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Surgery for Soft-Tissue Sarcoma in Patients Over Eighty Years Old: Presented at ESSO

By Chris Berrie

VENICE, ITALY -- December 5, 2006 -- Despite pre-existing comorbidities, surgery can be undertaken with acceptable morbidity and mortality in patients with soft-tissue sarcoma (STS) who are over 80 years old, according to research presented here at the 13^th Congress of the European Society of Surgical Oncology (ESSO).

Furthermore, to help combat high local recurrence rates, the indications for radiotherapy should be identical in these patients as in younger age groups.

This analysis from a prospective patient database was presented by principal investigator Andrew J. Hayes, MD, PhD, FRCS, consultant surgeon, sarcoma and melanoma unit, department of surgery, Royal Marsden Hospital, London, United Kingdom.

"Soft tissue sarcomas span quite a substantial age range, from the teenager right the way through to the elderly, but the median age of presentation is in the 5^th decade," Dr. Hayes said in a presentation on November 30^th. However, a significant proportion of patients with the condition present in their 8^th decade.

With the increasing age of the population and improving anaesthetic techniques, it can be expected that surgery for STS will increase in patients over 80. However, there are conflicting outcome data for elderly patients undergoing major cancer surgery, and little data in such patients undergoing surgery for STS.

Dr. Hayes and colleagues conducted their analysis of morbidity and outcome from data extracted from the prospective database covering 3,400 patients over 80 years of age who underwent surgery for STS from 1990 to 2003 at the Royal Marsden Hospital.

The total analysis was subdivided for primary and secondary surgery, and included specialist pathological review and surgical risk scoring, according to the American Society of Anesthesiologists (ASA) and the Portsmouth modified Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity (pPOSSUM) scales. The equivalent survivals for healthy controls were constructed from actuarial life tables.

Of the total 128 patients identified (median age, 83 years), 63 had undergone primary treatment; 13 had undergone non-surgical management, and 52 were referred after surgery elsewhere.

For the 50 patients included in the analysis, the STS characteristics included size (<10 cm, 4%; 5-10 cm, 40%; >10 cm, 56%) and grade (1, 14%; 2, 30%; 3, 56%), with mainly stages IIA (34%) and III (42%) at presentation.

A range of histological subtypes were seen, comprising: leiomyosarcoma (20%), myxofibrosarcoma (malignant fibrous histiocytoma type; 24%), liposarcoma (14%), angiosarcoma (8%), fibrosarcoma (8%), rhabdomyosarcoma (6%), and chondrosarcoma, clear-cell sarcoma, gastrointestinal stromal tumour and synovial sarcoma in single patients (2% each).Undifferentiated pleiomorphic/ spindle cell sarcoma with no obvious cellular lineage was seen in 12% of patients.

Surgical treatments related to the individual sarcomas were for functional compartmental resection (limb or limb girdle; 82%); retro/ intraperitoneal sarcomas (10%; half requiring visceral resection); and chest/ abdominal wall (8%). The primary amputation rate was 4% (Stewart-Treves syndrome), and 10% of patients underwent reconstruction after resection.

As expected, the comorbidities were high, comprising mainly (>10%): hypertension (28%), congestive cardiac failure/ ischaemic heart disease/ myocardial infarction (26%), renal impairment (20%), anaemia (18%), asthma/ chronic obstructive pulmonary disorder (16%), and atrial fibrillation (14%). Of note, 50% of patients had >1 pre-existing morbidity, although 18% showed none.

Calculations based on these morbidity data provided a median ASA score of 2, and an estimated pPOSSUM morbidity of 37.3%, with 3.3% for mortality. These estimates matched the observed morbidity of 34% and mortality of 4%. Median length of stay in hospital was relatively long, as expected, at 13.5 days.

With adjuvant radiotherapy used in 30% of the limb or limb girdle tumours, local recurrence reached 22%, as compared to the equivalent rate of 9% for all the patients in the database. Clear resection margins were obtained in 80% of cases.

Relative survival of this patient group was compared with that of a hypothetical age-matched population without the diagnosis of malignancy, using all patients undergoing resection surgery for primary disease with >12 months follow-up.

Based on the 95% confidence limits at 2 and 5 years for both extremity sarcomas and all sarcomas, the constructed actuarial survival curves for the age-matched population did show a significant difference at 2 years. However, this was not the case at 5 years, with no significant differences in survival between patient with STS surgery and the age-matched, no-malignancy, controls.

Thus, despite the significant pre-existing comorbidities and the advanced age of this patient group with STS, acceptable morbidity and mortality can be achieved with regard to the age-matched, no-malignancy population.

"Basically, what this retrospective analysis is showing us, is that if you look at our high local recurrence rates, really, your indications for radiotherapy should be exactly the same as you have in the younger cohorts," Dr. Hayes concluded.


[Presentation title: Surgery for Soft-Tissue Sarcoma in Patients Over Eighty Years Old. Abstract 040]

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