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MULTICENTRIC EVALUATION OF THE FRENCH SURGICAL SYSTEM IN SOFT TISSUE SARCOMA (STS).

MULTICENTRIC EVALUATION OF THE FRENCH SURGICAL SYSTEM IN SOFT TISSUE SARCOMA (STS). E. Stoeckle, S. Bonvalot, JY Blay, L. Guillou, J. Fraisse, JL. Verhaeghe, JM. Coindre, BN Bui From the French Sarcoma Group. Why another classification?. Surgery is no more the only treatment for STS:

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MULTICENTRIC EVALUATION OF THE FRENCH SURGICAL SYSTEM IN SOFT TISSUE SARCOMA (STS).

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  1. MULTICENTRIC EVALUATION OF THE FRENCH SURGICAL SYSTEM IN SOFT TISSUE SARCOMA (STS). E. Stoeckle, S. Bonvalot, JY Blay, L. Guillou, J. Fraisse, JL. Verhaeghe, JM. Coindre, BN Bui From the French Sarcoma Group

  2. Why another classification? • Surgery is no more the only treatment for STS: • Formerly, subjectivity of surgeon-based definitions of quality of surgery had no impact on treatment modalities: wait and see • Actually, multimodality treatment needs to know: - who will recur - to whom give additional treatment and how • Furthermore, homogenous treatment reporting is needed • However, quality of surgery remains subjective: • Surgeon – dependent or • Pathologist - dependent

  3. The UICC classification • The UICC recommends the R - classification in STS: • R0: resection in sano • R1: microscopic residual disease • R2: macroscopic residual disease • But it does not give instructions how to determine R! • Usually, Enneking’s classification is transposed into the R - classification

  4. Individual appreciation of quality of surgery is not appropriate! • Surgeons overestimate excision • Almost large • German registry (Junginger 2001): • Extremity sarcoma 82% R0 • Retroperitoneal sarcoma 64% R0 • Local recurrences remain elevated • Pathologists underestimate excision • Retraction of tissue • Negative specimen after re-excision in 50%

  5. The FSG system (I) • 1995: OP reports review in 8 participating centers: missing information • 1995 - 1996: multicentric feasibility study of items for OP reporting: • Only describe • Important issues: tumor seen? tumor rupture? • 1998: Recommendations for pathology reporting (Ghnassia). • Determination of resection type (UICC R system) by surgeon and pathologist.

  6. The FSG system (II) 4. 1996 - 1999: prospective validation in a single center (Bordeaux): 109 consecutive patients with trunk wall + extremity, conservative surgery, 68% R0 , 56 months FU: 3% R0 Local recurrence: 8% (P < 0,01) 19% R1 Negative predictive value of R0: 97% 5. Actual study: multicentric evaluation

  7. Methods • Methods: • FSG data base - multivariate prognostic factor analysis • Patients’ selection: • resection type (R) informed: 423 pts. 325 pts. with trunk wall or extremity STS 302 pts. N0 M0 • Inclusion and follow-up: • 1995 - 2002, FU: 21 months (1 – 104 months) • Accrual by center: Bordeaux 88 Villejuif 52 Lyon 52 Lausanne 24 Nancy 22 0ther centers 64

  8. Patients’ characteristics • M/F: 150/152 pts. • Localizations: • Shoulder girdle 12 4% • Upper extremity 36 12% • Trunk wall 31 10% • Pelvic girdle 24 8% • Lower extremity 199 66%

  9. Tumor extension • Superficial tumors: 56 pts. (18,5%) • Median size : 9 cm (1 – 26 cm) • Multifocality: 31 pts. (10,3%) • Vasc./nerve involvement: 47 pts. (15,6%) • AJC/UICC stage 1979: • I: 14% II: 28% III: 33% IV: 15% NP: 10% • AJC/UICC stage 2002: • IA: 15% IB: 35% IIA: 13% IIB: 2% III: 29% NP: 5%

  10. Pathology • Histological subtypes: • Liposarcoma 70 (23%) • Leiomyosarcoma 46 (15%) • MFH 44 (15%) • Synovialosarcoma 25 (8%) • MPNST + RhabdoS. 15 (5%) • Unclassified S. 39 (13%) • Others + NP 63 (21%) • Grade I: 17% II: 34% III: 45% NP: 5%

  11. Treatments • 302 operated patients: • First-line surgery: 83% • Resection types : R0 220 (73%) R1 68 (22%) R2 14 (5%) • Radiotherapy: 62% • Chemotherapy: 40%

  12. Treatment results R0 213 • CR: 272 (90%) R1 54 R2 5 • Survivors: 240 (80%) actuarial 65% • LR: crude 34 (13%) actuarial 21%

  13. Overall survival 1,0 ,9 ,8 ,7 ,6 ,5 ,4 ,3 ,2 Survie cumulée ,1 0,0 0 12 24 36 48 60 TSURV

  14. Resection-type according to center (NS) Center N R0 Bordeaux 88 73% Villejuif 52 73% Lyon 52 64% Lausanne 24 83% Nancy 22 64% Others 64 80%

  15. Resection type according to localization (NS) Localization N R0 Shoulder girdle 12 75% Upper extremity 36 56% Trunk wall 31 71% Pelvic girdle 24 67% Lower extremity 199 77%

  16. Local recurrence-free interval 1,0 ,9 ,8 ,7 ,6 ,5 ,4 ,3 ,2 Survie cumulée ,1 0,0 0 6 12 18 24 30 36 42 48 54 60 TRLOC

  17. Local recurrence according to R R0 P = 0,004 R1 + R2

  18. Local recurrence according to grade Grade 1 + 2 P = 0,019 Grade 3

  19. Local recurrence according to T3 (1979 UICC classification) T1 + T2 P = 0,049 T3

  20. Local recurrence according to stage AJC/UICC 1979 P = 0,0045

  21. Local recurrence according to stage AJC/UICC 2002 P = 0,042

  22. Prognostic factors/LR Variable RL N p R R0 20 213 0,004 R1+R2 14 59 Grade 1 3 460,02 2 7 92 3 23 122 T T1 +T2 23 218 0,05 T3 8 37 Histotype, Size (+/- 5 cm), Localization, Depth, Center, Radiotherapy: NS

  23. Independent prognostic factors for local recurrence Variables p RR CI No R0 0,003 3,06 1,47 - 6,38 Grade 3 0,004 3,35 1,48 - 7,55

  24. Conclusion • Resection type (R) as defined by FSG predicts independently local recurrence • FSG criteria are reproducible and can be used in a multicentric setting • Treatment results in the multicenter study are lower than in the single center: progress still needed.

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