Dose-Rate Brachytherapy for Soft-Tissue Sarcomas M. Kenjo, T. Kubo, S. Shimose, J. Fujimori, T. Nakashima, Y. Doi, T. Okabe, Y. Murakami, T. Kimura, Y. Kaneyasu, and Y. Nagata; Hiroshima University, Hiroshima, Japan Purpose/Objective(s): When malignant soft tissue sarcoma is located nearby major vessels or nerves, modified resection followed by brachytherapy is a reasonable choice for preserving leg or arm. The long term results and considerations about interstitial high dose rate brachytherapy (HDR-BT) for soft tissue sarcomas with 3-dimentional (3D) planning are shown on this paper. Materials/Methods: Twenty-six consecutive malignant soft tissue sarcoma patients received modified or marginal resection and treated with post-operative interstitial HDR-BT between 1995 and 2010 in single institution. Twentyone male and fifteen female patients were enrolled. Median age was 65 years (range 15-86). Primary tumor sites were located in femoral in 22 patients, fore arm in 5, lower led in 4 and others in 5. Eighteen patients were diagnosed as malignant histiocytoma, eight were as liposarcoma, and ten were as others. No patients had nodal or distant metastasis. Total resection was done with preserving nerve and vessels just attached to the tumor. Marginal evaluation of surgery were wide resection in 2 patients, marginal resection in 32 and intratumor resection were 2. Soft-tube applicators (median 10 catheters) were located enough to cover the tumor bed during surgery. Computed tomography based 3D planning was done for all cases with the reference of pre surgical magnetic resonance images. Clinical target volume (CTV) was defined to cover the tumor bed and surrounding areas bounded to critical structures Ir-192 high dose rate brachytherapy was initiated 7 to 12 days after surgery. Irradiation plan was made to cover the CTV by 100% isodose surface. Prescribed dose was 50 Gy per 10 fractions in one week. External irradiation or concurrent chemotherapy was not used. Follow up images were taken every 3 months up to 2 years, and twice a yare later. Results: All patients completed prescribed HDR-BT. Median follow up time was 40 months (range, 3-147). Overall survival rates at 3 and 5 years were 70% and 59%. Local control rate at 3 and 5 years were 90% and 90%. Four patients experienced local recurrence. All local recurrences were identified in patients who received marginal resection and occurred outside of CTV. All of them received additional resection. Thirteen patients (36%) developed distant metastases and 11 of them had the lesion in lung. Nine patients died of primary disease. Grade 3 acute and late complications were observed in 11% and 14%. Bone fracture or necrosis which needs local intervention occurred in 3 patients and severe nerve disorders were in 3. No grade 4 or 5 late adverse events were observed. Conclusions: Postoperative 3D HDR-BT following less invasive surgery is effective treatment for soft tissue sarcomas. As all local recurrences were occurred outside CTV, applicator placements and target volume settings are important for local control. Attention should be paid for bone and nerve late complications. Author Disclosure: M. Kenjo: None. T. Kubo: None. S. Shimose: None. J. Fujimori: None. T. Nakashima: None. Y. Doi: None. T. Okabe: None. Y. Murakami: None. T. Kimura: None. Y. Kaneyasu: None. Y. Nagata: None.
3402 Intraoperative Radiation Therapy (IORT) in the Management of Recurrent Extremity Soft-Tissue Sarcoma (STS) C.L. Tinkle, R.J. O’Donnell, V. Weinberg, and A.R. Gottschalk; University of California San Francisco, San Francisco, CA Purpose/Objective(s): To investigate the efficacy and morbidity of limbsparing surgery with IORT for patients with locally recurrent extremity STS. Materials/Methods: Twenty-six consecutively treated patients were identified in a single institution retrospective analysis of patients with locally recurrent extremity STS treated with IORT following salvage limbsparing resection from May 2000 to July 2011. Twenty patients (77%)
sustained a single recurrence, while 6 (23%) were multiply recurrent. Distant metastasis developed prior to re-resection and IORT in 5 patients (19%). Close (<2mm) or positive margins at IORT were found in 19 patients (73%). Fifteen patients (58%) received external beam radiation therapy (EBRT) prior to recurrence (median dose 6300 cGy), while 11 patients (42%) received EBRT following IORT (median dose 5220 cGy). The median IORT dose was 1500 cGy (range 1000-1800 cGy). Chemotherapy prior to recurrence was given to 6 patients (23%), while 14 patients (54%) received perioperative chemotherapy. The most common histologies were undifferentiated pleomorphic sarcoma and synovial sarcoma (27% and 19%, respectively), and most tumors were high grade (Coindre grade 2-3) (77%), deep in location (85%), and AJCC pathologic stage II or higher (77%). The Kaplan-Meier product limit method was used to estimate disease control and survival, subsets were compared using a log rank statistic, and toxicity was reported according to CTCAE v4.0 guidelines. Results: With a median duration of follow-up from surgery and IORT of 34.9 months (range 4 - 139 mos.), 10 patients developed a local recurrence all within 30 months of IORT with 4 subsequently undergoing amputation. The 5-year Kaplan-Meier estimates for local control (LC) were 58% (95% CI 36-75%); for amputation-free was 81% (95% CI 57-93%); for metastasis-free control (MFC) were 56% (95% CI 31-75%); for disease-free survival (DFS) were 35% (95% CI 17-54%); and for overall survival (OS) was 50% (95% CI 24-71%). Prior EBRT did not appear to influence disease control (LC, p Z 0.74; MFC, p Z 0.66) or survival (DFS, p Z 0.16; OS, p Z 0.58). Grade 3 or higher acute and late toxicities were reported for 6 (23%) and 8 (31%) patients, respectively. The frequency of both acute and late grade 3 or higher toxicities occurred equally between patients who received EBRT prior to or after IORT. Conclusions: IORT in combination with oncologic resection of recurrent extremity STS yields good rates of local control and limb-salvage with acceptable morbidity. Within the limitations of small subsets, these data suggest prior EBRT does not significantly influence disease control or toxicity. This technique offers a method of delivering focal therapy to achieve local control for the majority of patients who otherwise may require more radical surgical procedures. Author Disclosure: C.L. Tinkle: None. R.J. O’Donnell: None. V. Weinberg: None. A.R. Gottschalk: None.
3403 Outcomes of Patients With Synovial Sarcomas Treated With Multimodality Therapy: A Single-Institution Review A. Jacobson, C. Giraud, F. Hornicek, K. Raskin, J. Schwab, J. Mullen, D. Harmon, E. Choy, G. Nielsen, T. DeLaney, and Y. Chen; Massachusetts General Hospital, Boston, MA Purpose/Objective(s): Synovial sarcoma (SS) is a rare soft tissue sarcoma frequently found in young patients and most often found in the extremities. We assessed the impact of disease and treatment factors on patient outcome. Materials/Methods: Pathologically confirmed SS treated at our institution from 1978-2013 were retrospectively reviewed. Patients were re-staged according to AJCC 7th Edition. Kaplan-Meier and Cox proportional hazards models were used to assess overall survival (OS), disease specific survival, and local failure (LF) following definitive treatment of the primary tumor. Results: We identified 170 cases of SS presenting as follows: 58.2% male, 41.8% female; median age 36 (10-80); 52.8% biphasic and 37.7% monophasic histological subtypes; 64.7% in the lower extremity, 15.3% upper extremity/ shoulder, and 10% head and neck; 90.6% localized, 3% locally recurrent, and 6.5% metastatic. 165 patients (97%) underwent treatment of the primary tumor, of these 11 had oligometastatic disease. Most common stage at diagnosis was Stage IIB (70 patients, 41.2%) and Stage IIA (62 patients, 36.5%). Of the 159 patients presenting with non-metastatic disease, 91% received RT in addition to surgery. 15 (9%) were treated by surgery only with 7 amputations. RT was given pre-op in 68 (34 also had postop boost), and only postop in 46. The median follow-up time was 63 mo. (range 2-34 years). OS was 75.8% and 66.8%, local failure rate was 90.8% and 89.2%, end event-free survival (defined as survival without disease progression, local recurrence, or metastases) was