Neoadjuvant chemotherapy in soft tissue sarcomas: latest evidence and clinical implications

Abstract

Soft tissue sarcomas are a rare and multifaceted group of solid tumours. Neoadjuvant chemotherapy is increasingly used to limit loss of function after wide surgical excision with the ultimate aim of improving patient survival. Recently, advances in the identification of effective treatment strategies and improvements in patient risk stratification have been reached. A randomized trial demonstrated that neoadjuvant epirubicin and ifosfamide improves survival of patients affected by five high-risk soft tissue sarcoma histologies of trunk and extremities, including undifferentiated pleomorphic sarcoma, myxoid liposarcoma, synovial sarcoma, malignant peripheral nerve sheath tumours, and leiomyosarcoma. Selection of patients for these treatments is expected to be improved by the eighth edition of the American Joint Committee on Cancer (AJCC) TNM staging system, as it tailors T-stage categories on primary tumour site and considers a prognostic nomogram for retroperitoneal sarcoma, which also includes soft tissue sarcoma histology and other patient and tumour features not directly included in the TNM staging. Within this framework, this article will present neoadjuvant treatment strategies for high-risk soft tissue sarcoma, emphasizing the most recent advances and discussing the need for further research to improve the effectiveness of neoadjuvant treatments.

Completion surgery of residual disease after primary inadequate surgery of retroperitoneal sarcomas can salvage a selected subgroup of patients—A propensity score analysis

“…One could claim that a short chemotherapy course was able to exclude patients who progressed while on treatment, and hence a delay of completion resection may be prudent even in cases of persistent well‐differentiated liposarcoma. On the other hand, the efficacy of chemotherapy is still debated in the perioperative setting and a delay of surgery may risk missing the window of opportunity for patients . Hence an alternative approach will be to proceed with surgery as soon as patient condition permits.…”

“…On the other hand, the efficacy of chemotherapy is still debated in the perioperative setting and a delay of surgery may risk missing the window of opportunity for patients. 3,13,14 Hence an alternative approach will be to proceed with surgery as soon as patient condition permits. Further studies are needed to clarify this point.…”

Soft tissue tumors of the pelvis: Technical and histological considerations

“…11 Different soft tissue sarcoma subtypes may require (slightly) different treatment approaches, such as the need for radical surgery and/or (neo) adjuvant chemotherapy and radiotherapy. 12 The indications for radiotherapy for pelvic sarcomas do not essentially vary from the indications for RPS, as the logic behind it is the same and the lack of good evidence as well. For pelvic tumors with overt involvement of pelvic wall structures, radiotherapy might be considered given the likelihood of (planned) positive margins.…”

“…Although there is a lack of data regarding the incidence of the different sarcoma subtypes located specifically within the pelvis, there are subtypes that are seen more frequently within the pelvis . Different soft tissue sarcoma subtypes may require (slightly) different treatment approaches, such as the need for radical surgery and/or (neo) adjuvant chemotherapy and radiotherapy . The indications for radiotherapy for pelvic sarcomas do not essentially vary from the indications for RPS, as the logic behind it is the same and the lack of good evidence as well.…”

“…For pelvic tumors with overt involvement of pelvic wall structures, radiotherapy might be considered given the likelihood of (planned) positive margins. When it comes to the indications for (neo) adjuvant chemotherapy, this varies across histological subtypes, tumor size, and grade, and also across different sarcoma centers . Nevertheless, the variations in treatment strategies for different histological subtypes as described below highlight the importance of obtaining a tissue diagnosis before proceeding with surgery, despite the fact that obtaining a tissue diagnosis for tumors in the pelvis can at times be challenging.…”