Clinical Features of High-Grade Extremity and Trunk Sarcomas in Patients Aged 80 Years and Older: Why Are Outcomes Inferior?

Abstract

Background: The population of many countries is aging and a significant number of elderly patients with soft-tissue sarcoma are being seen at cancer centers. The unique therapeutic and prognostic implications of treating soft-tissue sarcoma in geriatric patients warrant further consideration in order to optimize outcomes. Patients and Methods: This is a single-institution retrospective study of consecutive non-metastatic primary extremity and trunk high-grade sarcomas surgically treated between 1996 and 2012, with at least 2 years of follow-up for survivors. Patient characteristics and oncological outcomes were compared between age groups (≥80 vs. <80 years), using Chi-square or Fisher-exact test and Log-Rank or Wilcoxon test, respectively. Deaths from other causes were censored for disease-specific survival estimation. A p< 0.05 was regarded as statistically significant. Results: A total of 333 cases were eligible for this study. Thirty-six patients (11%) were aged ≥80 years. Unplanned surgery incidence and surgical margin status were comparable between the age groups. Five-year local-recurrence-free, metastasis-free and disease-specific survivals were 72% (≥80 years) vs. 90% (<80 years) ( p = 0.004), 59 vs. 70% ( p = 0.07) and 55 vs. 80% ( p < 0.001), respectively. A significantly earlier first metastasis after surgery (8.3 months vs. 20.5 months, mean) and poorer survival after first metastasis ( p = 0.03) were observed. Cox analysis revealed “age ≥80 years” as an independent risk factor for local failure and disease-specific mortality, with hazard ratios of 2.41 (95% CI: 1.09–5.32) and 2.52 (1.33–4.13), respectively. A competing risks analysis also showed that “age ≥80 years” was significantly associated with the disease-specific mortality. Conclusions: Oncological outcomes were significantly worse in high-grade sarcoma patients aged ≥80 years. The findings of more frequent local failure regardless of a consistent primary treatment strategy, an earlier time to first metastasis after surgery, and poorer prognosis after first metastasis suggest that more aggressive tumor biology, in addition to multiple co-morbidity, may explain the inferiority.

Age-related differences of oncological outcomes in primary extremity soft tissue sarcoma: a multistate model including 6260 patients

“…This study found an increased risk of LR in the elderly population compared with YA, in accordance with previous reports [8,22], Also, an increased but less evident risk of DM was found in the middle-aged and elderly population compared with YA. After adjustment for tumour and treatment characteristics, the difference in cause-specific hazard of LR among the age groups decreased.…”

“…Another explanation for the higher 'whoops' rates in the YA compared with the elderly is that YA presented with smaller tumours, which might mistakenly be considered benign more frequently. This study showed a higher overall mortality in the elderly population compared with their younger counterparts, which is in accordance with previous studies [8,16]. In addition, elderly have a more than six and five times higher risk of dying in the ANED and LR state, respectively.…”

“…Because OS was taken as an end point rather than disease-specific survival, this was to be expected because elderly obviously have a higher risk of dying of natural causes. However, other studies have also shown an increased sarcoma-specific mortality in the older population [8,9,16,17].…”

“…Several studies have shown relative lack of improvement in clinical outcomes in the AYA population compared with their older and younger counterparts (4,7) and poorer disease-specific survival of the elderly patients compared to the younger counterparts [8]. With the increasing referrals for treatment of elderly patients with STS, as well as the lack of improvement in the AYA population, further evaluation of factors influencing outcome for the different age groups might help in the decision-making regarding treatment strategies for the different patient groups [4,7,9,10].…”

A phase II study of pazopanib as front-line therapy in patients with non-resectable or metastatic soft-tissue sarcomas who are not candidates for chemotherapy

“…Doxorubicin remains the most active single agent with a response rate of 18e22% [4,5,7,9,10]. The management of patients with advanced STS who are unsuitable for front-line cytotoxic therapy owing to age, comorbidities or poor performance status poses a treatment dilemma [11,12]. Until recently, there have been limited alternatives to best supportive care, and a study of patients with metastatic STS found that more than a third of patients greater than 75 years old are treated with best supportive care alone [11].…”