Mark Agulnik, MD

Introduction

The development of new cancer therapies relies on the successful development and completion of clinical trials. While clinical trials have led to significant improvements in cancer treatment, the success is dependent upon patient enrollment and participation. Unfortunately, fewer than 5% of adult patients enroll in trials.^1-3 This represents a significant barrier to the development and approval of new cancer treatments. Reasons for low accrual into trials are multifactorial, but include structural barriers (eg, clinic access), clinical barriers (eg, eligibility criteria), and physician and patient attitudes towards trial enrollment.^4,5 One study at the University of California Davis Cancer Center reported 49% of patients declined participation despite meeting eligibility criteria,^3,6 suggesting that psychosocial barriers such as knowledge of trials and attitudes towards clinical research are a major impediment to accrual.^7-9

Bone and soft tissue sarcoma represent a heterogeneous group of tumors of mesenchymal origin that are an important cause of morbidity and mortality. Local disease is often treated with a multidisciplinary approach including surgery, radiation, and systemic therapy. Metastatic disease is predominantly treated palliatively with systemic therapy.¹⁰ Given its rarity and heterogeneity, trial accrual is of particular importance in sarcoma and often requires multiple sites to enroll adequate numbers of patients. While sarcoma represents <1% of adult malignancies overall, it constitutes ~15% of malignancies in the adolescent and young adult (AYA) population (15- 39 years old).^11,12 Sarcoma represents a patient population in which low trial accrual has been correlated with lack of progress in cancer-related outcomes in both the adult and AYA populations.¹³ The reasons for low accrual rates among patients with sarcoma are poorly understood.

Sarcomas represent a molecularly and biologically heterogeneous group of malignancies with over 100 different subtypes.¹² As a result, there has been significant interest in performing molecular profiling, or genetic sequencing, to identify “targetable” mutations. Targetable mutations refer to a specific genetic change identified within the tumor molecular profile for which there is a specific drug that may demonstrate activity against a particular tumor. Given the widespread utilization of this technology in sarcoma, identifying and understanding patient perceptions with regard to molecular profiling is critically important in this disease.¹⁴

In this study, we use a cross-sectional design to describe patient perceptions of trial enrollment among patients with bone and soft tissue sarcoma through validated measures, including attitudes towards clinical trials, knowledge of clinical trials, and perceived ability (ie, self-efficacy) to carry out actions involved in making an informed decision about clinical trial participation, receptivity to learning more about clinical trials, and willingness to participate in clinical trials.6 In addition, we describe this patient cohort’s perceptions of molecular profiling, as current and future trials are increasingly driven by molecular or other biomarkers.

Methods

This was a cross-sectional electronic survey study of patients with bone and soft tissue sarcoma treated at Northwestern Medicine (NM) over a 5-year period. NM Enterprise Data Warehouse (NMEDW) is a single, comprehensive, and integrated repository of all clinical and research data sources within NM. The study was approved by the Northwestern University Institutional Review Board.

Survey

The investigators designed a self-administered, online survey, which was built using Research Electronic Data Capture (REDCap). The survey consisted of three sections that were answered using skip logic—a custom path through the survey that varied based on patients’ answers: (1) Patient demographic information and trial perceptions (answered by all patients); (2) Thoughts about molecular profiling (answered by patients who answered “yes” to the question, “Have you heard about molecular profiling of tumors?”); and (3) Considerations to undergo molecular profiling (answered by patients who answered “yes” to the question, “Have you undergone profiling of your cancer?”).

 

Clinical trial perceptions included questions assessing (1) patient knowledge about trials; (2) patient attitudes toward trials; (3) perceived ability (ie, self-efficacy) to carry out actions involved in making an informed decision about trial participation; (4) receptivity to learning more about trials; and (5) willingness to participate in trials. These outcome measures had been previously developed and pilot tested for reliability and validity (TABLE 1).⁶

tsj00304008_t1.jpg

Thoughts about molecular profiling of tumors were assessed using nine items (TABLE 1). Of these, items assessing potential benefit or harm of molecular profiling were assessed using a 7-step Likert scale. Items assessing maximal benefit or harm of therapy, importance of quality vs length of life, and concern about the cost of molecular testing were assessed using a 5-step Likert scale. The study team developed and piloted these questions because there is no validated survey assessing these domains.

Considerations to undergo molecular profiling were assessed using 17 items. Items were in response to the question, “To what extent did you consider the following issues or concerns at the time you decided to get molecular testing of your cancer?” Responses were assessed using a 5-point Likert scale.

Data Collection

Patients 18 years and older evaluated at NM between November 20, 2012, and November 20, 2017, with a diagnosis of sarcoma were identified by query of the NMEDW by ICD-10 codes (C40, C41.9, C44.99, C45-49, C55, C71.9, D48, D49.9, and M12.20) or equivalent ICD-9 codes. Patients were subsequently excluded if they did not have a diagnosis of bone or soft tissue sarcoma, no e-mail address listed, had died, or had not been evaluated at an NM clinic in the previous 5 years. Patients with a diagnosis of gastrointestinal stromal tumor and Kaposi’s sarcoma were also excluded.

A personalized contact e-mail was sent to patients containing an explanation of the survey and an internet link to the electronic survey through REDCap from January 2018 to March 2018. If patients did not respond to the survey, two follow-up reminder e-mails were sent 2 and 4 days following the initial survey. The link was protected so that each patient could complete the survey only once. Responses were collected through the REDCap platform. Patients read and signed an electronic consent form prior to completing the survey.

Upon completion of the survey, patients were offered a $50 VISA gift card as compensation, with an option to donate their compensation to the Robert H. Lurie Comprehensive Cancer Center Sarcoma Research Fund.

Over the described survey period, open clinical trials for patients with bone and soft tissue sarcoma available at NM were evaluated. The number of patients screened and accrued to each trial were recorded.

 

Statistical analysis

Responses were separated from the personal data for complete anonymization. Descriptive statistical analysis was performed for demographics and disease variables and were summarized using frequencies and percentages. Median and range were used for age. Correlations between continuous variables were analyzed using Spearman correlations. Scores were compared between subgroups using the Mann-Whitney test. Descriptive statistics for knowledge, attitude, and ability scores include means and 95% confidence intervals. Correlations were interpreted as small (r=0.10), medium (r=0.30), or large (r=0.50).15 Statistical significance was indicated when P<0.05.

Results

Patients

Seven hundred fifty patients were eligible to participate in the survey and received the initial and two follow-up e-mails. Twenty e-mailed surveys bounced back. Three hundred nine patients opened the initial e-mail and 283 patients (37.7% of total and 91.6% of opened) completed at least a portion of the survey, with 182 patients completing the entire survey (FIGURE 1). Data for analysis were used from patients who completed at least a portion of the survey.

tsj00304008_f1.jpg

tsj00304008_t2a.jpg

tsj00304008_t2b.jpg

Baseline characteristics of patients who responded can be seen in TABLE 2. Patients had a median age of 56, the majority were female (59.4%), white (88.2%), and most had college or university graduate degrees or higher educational level (69.0%). Patients had various different histological subtypes, with the most common being liposarcoma (16.5%) and leiomyosarcoma (16.0%). Slightly more than a quarter (26.8%) of patients had metastatic disease, and 84.2% had never been enrolled in a clinical trial. Previous treatments included surgery (91.1%), radiation (53.2%), and chemotherapy (51.6%). Prior to completing the survey, 85.4% reported being receptive to a cancer clinical trial, while 60.7% of patients reported willingness to participate in a clinical trial.

 

Knowledge, attitudes, and perceived ability

A statistically significant correlation was observed between greater knowledge of trials and more positive attitudes towards trials (P<0.001; r=0.5, FIGURE 2A). In relating patient attitudes with perceived ability, again a significant correlation was seen (P<0.001; r=0.4, FIGURE 2B). In contrast, knowledge had a weak correlation with perceived ability (P=0.024; r=0.2, FIGURE 2C). There was no difference regarding patient knowledge, attitudes, or perceived ability by age, gender, race, or income.

tsj00304008_f2.jpg

Knowledge, attitudes, perceived ability, and clinical trial enrollment

Thirty patients reported clinical trial experience (either previously or currently enrolled in trials) and 160 patients were never enrolled. Of the 30 patients with trial experience, 7 reported being currently enrolled, while 23 reported previous enrollment. Of these patients, 16 had metastatic disease, while 12 had non-metastatic disease, and 2 were unsure whether or not they had metastatic disease.

Patients with previous clinical trial exposure (currently or previously enrolled in clinical trials) demonstrated significantly greater trial knowledge, with a mean knowledge score of 9.3 (CI 8.5-10.0) compared with 7.7 (CI 7.3-8.1) among patients without trial exposure (P=0.002; FIGURE 3A). Similarly, patients with trial experience also had statistically significant more positive attitudes towards trials as compared with patients with no trial experience, with a mean attitude score of 3.8 (CI 3.6-4.0) and 3.5 (CI 3.4-3.6), respectively (P=0.001; FIGURE 3B). While numerically patients with trial experience have greater perceived ability compared with patients with no trial experience, with a mean score of 4.4 (CI 4.2-4.6) and 4.2 (CI 4.1-4.3), respectively, this difference did not reach statistical significance (FIGURE 3C).

tsj00304008_f3.jpg

Knowledge, attitudes, perceived ability, and disease stage

An analysis was performed comparing patients with metastatic vs non-metastatic disease. It was observed that patients with metastatic disease had similar knowledge of trials compared with non-metastatic patients, with a mean knowledge score of 8.4 (CI 7.7- 9.1) and 7.9 (CI 7.5-8.4), respectively, (P=0.3; FIGURE 4A). In contrast, patients with metastatic disease had more positive attitudes compared with non-metastatic patients, with a mean score of 3.7 (CI 3.5-3.8) and 3.5 (CI 3.4-3.6), respectively, which was statistically significant (P=0.03; FIGURE 4B). There was no difference in perceived ability in metastatic vs non-metastatic patients (FIGURE 4C).

tsj00304008_f4.jpg

Thoughts about molecular profiling

Of the total number of patients, 46 patients had heard of molecular profiling and were presented with questions regarding their thoughts (TABLE 3). Approximately two-thirds (65.2%) thought there would be a 50% or greater likelihood of finding a targetable result in their tumor molecular profile. A majority (71.7%) of patients thought that a new experimental therapy chosen based on a patient’s tumor molecular profile would have at least a 50% chance of controlling the cancer. Somewhat less than a third (30.4%) of patients thought that total cure is the maximal benefit a patient could experience as a result of a treatment on a clinical trial using a drug chosen based on molecular tests. About half (52.2%) of patients agreed with the statement, “I am concerned about the cost of the test to molecularly profile my cancer.”

tsj00304008_t3.jpg

Considerations to undergo molecular profiling

Eighteen patients had undergone molecular profiling of their tumor. These patients were posed the question, “To what extent did you consider the following issues or concerns at the time you decided to get molecular testing of your cancer?” (TABLE 4). A majority (83.3%) of patients stated that wanting to live as long as possible was important, and 72.2% of patients stated that quality of life was important. A majority (83.3%) of patients stated that hope for a cure was an extremely or quite a bit important consideration. Helping future cancer patients was extremely or quite a bit important for 77.8% of patients, while wanting to be a part of research was not at all or of little importance in 50.0% of patients.

tsj00304008_t4.jpg

Clinical trials at NM

Twenty-four clinical trials were available at NM between the years 2012 and 2017 for patients with bone and soft tissue sarcoma. Of these trials, 3 of 24 were for non-metastatic patients, while the remaining 21 were open only to metastatic patients. The median number of patients screened per trial was 11 (range 0-66) and the median number of patients accrued per trial was 9 (range 0-58). Of the 24 trials, 17 were not subtype specific (13 included soft tissue sarcoma alone while 4 included both bone and soft tissue sarcoma). The remaining 7 trials were sarcoma subtype specific (eg, angiosarcoma, liposarcoma, etc). Trials available at NM during this period are included in TABLE 5. There were 318 patients screened and 262 patients accrued to sarcoma trials over this time period, with a screen failure rate of 17.6% overall.

tsj00304008_t5.jpg

Discussion

Our study sought to describe perceptions of clinical trial enrollment among patients with bone and soft tissue sarcoma in order to elucidate and overcome barriers to enrollment, which to the best of our knowledge had not been previously described. Using previously validated patient- reported outcomes in the literature,⁶ our data reveal a correlation between knowledge of trials and more positive attitudes towards trials. This underscores the importance of awareness and educational strategies in this cancer population as a whole. Interventions should focus on patient perceptions that contribute to lack of participation, such as fear of side effects, loss of control (eg, idea of placebo or randomization), logistical challenges (eg, additional time or convenient location), and cost.^3,5,7,16,17 For example, patients concerned about randomization should be educated on equipoise and other ethical considerations in trial design.⁵ Previous research has suggested that a multimedia psychoeducational intervention was effective in improving attitudes toward trials.⁶ Educating patients on the essential role of trials in oncology care, as demonstrated by the vast number of new drug approvals in recent years, is an essential strategy to improve attitudes, and subsequently leads to higher patient accrual rates. 

 

In our study, both knowledge and at titudes were increased in patients with previous trial exposure. This suggests that either patients with greater knowledge and more positive attitudes are more likely to enroll in trials, or that patients with direct trial exposure are more knowledgeable and develop more positive attitudes. Our patient population was overall receptive to learning more about clinical trials (85.4%) and willing to participate (65.8%). At the same time, our study demonstrated low to medium correlations between attitudes and perceived ability to take steps towards making an informed decision to enroll in a trial (r=0.4), which may partially be explained by the absence of a tangible trial opportunity. While we did not assess specifically whether patients in our study were offered a trial, there was a substantial trial menu at NM with limited screen failures and decent trial accrual over the time frame of our study. This underscores the importance not only of patient-focused strategies to increase educational and attitudinal resources, but also a need to focus on research-site optimization that includes opening of multiple trials in various settings, systematic pre-screening of patients, and eligibility criteria that are inclusive and rational.⁵

The patient population with metastatic disease demonstrated more positive attitudes towards enrolling in clinical trials. This cohort accrued well to clinical trials, with 21 of 24 trials enrolling specifically patients with metastatic disease. Of the patients who responded to our survey, patients with previous trial exposure were enriched for patients with metastatic disease (53.3% metastatic among previous trial exposure versus 26.8% metastatic overall). These observations are likely reflective of the need for novel therapies in this disease setting. At the same time, approximately 25% of patients with localized soft tissue sarcoma will develop distant metastatic disease after successful treatment of their primary tumor, which increases to 40% to 50% in larger and higher-grade tumors.¹⁸ Three of 24 trials were open for patients with non-metastatic disease, of which one managed to accrue patients. Patients with non-metastatic disease had more negative attitudes towards trial enrollment. These disproportionate findings suggest a need for interventions to increase patient awareness and attitudes towards trial enrollment among this patient population and the importance of research-site optimization for trial opportunities across disease states.

Molecular profiling of tumors and biomarker identification has become a critical component of further characterizing cancer subtypes. In our study, a majority (65.2%) thought there would be a 50% or greater likelihood of finding a targetable result in their molecular profile. Molecular data on 5,749 bone and soft tissue sarcomas suggested that 9.5% of tumors demonstrate a “targetable result,” defined as a new molecular finding for which there is an FDA-approved drug for malignancies other than sarcoma (eg, BRAF V600E, Her2, etc.),¹⁹ suggesting an overestimation in our patient cohort of the likelihood of benefit of molecular profiling. These results highlight that the growing use of molecular profiling has increased the need for educational and supportive resources to help patients understand the utility of molecular profiling and aid in shared decision-making surrounding the results.

At the same time, the importance of identifying a targetable mutation in patients with sarcoma cannot be understated. As a recent example of this paradigm, tumors that harbor fusions with the neurotrophic receptor tyrosine kinase 1, 2, or 3 (NTRK1, 2, and 3) have a high response rate (~75%) to drugs that target these fusions, such as larotrectinib and entrectinib.¹³ Molecular profiling and identification of predictive biomarkers in small patient subsets has led to great challenges in trial design and research-site optimization. Novel designs that incorporate molecular profiling,²⁰ such as the Lung- MAP trial²¹ and NCI’s Molecular Analysis for Therapy Choice (MATCH) trial,²² are emerging to identify new therapies for small patient subsets. As a rare and increasingly heterogeneous cancer, sarcoma represents a paradigm to provide insight into optimizing patient perceptions and research enterprises to maximize clinical trial enrollment. 

Some limitations of our study include a homogeneous and selected patient population that was predominantly Caucasian and highly educated. Therefore, these findings should not be extrapolated to other populations with barriers to trial accrual, such as lower socioeconomic or minority populations. The low response rate and failure of some to complete the survey may have introduced some bias. Additionally, our data include self-reported outcomes, which could have affected our results. Finally, the limited number of patients who had undergone or heard of molecular profiling limited our ability to draw definitive conclusions, and should be assessed in larger patient cohorts.

While our paper addresses a unique population—the sarcoma patient—similar themes and issues pertain to all oncology patients. A recent review was published in the American Society of Clinical Oncology Educational Book²³ looking at methods to overcome barriers to clinical trial enrollment. Their paper clearly illustrates mechanisms to assist with overcoming financial burdens associated with cancer clinical trials, overcoming barriers as they relate to patient and clinician difficulty in coping with the uncertainty inherent in clinical trial participation, and highlight the role of a patient navigator in clinical trial participation.

Conclusions

Interventions aimed at increasing awareness, knowledge, and attitudes towards clinical trials among sarcoma patients may lead to increased trial enrollment and greater progress in cancer treatment in this population. In addition to patient- focused interventions, thoughtful and strategic clinical trial designs that allow for the development of biomarker- driven therapeutics, while at the same time optimizing patient accrual rates, should be developed. Evaluation of barriers to clinical trial enrollment and molecular profiling of tumors among bone and soft tissue sarcoma patients at an academic center can serve as a paradigm to overcome barriers to enrollment in the era of an increasingly heterogeneous cancer population. TSJ

Introduction

The development of new cancer therapies relies on the successful development and completion of clinical trials. While clinical trials have led to significant improvements in cancer treatment, the success is dependent upon patient enrollment and participation. Unfortunately, fewer than 5% of adult patients enroll in trials.^1-3 This represents a significant barrier to the development and approval of new cancer treatments. Reasons for low accrual into trials are multifactorial, but include structural barriers (eg, clinic access), clinical barriers (eg, eligibility criteria), and physician and patient attitudes towards trial enrollment.^4,5 One study at the University of California Davis Cancer Center reported 49% of patients declined participation despite meeting eligibility criteria,^3,6 suggesting that psychosocial barriers such as knowledge of trials and attitudes towards clinical research are a major impediment to accrual.^7-9

Bone and soft tissue sarcoma represent a heterogeneous group of tumors of mesenchymal origin that are an important cause of morbidity and mortality. Local disease is often treated with a multidisciplinary approach including surgery, radiation, and systemic therapy. Metastatic disease is predominantly treated palliatively with systemic therapy.¹⁰ Given its rarity and heterogeneity, trial accrual is of particular importance in sarcoma and often requires multiple sites to enroll adequate numbers of patients. While sarcoma represents <1% of adult malignancies overall, it constitutes ~15% of malignancies in the adolescent and young adult (AYA) population (15- 39 years old).^11,12 Sarcoma represents a patient population in which low trial accrual has been correlated with lack of progress in cancer-related outcomes in both the adult and AYA populations.¹³ The reasons for low accrual rates among patients with sarcoma are poorly understood.

Sarcomas represent a molecularly and biologically heterogeneous group of malignancies with over 100 different subtypes.¹² As a result, there has been significant interest in performing molecular profiling, or genetic sequencing, to identify “targetable” mutations. Targetable mutations refer to a specific genetic change identified within the tumor molecular profile for which there is a specific drug that may demonstrate activity against a particular tumor. Given the widespread utilization of this technology in sarcoma, identifying and understanding patient perceptions with regard to molecular profiling is critically important in this disease.¹⁴

In this study, we use a cross-sectional design to describe patient perceptions of trial enrollment among patients with bone and soft tissue sarcoma through validated measures, including attitudes towards clinical trials, knowledge of clinical trials, and perceived ability (ie, self-efficacy) to carry out actions involved in making an informed decision about clinical trial participation, receptivity to learning more about clinical trials, and willingness to participate in clinical trials.6 In addition, we describe this patient cohort’s perceptions of molecular profiling, as current and future trials are increasingly driven by molecular or other biomarkers.

Methods

This was a cross-sectional electronic survey study of patients with bone and soft tissue sarcoma treated at Northwestern Medicine (NM) over a 5-year period. NM Enterprise Data Warehouse (NMEDW) is a single, comprehensive, and integrated repository of all clinical and research data sources within NM. The study was approved by the Northwestern University Institutional Review Board.

Survey

The investigators designed a self-administered, online survey, which was built using Research Electronic Data Capture (REDCap). The survey consisted of three sections that were answered using skip logic—a custom path through the survey that varied based on patients’ answers: (1) Patient demographic information and trial perceptions (answered by all patients); (2) Thoughts about molecular profiling (answered by patients who answered “yes” to the question, “Have you heard about molecular profiling of tumors?”); and (3) Considerations to undergo molecular profiling (answered by patients who answered “yes” to the question, “Have you undergone profiling of your cancer?”).

 

Clinical trial perceptions included questions assessing (1) patient knowledge about trials; (2) patient attitudes toward trials; (3) perceived ability (ie, self-efficacy) to carry out actions involved in making an informed decision about trial participation; (4) receptivity to learning more about trials; and (5) willingness to participate in trials. These outcome measures had been previously developed and pilot tested for reliability and validity (TABLE 1).⁶

tsj00304008_t1.jpg

Thoughts about molecular profiling of tumors were assessed using nine items (TABLE 1). Of these, items assessing potential benefit or harm of molecular profiling were assessed using a 7-step Likert scale. Items assessing maximal benefit or harm of therapy, importance of quality vs length of life, and concern about the cost of molecular testing were assessed using a 5-step Likert scale. The study team developed and piloted these questions because there is no validated survey assessing these domains.

Considerations to undergo molecular profiling were assessed using 17 items. Items were in response to the question, “To what extent did you consider the following issues or concerns at the time you decided to get molecular testing of your cancer?” Responses were assessed using a 5-point Likert scale.

Data Collection

Patients 18 years and older evaluated at NM between November 20, 2012, and November 20, 2017, with a diagnosis of sarcoma were identified by query of the NMEDW by ICD-10 codes (C40, C41.9, C44.99, C45-49, C55, C71.9, D48, D49.9, and M12.20) or equivalent ICD-9 codes. Patients were subsequently excluded if they did not have a diagnosis of bone or soft tissue sarcoma, no e-mail address listed, had died, or had not been evaluated at an NM clinic in the previous 5 years. Patients with a diagnosis of gastrointestinal stromal tumor and Kaposi’s sarcoma were also excluded.

A personalized contact e-mail was sent to patients containing an explanation of the survey and an internet link to the electronic survey through REDCap from January 2018 to March 2018. If patients did not respond to the survey, two follow-up reminder e-mails were sent 2 and 4 days following the initial survey. The link was protected so that each patient could complete the survey only once. Responses were collected through the REDCap platform. Patients read and signed an electronic consent form prior to completing the survey.

Upon completion of the survey, patients were offered a $50 VISA gift card as compensation, with an option to donate their compensation to the Robert H. Lurie Comprehensive Cancer Center Sarcoma Research Fund.

Over the described survey period, open clinical trials for patients with bone and soft tissue sarcoma available at NM were evaluated. The number of patients screened and accrued to each trial were recorded.

 

Statistical analysis

Responses were separated from the personal data for complete anonymization. Descriptive statistical analysis was performed for demographics and disease variables and were summarized using frequencies and percentages. Median and range were used for age. Correlations between continuous variables were analyzed using Spearman correlations. Scores were compared between subgroups using the Mann-Whitney test. Descriptive statistics for knowledge, attitude, and ability scores include means and 95% confidence intervals. Correlations were interpreted as small (r=0.10), medium (r=0.30), or large (r=0.50).15 Statistical significance was indicated when P<0.05.

Results

Patients

Seven hundred fifty patients were eligible to participate in the survey and received the initial and two follow-up e-mails. Twenty e-mailed surveys bounced back. Three hundred nine patients opened the initial e-mail and 283 patients (37.7% of total and 91.6% of opened) completed at least a portion of the survey, with 182 patients completing the entire survey (FIGURE 1). Data for analysis were used from patients who completed at least a portion of the survey.

tsj00304008_f1.jpg

tsj00304008_t2a.jpg

tsj00304008_t2b.jpg

Baseline characteristics of patients who responded can be seen in TABLE 2. Patients had a median age of 56, the majority were female (59.4%), white (88.2%), and most had college or university graduate degrees or higher educational level (69.0%). Patients had various different histological subtypes, with the most common being liposarcoma (16.5%) and leiomyosarcoma (16.0%). Slightly more than a quarter (26.8%) of patients had metastatic disease, and 84.2% had never been enrolled in a clinical trial. Previous treatments included surgery (91.1%), radiation (53.2%), and chemotherapy (51.6%). Prior to completing the survey, 85.4% reported being receptive to a cancer clinical trial, while 60.7% of patients reported willingness to participate in a clinical trial.

 

Knowledge, attitudes, and perceived ability

A statistically significant correlation was observed between greater knowledge of trials and more positive attitudes towards trials (P<0.001; r=0.5, FIGURE 2A). In relating patient attitudes with perceived ability, again a significant correlation was seen (P<0.001; r=0.4, FIGURE 2B). In contrast, knowledge had a weak correlation with perceived ability (P=0.024; r=0.2, FIGURE 2C). There was no difference regarding patient knowledge, attitudes, or perceived ability by age, gender, race, or income.

tsj00304008_f2.jpg

Knowledge, attitudes, perceived ability, and clinical trial enrollment

Thirty patients reported clinical trial experience (either previously or currently enrolled in trials) and 160 patients were never enrolled. Of the 30 patients with trial experience, 7 reported being currently enrolled, while 23 reported previous enrollment. Of these patients, 16 had metastatic disease, while 12 had non-metastatic disease, and 2 were unsure whether or not they had metastatic disease.

Patients with previous clinical trial exposure (currently or previously enrolled in clinical trials) demonstrated significantly greater trial knowledge, with a mean knowledge score of 9.3 (CI 8.5-10.0) compared with 7.7 (CI 7.3-8.1) among patients without trial exposure (P=0.002; FIGURE 3A). Similarly, patients with trial experience also had statistically significant more positive attitudes towards trials as compared with patients with no trial experience, with a mean attitude score of 3.8 (CI 3.6-4.0) and 3.5 (CI 3.4-3.6), respectively (P=0.001; FIGURE 3B). While numerically patients with trial experience have greater perceived ability compared with patients with no trial experience, with a mean score of 4.4 (CI 4.2-4.6) and 4.2 (CI 4.1-4.3), respectively, this difference did not reach statistical significance (FIGURE 3C).

tsj00304008_f3.jpg

Knowledge, attitudes, perceived ability, and disease stage

An analysis was performed comparing patients with metastatic vs non-metastatic disease. It was observed that patients with metastatic disease had similar knowledge of trials compared with non-metastatic patients, with a mean knowledge score of 8.4 (CI 7.7- 9.1) and 7.9 (CI 7.5-8.4), respectively, (P=0.3; FIGURE 4A). In contrast, patients with metastatic disease had more positive attitudes compared with non-metastatic patients, with a mean score of 3.7 (CI 3.5-3.8) and 3.5 (CI 3.4-3.6), respectively, which was statistically significant (P=0.03; FIGURE 4B). There was no difference in perceived ability in metastatic vs non-metastatic patients (FIGURE 4C).

tsj00304008_f4.jpg

Thoughts about molecular profiling

Of the total number of patients, 46 patients had heard of molecular profiling and were presented with questions regarding their thoughts (TABLE 3). Approximately two-thirds (65.2%) thought there would be a 50% or greater likelihood of finding a targetable result in their tumor molecular profile. A majority (71.7%) of patients thought that a new experimental therapy chosen based on a patient’s tumor molecular profile would have at least a 50% chance of controlling the cancer. Somewhat less than a third (30.4%) of patients thought that total cure is the maximal benefit a patient could experience as a result of a treatment on a clinical trial using a drug chosen based on molecular tests. About half (52.2%) of patients agreed with the statement, “I am concerned about the cost of the test to molecularly profile my cancer.”

tsj00304008_t3.jpg

Considerations to undergo molecular profiling

Eighteen patients had undergone molecular profiling of their tumor. These patients were posed the question, “To what extent did you consider the following issues or concerns at the time you decided to get molecular testing of your cancer?” (TABLE 4). A majority (83.3%) of patients stated that wanting to live as long as possible was important, and 72.2% of patients stated that quality of life was important. A majority (83.3%) of patients stated that hope for a cure was an extremely or quite a bit important consideration. Helping future cancer patients was extremely or quite a bit important for 77.8% of patients, while wanting to be a part of research was not at all or of little importance in 50.0% of patients.

tsj00304008_t4.jpg

Clinical trials at NM

Twenty-four clinical trials were available at NM between the years 2012 and 2017 for patients with bone and soft tissue sarcoma. Of these trials, 3 of 24 were for non-metastatic patients, while the remaining 21 were open only to metastatic patients. The median number of patients screened per trial was 11 (range 0-66) and the median number of patients accrued per trial was 9 (range 0-58). Of the 24 trials, 17 were not subtype specific (13 included soft tissue sarcoma alone while 4 included both bone and soft tissue sarcoma). The remaining 7 trials were sarcoma subtype specific (eg, angiosarcoma, liposarcoma, etc). Trials available at NM during this period are included in TABLE 5. There were 318 patients screened and 262 patients accrued to sarcoma trials over this time period, with a screen failure rate of 17.6% overall.

tsj00304008_t5.jpg

Discussion

Our study sought to describe perceptions of clinical trial enrollment among patients with bone and soft tissue sarcoma in order to elucidate and overcome barriers to enrollment, which to the best of our knowledge had not been previously described. Using previously validated patient- reported outcomes in the literature,⁶ our data reveal a correlation between knowledge of trials and more positive attitudes towards trials. This underscores the importance of awareness and educational strategies in this cancer population as a whole. Interventions should focus on patient perceptions that contribute to lack of participation, such as fear of side effects, loss of control (eg, idea of placebo or randomization), logistical challenges (eg, additional time or convenient location), and cost.^3,5,7,16,17 For example, patients concerned about randomization should be educated on equipoise and other ethical considerations in trial design.⁵ Previous research has suggested that a multimedia psychoeducational intervention was effective in improving attitudes toward trials.⁶ Educating patients on the essential role of trials in oncology care, as demonstrated by the vast number of new drug approvals in recent years, is an essential strategy to improve attitudes, and subsequently leads to higher patient accrual rates. 

 

In our study, both knowledge and at titudes were increased in patients with previous trial exposure. This suggests that either patients with greater knowledge and more positive attitudes are more likely to enroll in trials, or that patients with direct trial exposure are more knowledgeable and develop more positive attitudes. Our patient population was overall receptive to learning more about clinical trials (85.4%) and willing to participate (65.8%). At the same time, our study demonstrated low to medium correlations between attitudes and perceived ability to take steps towards making an informed decision to enroll in a trial (r=0.4), which may partially be explained by the absence of a tangible trial opportunity. While we did not assess specifically whether patients in our study were offered a trial, there was a substantial trial menu at NM with limited screen failures and decent trial accrual over the time frame of our study. This underscores the importance not only of patient-focused strategies to increase educational and attitudinal resources, but also a need to focus on research-site optimization that includes opening of multiple trials in various settings, systematic pre-screening of patients, and eligibility criteria that are inclusive and rational.⁵

The patient population with metastatic disease demonstrated more positive attitudes towards enrolling in clinical trials. This cohort accrued well to clinical trials, with 21 of 24 trials enrolling specifically patients with metastatic disease. Of the patients who responded to our survey, patients with previous trial exposure were enriched for patients with metastatic disease (53.3% metastatic among previous trial exposure versus 26.8% metastatic overall). These observations are likely reflective of the need for novel therapies in this disease setting. At the same time, approximately 25% of patients with localized soft tissue sarcoma will develop distant metastatic disease after successful treatment of their primary tumor, which increases to 40% to 50% in larger and higher-grade tumors.¹⁸ Three of 24 trials were open for patients with non-metastatic disease, of which one managed to accrue patients. Patients with non-metastatic disease had more negative attitudes towards trial enrollment. These disproportionate findings suggest a need for interventions to increase patient awareness and attitudes towards trial enrollment among this patient population and the importance of research-site optimization for trial opportunities across disease states.

Molecular profiling of tumors and biomarker identification has become a critical component of further characterizing cancer subtypes. In our study, a majority (65.2%) thought there would be a 50% or greater likelihood of finding a targetable result in their molecular profile. Molecular data on 5,749 bone and soft tissue sarcomas suggested that 9.5% of tumors demonstrate a “targetable result,” defined as a new molecular finding for which there is an FDA-approved drug for malignancies other than sarcoma (eg, BRAF V600E, Her2, etc.),¹⁹ suggesting an overestimation in our patient cohort of the likelihood of benefit of molecular profiling. These results highlight that the growing use of molecular profiling has increased the need for educational and supportive resources to help patients understand the utility of molecular profiling and aid in shared decision-making surrounding the results.

At the same time, the importance of identifying a targetable mutation in patients with sarcoma cannot be understated. As a recent example of this paradigm, tumors that harbor fusions with the neurotrophic receptor tyrosine kinase 1, 2, or 3 (NTRK1, 2, and 3) have a high response rate (~75%) to drugs that target these fusions, such as larotrectinib and entrectinib.¹³ Molecular profiling and identification of predictive biomarkers in small patient subsets has led to great challenges in trial design and research-site optimization. Novel designs that incorporate molecular profiling,²⁰ such as the Lung- MAP trial²¹ and NCI’s Molecular Analysis for Therapy Choice (MATCH) trial,²² are emerging to identify new therapies for small patient subsets. As a rare and increasingly heterogeneous cancer, sarcoma represents a paradigm to provide insight into optimizing patient perceptions and research enterprises to maximize clinical trial enrollment. 

Some limitations of our study include a homogeneous and selected patient population that was predominantly Caucasian and highly educated. Therefore, these findings should not be extrapolated to other populations with barriers to trial accrual, such as lower socioeconomic or minority populations. The low response rate and failure of some to complete the survey may have introduced some bias. Additionally, our data include self-reported outcomes, which could have affected our results. Finally, the limited number of patients who had undergone or heard of molecular profiling limited our ability to draw definitive conclusions, and should be assessed in larger patient cohorts.

While our paper addresses a unique population—the sarcoma patient—similar themes and issues pertain to all oncology patients. A recent review was published in the American Society of Clinical Oncology Educational Book²³ looking at methods to overcome barriers to clinical trial enrollment. Their paper clearly illustrates mechanisms to assist with overcoming financial burdens associated with cancer clinical trials, overcoming barriers as they relate to patient and clinician difficulty in coping with the uncertainty inherent in clinical trial participation, and highlight the role of a patient navigator in clinical trial participation.

Conclusions

Interventions aimed at increasing awareness, knowledge, and attitudes towards clinical trials among sarcoma patients may lead to increased trial enrollment and greater progress in cancer treatment in this population. In addition to patient- focused interventions, thoughtful and strategic clinical trial designs that allow for the development of biomarker- driven therapeutics, while at the same time optimizing patient accrual rates, should be developed. Evaluation of barriers to clinical trial enrollment and molecular profiling of tumors among bone and soft tissue sarcoma patients at an academic center can serve as a paradigm to overcome barriers to enrollment in the era of an increasingly heterogeneous cancer population. TSJ

Introduction

The development of new cancer therapies relies on the successful development and completion of clinical trials. While clinical trials have led to significant improvements in cancer treatment, the success is dependent upon patient enrollment and participation. Unfortunately, fewer than 5% of adult patients enroll in trials.^1-3 This represents a significant barrier to the development and approval of new cancer treatments. Reasons for low accrual into trials are multifactorial, but include structural barriers (eg, clinic access), clinical barriers (eg, eligibility criteria), and physician and patient attitudes towards trial enrollment.^4,5 One study at the University of California Davis Cancer Center reported 49% of patients declined participation despite meeting eligibility criteria,^3,6 suggesting that psychosocial barriers such as knowledge of trials and attitudes towards clinical research are a major impediment to accrual.^7-9

Bone and soft tissue sarcoma represent a heterogeneous group of tumors of mesenchymal origin that are an important cause of morbidity and mortality. Local disease is often treated with a multidisciplinary approach including surgery, radiation, and systemic therapy. Metastatic disease is predominantly treated palliatively with systemic therapy.¹⁰ Given its rarity and heterogeneity, trial accrual is of particular importance in sarcoma and often requires multiple sites to enroll adequate numbers of patients. While sarcoma represents <1% of adult malignancies overall, it constitutes ~15% of malignancies in the adolescent and young adult (AYA) population (15- 39 years old).^11,12 Sarcoma represents a patient population in which low trial accrual has been correlated with lack of progress in cancer-related outcomes in both the adult and AYA populations.¹³ The reasons for low accrual rates among patients with sarcoma are poorly understood.

Sarcomas represent a molecularly and biologically heterogeneous group of malignancies with over 100 different subtypes.¹² As a result, there has been significant interest in performing molecular profiling, or genetic sequencing, to identify “targetable” mutations. Targetable mutations refer to a specific genetic change identified within the tumor molecular profile for which there is a specific drug that may demonstrate activity against a particular tumor. Given the widespread utilization of this technology in sarcoma, identifying and understanding patient perceptions with regard to molecular profiling is critically important in this disease.¹⁴

In this study, we use a cross-sectional design to describe patient perceptions of trial enrollment among patients with bone and soft tissue sarcoma through validated measures, including attitudes towards clinical trials, knowledge of clinical trials, and perceived ability (ie, self-efficacy) to carry out actions involved in making an informed decision about clinical trial participation, receptivity to learning more about clinical trials, and willingness to participate in clinical trials.6 In addition, we describe this patient cohort’s perceptions of molecular profiling, as current and future trials are increasingly driven by molecular or other biomarkers.

Methods

This was a cross-sectional electronic survey study of patients with bone and soft tissue sarcoma treated at Northwestern Medicine (NM) over a 5-year period. NM Enterprise Data Warehouse (NMEDW) is a single, comprehensive, and integrated repository of all clinical and research data sources within NM. The study was approved by the Northwestern University Institutional Review Board.

Survey

The investigators designed a self-administered, online survey, which was built using Research Electronic Data Capture (REDCap). The survey consisted of three sections that were answered using skip logic—a custom path through the survey that varied based on patients’ answers: (1) Patient demographic information and trial perceptions (answered by all patients); (2) Thoughts about molecular profiling (answered by patients who answered “yes” to the question, “Have you heard about molecular profiling of tumors?”); and (3) Considerations to undergo molecular profiling (answered by patients who answered “yes” to the question, “Have you undergone profiling of your cancer?”).

 

Clinical trial perceptions included questions assessing (1) patient knowledge about trials; (2) patient attitudes toward trials; (3) perceived ability (ie, self-efficacy) to carry out actions involved in making an informed decision about trial participation; (4) receptivity to learning more about trials; and (5) willingness to participate in trials. These outcome measures had been previously developed and pilot tested for reliability and validity (TABLE 1).⁶

tsj00304008_t1.jpg

Thoughts about molecular profiling of tumors were assessed using nine items (TABLE 1). Of these, items assessing potential benefit or harm of molecular profiling were assessed using a 7-step Likert scale. Items assessing maximal benefit or harm of therapy, importance of quality vs length of life, and concern about the cost of molecular testing were assessed using a 5-step Likert scale. The study team developed and piloted these questions because there is no validated survey assessing these domains.

Considerations to undergo molecular profiling were assessed using 17 items. Items were in response to the question, “To what extent did you consider the following issues or concerns at the time you decided to get molecular testing of your cancer?” Responses were assessed using a 5-point Likert scale.

Data Collection

Patients 18 years and older evaluated at NM between November 20, 2012, and November 20, 2017, with a diagnosis of sarcoma were identified by query of the NMEDW by ICD-10 codes (C40, C41.9, C44.99, C45-49, C55, C71.9, D48, D49.9, and M12.20) or equivalent ICD-9 codes. Patients were subsequently excluded if they did not have a diagnosis of bone or soft tissue sarcoma, no e-mail address listed, had died, or had not been evaluated at an NM clinic in the previous 5 years. Patients with a diagnosis of gastrointestinal stromal tumor and Kaposi’s sarcoma were also excluded.

A personalized contact e-mail was sent to patients containing an explanation of the survey and an internet link to the electronic survey through REDCap from January 2018 to March 2018. If patients did not respond to the survey, two follow-up reminder e-mails were sent 2 and 4 days following the initial survey. The link was protected so that each patient could complete the survey only once. Responses were collected through the REDCap platform. Patients read and signed an electronic consent form prior to completing the survey.

Upon completion of the survey, patients were offered a $50 VISA gift card as compensation, with an option to donate their compensation to the Robert H. Lurie Comprehensive Cancer Center Sarcoma Research Fund.

Over the described survey period, open clinical trials for patients with bone and soft tissue sarcoma available at NM were evaluated. The number of patients screened and accrued to each trial were recorded.

 

Statistical analysis

Responses were separated from the personal data for complete anonymization. Descriptive statistical analysis was performed for demographics and disease variables and were summarized using frequencies and percentages. Median and range were used for age. Correlations between continuous variables were analyzed using Spearman correlations. Scores were compared between subgroups using the Mann-Whitney test. Descriptive statistics for knowledge, attitude, and ability scores include means and 95% confidence intervals. Correlations were interpreted as small (r=0.10), medium (r=0.30), or large (r=0.50).15 Statistical significance was indicated when P<0.05.

Results

Patients

Seven hundred fifty patients were eligible to participate in the survey and received the initial and two follow-up e-mails. Twenty e-mailed surveys bounced back. Three hundred nine patients opened the initial e-mail and 283 patients (37.7% of total and 91.6% of opened) completed at least a portion of the survey, with 182 patients completing the entire survey (FIGURE 1). Data for analysis were used from patients who completed at least a portion of the survey.

tsj00304008_f1.jpg

tsj00304008_t2a.jpg

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Baseline characteristics of patients who responded can be seen in TABLE 2. Patients had a median age of 56, the majority were female (59.4%), white (88.2%), and most had college or university graduate degrees or higher educational level (69.0%). Patients had various different histological subtypes, with the most common being liposarcoma (16.5%) and leiomyosarcoma (16.0%). Slightly more than a quarter (26.8%) of patients had metastatic disease, and 84.2% had never been enrolled in a clinical trial. Previous treatments included surgery (91.1%), radiation (53.2%), and chemotherapy (51.6%). Prior to completing the survey, 85.4% reported being receptive to a cancer clinical trial, while 60.7% of patients reported willingness to participate in a clinical trial.

 

Knowledge, attitudes, and perceived ability

A statistically significant correlation was observed between greater knowledge of trials and more positive attitudes towards trials (P<0.001; r=0.5, FIGURE 2A). In relating patient attitudes with perceived ability, again a significant correlation was seen (P<0.001; r=0.4, FIGURE 2B). In contrast, knowledge had a weak correlation with perceived ability (P=0.024; r=0.2, FIGURE 2C). There was no difference regarding patient knowledge, attitudes, or perceived ability by age, gender, race, or income.

tsj00304008_f2.jpg

Knowledge, attitudes, perceived ability, and clinical trial enrollment

Thirty patients reported clinical trial experience (either previously or currently enrolled in trials) and 160 patients were never enrolled. Of the 30 patients with trial experience, 7 reported being currently enrolled, while 23 reported previous enrollment. Of these patients, 16 had metastatic disease, while 12 had non-metastatic disease, and 2 were unsure whether or not they had metastatic disease.

Patients with previous clinical trial exposure (currently or previously enrolled in clinical trials) demonstrated significantly greater trial knowledge, with a mean knowledge score of 9.3 (CI 8.5-10.0) compared with 7.7 (CI 7.3-8.1) among patients without trial exposure (P=0.002; FIGURE 3A). Similarly, patients with trial experience also had statistically significant more positive attitudes towards trials as compared with patients with no trial experience, with a mean attitude score of 3.8 (CI 3.6-4.0) and 3.5 (CI 3.4-3.6), respectively (P=0.001; FIGURE 3B). While numerically patients with trial experience have greater perceived ability compared with patients with no trial experience, with a mean score of 4.4 (CI 4.2-4.6) and 4.2 (CI 4.1-4.3), respectively, this difference did not reach statistical significance (FIGURE 3C).

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Knowledge, attitudes, perceived ability, and disease stage

An analysis was performed comparing patients with metastatic vs non-metastatic disease. It was observed that patients with metastatic disease had similar knowledge of trials compared with non-metastatic patients, with a mean knowledge score of 8.4 (CI 7.7- 9.1) and 7.9 (CI 7.5-8.4), respectively, (P=0.3; FIGURE 4A). In contrast, patients with metastatic disease had more positive attitudes compared with non-metastatic patients, with a mean score of 3.7 (CI 3.5-3.8) and 3.5 (CI 3.4-3.6), respectively, which was statistically significant (P=0.03; FIGURE 4B). There was no difference in perceived ability in metastatic vs non-metastatic patients (FIGURE 4C).

tsj00304008_f4.jpg

Thoughts about molecular profiling

Of the total number of patients, 46 patients had heard of molecular profiling and were presented with questions regarding their thoughts (TABLE 3). Approximately two-thirds (65.2%) thought there would be a 50% or greater likelihood of finding a targetable result in their tumor molecular profile. A majority (71.7%) of patients thought that a new experimental therapy chosen based on a patient’s tumor molecular profile would have at least a 50% chance of controlling the cancer. Somewhat less than a third (30.4%) of patients thought that total cure is the maximal benefit a patient could experience as a result of a treatment on a clinical trial using a drug chosen based on molecular tests. About half (52.2%) of patients agreed with the statement, “I am concerned about the cost of the test to molecularly profile my cancer.”

tsj00304008_t3.jpg

Considerations to undergo molecular profiling

Eighteen patients had undergone molecular profiling of their tumor. These patients were posed the question, “To what extent did you consider the following issues or concerns at the time you decided to get molecular testing of your cancer?” (TABLE 4). A majority (83.3%) of patients stated that wanting to live as long as possible was important, and 72.2% of patients stated that quality of life was important. A majority (83.3%) of patients stated that hope for a cure was an extremely or quite a bit important consideration. Helping future cancer patients was extremely or quite a bit important for 77.8% of patients, while wanting to be a part of research was not at all or of little importance in 50.0% of patients.

tsj00304008_t4.jpg

Clinical trials at NM

Twenty-four clinical trials were available at NM between the years 2012 and 2017 for patients with bone and soft tissue sarcoma. Of these trials, 3 of 24 were for non-metastatic patients, while the remaining 21 were open only to metastatic patients. The median number of patients screened per trial was 11 (range 0-66) and the median number of patients accrued per trial was 9 (range 0-58). Of the 24 trials, 17 were not subtype specific (13 included soft tissue sarcoma alone while 4 included both bone and soft tissue sarcoma). The remaining 7 trials were sarcoma subtype specific (eg, angiosarcoma, liposarcoma, etc). Trials available at NM during this period are included in TABLE 5. There were 318 patients screened and 262 patients accrued to sarcoma trials over this time period, with a screen failure rate of 17.6% overall.

tsj00304008_t5.jpg

Discussion

Our study sought to describe perceptions of clinical trial enrollment among patients with bone and soft tissue sarcoma in order to elucidate and overcome barriers to enrollment, which to the best of our knowledge had not been previously described. Using previously validated patient- reported outcomes in the literature,⁶ our data reveal a correlation between knowledge of trials and more positive attitudes towards trials. This underscores the importance of awareness and educational strategies in this cancer population as a whole. Interventions should focus on patient perceptions that contribute to lack of participation, such as fear of side effects, loss of control (eg, idea of placebo or randomization), logistical challenges (eg, additional time or convenient location), and cost.^3,5,7,16,17 For example, patients concerned about randomization should be educated on equipoise and other ethical considerations in trial design.⁵ Previous research has suggested that a multimedia psychoeducational intervention was effective in improving attitudes toward trials.⁶ Educating patients on the essential role of trials in oncology care, as demonstrated by the vast number of new drug approvals in recent years, is an essential strategy to improve attitudes, and subsequently leads to higher patient accrual rates. 

 

In our study, both knowledge and at titudes were increased in patients with previous trial exposure. This suggests that either patients with greater knowledge and more positive attitudes are more likely to enroll in trials, or that patients with direct trial exposure are more knowledgeable and develop more positive attitudes. Our patient population was overall receptive to learning more about clinical trials (85.4%) and willing to participate (65.8%). At the same time, our study demonstrated low to medium correlations between attitudes and perceived ability to take steps towards making an informed decision to enroll in a trial (r=0.4), which may partially be explained by the absence of a tangible trial opportunity. While we did not assess specifically whether patients in our study were offered a trial, there was a substantial trial menu at NM with limited screen failures and decent trial accrual over the time frame of our study. This underscores the importance not only of patient-focused strategies to increase educational and attitudinal resources, but also a need to focus on research-site optimization that includes opening of multiple trials in various settings, systematic pre-screening of patients, and eligibility criteria that are inclusive and rational.⁵

The patient population with metastatic disease demonstrated more positive attitudes towards enrolling in clinical trials. This cohort accrued well to clinical trials, with 21 of 24 trials enrolling specifically patients with metastatic disease. Of the patients who responded to our survey, patients with previous trial exposure were enriched for patients with metastatic disease (53.3% metastatic among previous trial exposure versus 26.8% metastatic overall). These observations are likely reflective of the need for novel therapies in this disease setting. At the same time, approximately 25% of patients with localized soft tissue sarcoma will develop distant metastatic disease after successful treatment of their primary tumor, which increases to 40% to 50% in larger and higher-grade tumors.¹⁸ Three of 24 trials were open for patients with non-metastatic disease, of which one managed to accrue patients. Patients with non-metastatic disease had more negative attitudes towards trial enrollment. These disproportionate findings suggest a need for interventions to increase patient awareness and attitudes towards trial enrollment among this patient population and the importance of research-site optimization for trial opportunities across disease states.

Molecular profiling of tumors and biomarker identification has become a critical component of further characterizing cancer subtypes. In our study, a majority (65.2%) thought there would be a 50% or greater likelihood of finding a targetable result in their molecular profile. Molecular data on 5,749 bone and soft tissue sarcomas suggested that 9.5% of tumors demonstrate a “targetable result,” defined as a new molecular finding for which there is an FDA-approved drug for malignancies other than sarcoma (eg, BRAF V600E, Her2, etc.),¹⁹ suggesting an overestimation in our patient cohort of the likelihood of benefit of molecular profiling. These results highlight that the growing use of molecular profiling has increased the need for educational and supportive resources to help patients understand the utility of molecular profiling and aid in shared decision-making surrounding the results.

At the same time, the importance of identifying a targetable mutation in patients with sarcoma cannot be understated. As a recent example of this paradigm, tumors that harbor fusions with the neurotrophic receptor tyrosine kinase 1, 2, or 3 (NTRK1, 2, and 3) have a high response rate (~75%) to drugs that target these fusions, such as larotrectinib and entrectinib.¹³ Molecular profiling and identification of predictive biomarkers in small patient subsets has led to great challenges in trial design and research-site optimization. Novel designs that incorporate molecular profiling,²⁰ such as the Lung- MAP trial²¹ and NCI’s Molecular Analysis for Therapy Choice (MATCH) trial,²² are emerging to identify new therapies for small patient subsets. As a rare and increasingly heterogeneous cancer, sarcoma represents a paradigm to provide insight into optimizing patient perceptions and research enterprises to maximize clinical trial enrollment. 

Some limitations of our study include a homogeneous and selected patient population that was predominantly Caucasian and highly educated. Therefore, these findings should not be extrapolated to other populations with barriers to trial accrual, such as lower socioeconomic or minority populations. The low response rate and failure of some to complete the survey may have introduced some bias. Additionally, our data include self-reported outcomes, which could have affected our results. Finally, the limited number of patients who had undergone or heard of molecular profiling limited our ability to draw definitive conclusions, and should be assessed in larger patient cohorts.

While our paper addresses a unique population—the sarcoma patient—similar themes and issues pertain to all oncology patients. A recent review was published in the American Society of Clinical Oncology Educational Book²³ looking at methods to overcome barriers to clinical trial enrollment. Their paper clearly illustrates mechanisms to assist with overcoming financial burdens associated with cancer clinical trials, overcoming barriers as they relate to patient and clinician difficulty in coping with the uncertainty inherent in clinical trial participation, and highlight the role of a patient navigator in clinical trial participation.

Conclusions

Interventions aimed at increasing awareness, knowledge, and attitudes towards clinical trials among sarcoma patients may lead to increased trial enrollment and greater progress in cancer treatment in this population. In addition to patient- focused interventions, thoughtful and strategic clinical trial designs that allow for the development of biomarker- driven therapeutics, while at the same time optimizing patient accrual rates, should be developed. Evaluation of barriers to clinical trial enrollment and molecular profiling of tumors among bone and soft tissue sarcoma patients at an academic center can serve as a paradigm to overcome barriers to enrollment in the era of an increasingly heterogeneous cancer population. TSJ

INTRODUCTION

Soft tissue sarcomas (STSs) are rare adult tumors, with 3.4 new cases per 100,000 persons or 12,310 expected new cases in 2016.¹ Sarcomas are a heterogeneous collection of tumors that affect fat, muscle, nerve, nerve sheath, vascular, and connective tissues. There are more than 50 histological subtypes that comprise this diverse category of tumors. Treatment varies by stage, with limb-sparing surgery representing the mainstay of curative-intent treatment. Radiation and chemotherapy may also be considered depending on the size, grade, and location of the tumor. Survival rates have been stagnant until recently, with a disease-specific survival hovering around 65%.¹ Given the complexity of these cases, all patients ideally should be evaluated and treated by a multidisciplinary team at an institution with extensive experience treating STS.²

EPIDEMIOLOGY AND CLASSIFICATION

The most common STS subtypes are gastrointestinal stromal tumor (GIST), undifferentiate pleomorphic sarcoma (previously referred to as malignant fibrous histiocytoma), liposarcoma, leiomyosarcoma, synovial sarcoma, malignant peripheral nerve sheath tumor, rhabdomyosarcoma, and unclassified sarcoma.³ Liposarcoma is one of the most common subtypes, comprising 20% of all STSs; it is subdivided into well-differentiated/dedifferentiated liposarcomas, myxoid/round cell liposarcomas, and pleomorphic liposarcomas. Well-differentiated liposarcomas tend to occur in the retroperitoneum and limbs, while both myxoid and round cell as well as pleomorphic liposarcomas more commonly originate on the limbs. Histology varies based on subtype and ranges from mature-appearing adipocytes and fibroblasts to undifferentiated cells with minimal lipogenic differentiation.⁴

Leiomyosarcomas are smooth muscle tumors and are usually located in the retroperitoneum, but have also been associated with peripheral soft tissue and vasculature. Typical histology ranges from well-defined areas of spindle-shaped cells to poorly differentiated anaplastic spindle cells.^5,6 Synovial sarcomas are a distinct type of STS that can show epithelial differentiation and account for 5% of adult STSs. The extremities are the most common presenting location (90%).⁷

Rhabdomyosarcomas are skeletal muscle tumors and are further subdivided into embryonal, alveolar, and pleomorphic subtypes. Embryonal histology ranges from primitive mesenchymal-appearing cells to highly differentiated muscle cells. Alveolar rhabdomyosarcoma has the worst prognosis of the subtypes and consists of round cells with high nuclear-to-chromatin ratios that form “glandular-like” or “alveolar” spaces.⁸ Pleomorphic rhabdomyosarcomas are composed of rhabdomyoblasts that can affect many different locations, but most commonly present on the lower extremities.⁹

Malignant peripheral nerve sheath tumor (MPNST) comprises 5% to 10% of all STSs. These tumors are associated with neurofibromatosis type 1 (NF-1), with 25% to 50% of tumors occurring in NF-1 patients. Additionally, most patients have a truncating lesion in the NF1 gene on chromosome 17.¹⁰ Anghileri et al in their single institution analysis of 205 patients with MPNSTs found the 2 most common presenting sites were the trunk and extremities. Histologically, these tumors have dense fascicles of spindle cells.¹⁰

GISTs are the most common STS of the gastrointestinal (GI) tract. Previously, GISTs were classified as smooth muscle tumors and were not accounted for in the literature as a separate entity distinct from leiomyomas, leiomyoblastomas, and leiomyosarcomas.¹¹ GISTs are found throughout the GI tract: the most common sites are the stomach (60%) and small intestine (30%). Less common sites include duodenum (4%–5%), esophagus (1%), rectum (1%–2%), and appendix (< 0.2%).¹² GISTs can be spindle cell, epithelioid, or mesenchymal tumors. Immunohistochemically, GISTs are KIT (CD117) positive. Other cell markers that are also commonly positive include CD34 (60%–70%) and smooth muscle actin (SMA) (25%).¹¹ The majority of GISTs (80%) have an activating c-KIT gene mutation. The most common mutation site is exon 11, with less common c-KIT gene mutations also occurring at exon 9 or 13. Not all GISTs have KIT mutations. The second most common mutation is the PDGFRA mutation (5%–10% of GISTs).² A minority of GISTs are negative for both KIT and PDGFRA mutations. These tumors were previously called wild-type, but as the majority have either a succinate dehydrogenase (SDH) loss of function or loss of SDHB protein expression, they are now referred to as SDH-deficient GISTs.² GISTs vary in aggressiveness from incidental to aggressive. Typically, small intestine and rectal GISTs are more aggressive than gastric GISTs. Both size and mitotic rate help to predict the metastatic potential of the tumor. Tumors less than 2 cm in size and having a mitotic rate of less than 5 per 50 high-power fields (hpf) have the lowest risk of metastases, while tumors greater than 5 cm and with more than 5 mitoses per 50 hpf have the highest rates of metastases.¹²

 

Angiosarcomas are rare tumors comprising 4% of all STSs. Although they can occur in any site, the majority are cutaneous and occur most frequently in the head and neck regions. These tumors are either of vascular or lymphatic origin and are comprised of abnormal, pleomorphic, malignant endothelial cells. The most useful immunohistochemical markers include von Willebrand factor, CD31, and Ulex europaeus agglutinin 1. The majority of these tumors occur sporadically; however, radiation exposure, chronic lymphedema, and certain toxins including vinyl chloride and thorium dioxide are known risk factors.¹³

Undifferentiated sarcomas have no specific features and typically consist of primitive mesenchymal cells.

CLINICAL EVALUATION

CASE PRESENTATION

Initial Presentation and History

A 55-year-old man presents to his primary care physician with a painless mass in his anterior thigh. The mass has been present for the past 3 months and he believes that it is enlarging. The patient has a history of well-controlled hypertension and hyperlipidemia. His medications include atorvastatin and hydrochlorothiazide. He has no known drug allergies. Family history is notable for diabetes and hypertension. He drinks 4 to 5 alcoholic drinks a week and he is a former smoker. He quit smoking in his 30s and only smoked intermittently prior to quitting. He denies any illicit drug use. He works as a high school principal. Currently, he feels well. His review of systems is otherwise noncontributory.

Physical Examination

On physical exam, he is afebrile with a blood pressure of 132/75 mm Hg, respiratory rate of 10 breaths/min, and oxygen saturation of 99% on room air. He is a well appearing, overweight male. His head and neck exam is unremarkable. Lung exam reveals clear breath sounds, and cardiac exam reveals a regular rate and rhythm. His abdomen is obese, soft, and without hepatosplenomegaly. There is a large, fixed mass on the anterior lateral aspect of his right thigh. He has no appreciable lymphadenopathy. His neurological exam is unremarkable.

• What are risk factors for sarcoma?

There are few known risk factors for sarcoma. Established risks factors include prior radiation therapy, chronic lymphedema, viruses, and genetic cancer syndromes including Li-Fraumeni syndrome, hereditary retinoblastoma, and NF-1. Other environmental exposures include phenoxyacetic acids and chlorophenols.¹⁴ The majority of cases are sporadic, with only a minority of patients having one of these known risk factors.¹⁵ Up to one third of sarcomas have a specific translocation and are driven by fusion oncogenes (Table 1).

table1_hpho_sarcoma_010117.jpg

• What is the typical presentation for sarcomas?

A painless mass is the most typical presenting symptom. Size at presentation varies based on location, with extremity and head and neck locations typically presenting at smaller sizes than retroperitoneal tumors.¹⁴ Patients may experience pain and numbness as the mass enlarges and impinges on surrounding structures including nerves and vasculature. The vast majority of patients are without systemic symptoms.

• How is sarcoma staged?

The American Joint Committee on Cancer (AJCC) staging system is the most widely used staging system in the United States. The latest AJCC manual was updated in 2010 to include a 3-tiered grading system where the tumor is classified according to tumor size, lymph node involvement, metastases, and grade at time of diagnosis (Table 2 and Table 3). Additionally, tumor depth in relation to deep fascia is also taken into account, with superficial tumors being assigned a designation of “a” and deep tumors a designation of “b.”

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Previously, 2 of the most widely used grading systems were the National Cancer Institute (NCI) and French Federation of Cancer Centers Sarcoma Group (FNCLCC) systems, both 3-tier grading systems. The main components that determine the NCI grade are the tumor’s histologic type and location and the amount of tumor necrosis. The FNCLCC system evaluation focuses on tumor differentiation, mitotic rate, and amount of tumor necrosis. A study that compared the NCI and FNCLCC grading systems found that FNCLCC was a better predictor of mortality and distant metastasis.¹⁶ Previously, the AJCC was a 4-tier grading system, but the 2010 version was updated to the 3-tier FNCLCC grading system. Additionally, the AJCC system has reclassified single lymph node disease as stage III as it confers better survival than metastatic disease.¹⁷ It is important that pathology be evaluated by a sarcoma specialist as disagreements with regard to histologic subtype and grade are common.^18,19

• What are the most important prognostic factors?

Prognostic factors include grade, size, and presence of metastases at presentation. Best survival is associated with low-grade, small tumors with no metastases at time of diagnosis.¹⁴

 

• What imaging should be considered?

Imaging should be undertaken to help differentiate between benign and malignant lesions. Ideally, it should be undertaken before a biopsy is planned as the imaging can be used to plan biopsy as well as provide invaluable prognostic information. There are several imaging modalities that should be considered during the preliminary work-up and staging of STSs. Conventional imaging includes magnetic resonance imaging (MRI) of the original tumor site; computed tomography (CT) to evaluate for pulmonary metastases and, depending on location, liver metastases; and in the case of small, low-grade tumors, chest radiography. MRI is considered the test of choice for soft tissue masses and can help delineate benign masses such as hematomas, lipomas, and hemangiomas from sarcomas.²⁰ It is difficult to compare the accuracy of positron emission tomography (PET)/CT to CT and MRI because most studies have evaluated PET/CT in parallel with CT and MRI.²¹ Tateishi et al compared the accuracy of conventional imaging, PET/CT, and PET/CT combined with conventional imaging at determining the TNM staging for 117 patients. They found that conventional imaging correctly classified 77% of patients, PET alone correctly classified 70%, PET/CT correctly classified 83%, and PET/CT combined with conventional imaging correctly staged 87%.²²

• Which subtypes are most likely to metastasize?

Although the vast majority of sarcomas spread hematogenously, 3 have a propensity to spread lymphogenously: epithelioid sarcoma, rhabdomyosarcoma, and clear-cell sarcoma. Additionally, certain subtypes are more likely to metastasize: leiomyosarcomas, synovial sarcomas, neurogenic sarcomas, rhabdomyosarcomas, and epithelioid sarcomas.²³ Sarcomas metastasize to the lungs more frequently than to the liver. The metastatic pattern is defined primarily by sarcoma subtype and site of primary tumor. Sarcomas rarely metastasize to the brain (~1%).

MANAGEMENT

CASE CONTINUED

The patient undergoes an ultrasound to better visualize the mass. Given the heterogeneous character of the mass, he is referred for an MRI to evaluate the mass and a CT scan of the chest, abdomen, and pelvis to evaluate for distant metastases. MRI reveals a 5.1 cm × 4.6 cm heterogeneous mass invading the superficial fascia of the rectus femoris muscle. No suspicious lymph nodes or other masses are identified on imaging. The patient next undergoes an image-guided core needle biopsy. Pathology from that procedure is consistent with a stage III, T2bNxMx, grade 3, dedifferentiated liposarcoma.

• What is the best management approach for this patient?

SURGERY

Surgery is the mainstay of treatment for STS. Patients with the best prognosis are those who undergo complete resection with negative surgical margins.^24,25 Goal tumor-free margin is 1 to 3 cm.²⁶ Complete resection confers the best long-term survival. Both local and metastatic recurrence is higher in patients with incomplete resection and positive margins.^24,25 In a study that analyzed 2084 localized primary STSs, patients with negative margins had a local recurrence rate of 15% versus a rate of 28% in patients with positive margins. This translated into higher 5-year local recurrence-free survival for patients with negative surgical margins (82%) compared to patients with positive margins (65%).²⁷ Another study similarly found that patients with negative margins at referral to their institution who underwent postoperative radiation had high local control rates of 93% (95% confidence interval [CI] 87% to 97%) at 5, 10, and 15 years.²⁶ Although radiation improves local control, neither preoperative or postoperative radiation has been shown to improve progression-free or overall survival.²⁸ Other factors that are associated with risk of recurrence are tumor location, history of previous recurrence, age of patient, histopathology, tumor grade, and tumor size. Approximately 40% to 50% of patients with high-grade tumors (defined as size > 5 cm, deep location, and high grade) will develop distant metastases.²⁹

Zagars et al found that positive or uncertain resection margin had a relative risk of local recurrence of 2.0 (95% CI 1.3 to 3.1; P = 0.002), and presentation with locally recurrent disease (vs new tumor) had a relative risk of local recurrence of 2.0 (95% CI 1.2 to 3.4; P = 0.013).²⁶ Patients with STS of head and neck and deep trunk have higher recurrence rates than those with superficial trunk and extremity STS. A single-institution retrospective review demonstrated that patients with completely resectable retroperitoneal sarcomas have longer median survival (103 months) compared to patients with incompletely resected abdominal sarcomas (18 months).²⁵

 

Rosenberg and colleagues compared amputation to limb-sparing surgery and radiation.²⁴ Their prospective analysis of 65 patients found no difference in disease-free and overall survival between the 2 treatment groups.The limb-sparing treatment group had higher rates of local recurrence, which was highly correlated with positive surgical margins on pathology.²⁴ Evidence from this and similar studies has resulted in radical amputations being replaced by conservative limb-sparing procedures and radiation therapy. In those found to have positive margins, re-resection is an option for some. Patients who undergo re-resection have higher local control rates than patients with positive margins who do not undergo re-resection. The 5-year control rate for patients who undergo re-resection is 85% (95% CI 80% to 89%) compared to 78% (95% CI 71% to 83%) for those who do not undergo re-resection. Similarly, patients who undergo re-resection have lower rates of metastases at 5, 10, and 15 years as well as higher 5-, 10-, and 15-year disease-free survival rates.²⁶

CASE CONTINUED

The patient is referred for limb-sparing surgery after presentation at a multidisciplinary tumor board. Prior to undergoing resection of the tumor, he is also referred to radiation-oncology to discuss the risks and benefits of combination radiotherapy and surgery as opposed to surgical resection alone.

• What is the evidence for radiation therapy?

RADIATION THERAPY

Radiation therapy is used in the preoperative, intraoperative, and postoperative settings to reduce the risk of local recurrence. There are several options for radiation, including external beam radiation therapy (EBRT), intraoperative radiation, and brachytherapy. A newer strategy, intensity-modulated radiation therapy (IMRT), utilizes 3-dimensional modeling to reduce radiation dosages. Overall there are no differences in overall survival or local recurrence rates between preoperative and postoperative radiation in STS.²⁸

The rationale behind preoperative radiation is that it reduces seeding of tumor cells, especially at the time of surgery.³⁰ Additionally, for EBRT, preoperative radiation has smaller field sizes and lower radiation doses. It can also help to reduce the size of the tumor prior to resection. Intraoperative radiation is often paired with preoperative radiation as a boost dose given only to the area of residual tumor.

Suit et al reviewed patients treated at a single institution with limb-sparing surgery and different radiation strategies. Local control rates between preoperative and postoperative radiation groups were not statistically significant. Local recurrence was linked to grade and size of the tumor in both groups. The authors did note, however, that the preoperative radiation group tended to have larger tumor sizes at baseline compared to the patients who received postoperative radiation.³⁰ A study that compared 190 patients who received preoperative and postoperative EBRT or brachytherapy (primary end point was wound complications, and local control was a secondary end point) showed a trend towards greater local control with preoperative radiation; however, the preoperative radiation group had significantly more wound complications compared to the postoperative radiation group.³¹

Yang et al found that postoperative EBRT decreases rates of local recurrence compared to surgery alone in high-grade extremity sarcomas.³² However, there were no differences in rates of distant metastases and overall survival between the 2 treatment groups. Similarly, in patients with low-grade sarcoma, there were fewer local recurrences in those who received EBRT and surgery as compared to surgery alone.³² Another study that evaluated 164 patients who received either adjuvant brachytherapy or no further therapy after complete resection found that brachytherapy reduced local recurrence in high-grade sarcomas. No difference in local recurrence rates was found in patients with low-grade sarcomas, nor was a significant difference found in the rates of distant metastases and overall survival between the 2 treatment groups.³³ With regards to IMRT, a single institution cohort experience with 41 patients who received IMRT following limb-sparing surgery had similar local control rates when compared to historical controls.³⁴

CASE CONTINUED

After discussion of the risks and benefits of radiation therapy, the patient opts for preoperative radiation prior to resection of his liposarcoma. He receives 50 Gy of EBRT prior to undergoing resection. Resection results in R1 margin consistent with microscopic disease. He receives 16 Gy of EBRT as a boost after recovery from his resection.²

• What is the evidence for neoadjuvant and adjuvant chemotherapy for stage I tumors?

CHEMOTHERAPY

Localized Sarcoma

For localized sarcoma, limb-sparing resection with or without radiation forms the backbone of treatment. Studies have evaluated chemotherapy in both the neoadjuvant and adjuvant settings, with the vast majority of studies evaluating doxorubicin-based chemotherapy regimens in the adjuvant settings. Due to the rare nature of sarcomas, most studies are not sufficiently powered to detect significant benefit from chemotherapy. Several trials evaluating chemotherapy regimens in the neoadjuvant and adjuvant settings needed to be terminated prematurely due to inadequate enrollment into the study. ^35,36

 

For stage IA (T1a-Tb, N0, M0, low grade) tumors, no additional therapy is recommended after limb-sparing surgery with appropriate surgical margins. For stage IB (T2a-2b, N0, M0, low grade) tumors with insufficient margins, re-resection and radiation therapy should be considered, while for stage IIA (T1a-1b, N0, M0, G2-3) tumors preoperative or postoperative radiation therapy is recommended.² Studies have not found benefit of adjuvant chemotherapy in these low-grade, stage I tumors in terms of progression-free survival and overall survival.³⁷

• At what stage should chemotherapy be considered?

For stage IIb and stage III tumors, surgery and radiation therapy again form the backbone of therapy; however, neoadjuvant and adjuvant chemotherapy are also recommended as considerations. Anthracycline-based chemotherapy with either single-agent doxorubicin or doxorubicin and ifosfamide in combination are considered first-line chemotherapy agents in locally advanced STS.^2,29,37

Evidence regarding the efficacy of both neoadjuvant and adjuvant chemotherapy regimens in the setting of locally advanced high-grade STS has been mixed. The Sarcoma Meta-analysis Collaboration evaluated 14 trials of doxorubicin-based adjuvant chemotherapy and found a trend towards overall survival in the treatment groups that received chemotherapy.³⁷ All trials included in the meta-analysis compared patients with localized resectable soft-tissue sarcomas who were randomized to either adjuvant chemotherapy or no adjuvant chemotherapy after limb-sparing surgery with or without radiation therapy. None of the individual trials showed a significant benefit, and all trials had large confidence intervals; however, the meta-analysis showed significant benefit in the chemotherapy treatment groups with regard to local recurrence, distant recurrence, and progression-free survival. No significant difference in overall survival was found.³⁷ Pervais et al updated the Sarcoma Meta-analysis Collaboration’s 1997 meta-analysis with the inclusion of 4 new trials that evaluated doxorubicin combined with ifosfamide and found that both patients who received doxorubicin-based regimens or doxorubicin with ifosfamide had significant decreases in distant and overall recurrences. Only the trials that utilized doxorubicin and ifosfamide had an improved overall survival that was statistically significant (hazard ratio 0.56 [95% CI 0.36 to 0.85]; P = 0.01).²⁹ Although no significant heterogeneity was found among the trials included in either meta-analysis, a variety of sarcomas were included in each clinical trial evaluated. Given the extremely small number of each sarcoma subtype present in each trial, subgroup analysis is difficult and prone to inaccuracies. As a result, it is not known if certain histological subtypes are more or less responsive to chemotherapy.^37–39

One randomized controlled trial evaluated neoadjuvant chemotherapy in high-risk sarcomas defined as tumors greater than 8 cm or grade II/III tumors. This study evaluated doxorubicin and ifosfamide and found no significant difference in disease-free and overall survival in the neoadjuvant therapy group compared to the control group.³⁵ There remains controversy in the literature with regards to adjuvant chemotherapy. Many oncologists offer adjuvant chemotherapy to patients with certain stage III subtypes. Examples of subtypes that may be offered adjuvant therapy include myxoid liposarcomas, synovial sarcomas, and leiomyosarcomas.² With regards to how many cycles of chemotherapy should be considered, a noninferiority study compared 3 cycles of epirubicin and ifosfamide to 5 cycles of epirubicin and ifosfamide in patients with high-risk locally advanced adult STSs. Three cycles of preoperative epirubicin and ifosfamide was found to be noninferior to 5 cycles with regards to overall survival.³⁸

• What is this patient’s risk for recurrence?

The patient is at intermediate risk for recurrence. Numerous studies have demonstrated that tumor size, grade, and location are the most important factors to determine risk of recurrence, with larger size, higher grades, and deeper locations being associated with higher risk of recurrence. In an analysis of 1041 patients with STS of the extremities, high grade was the most important risk factor for distant metastases.³⁹ The highest risk of recurrence is within the first 2 years. Given that the patient’s initial tumor was located in the extremity, he is more likely to have a distant metastasis as his site of recurrence; individuals with retroperitoneal tumors and visceral tumors are more likely to recur locally.⁴⁰ For STSs of the extremity, distant metastases determine overall survival, whereas patients with retroperitoneal sarcomas can die from complications of local metastases.⁴¹ Once a patient develops distant metastases, the most important prognostic factor is the size of the tumor, with tumors larger than 10 cm having a relative risk of 1.5 (95% CI 1.0 to 2.0).³⁹

• What are the recommendations for surveillance?

Surveillance recommendations are based on the stage of the sarcoma. Stage I tumors are the least likely to recur either locally or distally. As a result, it is recommended that stage I tumors be followed with history and physical exam every 3 to 6 months for the first 2 to 3 years, and then annually after the first 2 to 3 years. Chest x-rays should be considered every 6 to 12 months.² For stage II–IV tumors, history and physical exam is recommended every 3 to 6 months for the first 2 to 3 years. Chest and distant metastases imaging should also be performed every 3 to 6 months during this time frame. For the next 2 years, history and physical exam and imaging are recommended every 6 months. After the first 4 to 5 years, annual follow-up is recommended.²

 

A study that followed 141 patients with primary extremity STSs for a median interval of 49 months found that high-grade tumors were most likely to recur during the first 2 years, with 20% of their patients recurring locally and 40% recurring distally. Chest x-rays performed during surveillance follow-up found distant lung metastases in 36 asymptomatic patients and had a positive predictive value of 92%, a negative predictive value of 97%, and a quality-adjusted life-year of $30,000.^40,41 No laboratory testing was found to aid in detection of recurrence.

CASE CONTINUED

The patient does well for 1 year. With physical therapy, he regains most of the strength and coordination of the lower extremity. He is followed every 3 months with chest x-rays and a MRI of the thigh for the first year. On his fourth follow-up clinic visit, he describes increased dyspnea on exertion over the previous few weeks and is found to have multiple lung metastases in both lungs on chest x-ray. He undergoes further evaluation for metastases and is not found to have any other metastatic lesions. Bronchoscopy and biopsy of 1 of the lung nodules confirms recurrent dedifferentiated liposarcoma.

• Should this patient undergo metastectomy?

An analysis of 3149 patients with STS treated at Memorial Sloan-Kettering who developed lung metastases found that patients with pulmonary metastases have survival rates of 25%. The most important prognostic factor for survival was complete resection of all metastases.⁴² For stage IV disease, surgery is used only in certain instances. In instances where tumor is more localized or limited, removal of metastases or metastectomy can play a role in management.²

CASE CONTINUED

Because the patient’s metastases are limited to the lungs, he is referred for metastectomy. He undergoes wedge resection for definitive diagnosis but it is not possible to completely resect all of the metastases. He is thus referred to a medical oncologist to discuss his treatment options.

• What are treatment options for unresectable or metastatic disease?

Metastatic Disease

Unlike local and locally advanced disease, chemotherapy forms the backbone of treatment in stage IV disease. Doxorubicin and olaratumab or doxorubicin and ifosfamide in combination are considered first line in metastatic disease. Response rates for single-agent doxorubicin range from 16% to 27%, while phase 2 and phase 3 studies of doxorubicin and ifosfamide have found response rates ranging from 18% to 36%.⁴³ In addition, the effectiveness of doxorubicin and ifosfamide phase 2 and 3 trials varied. Edmonson et al found a tumor regression rate of 34% for doxorubicin and ifosfamide as compared to 20% for doxorubicin alone.⁴⁴ In comparison, Santoro et al found a response rate of 21.3% for doxorubicin alone and 25.2% for doxorubicin and ifosfamide.⁴⁵ Neither study found increased survival benefit for doxorubicin and ifosfamide when compared to doxorubicin alone. In a Cochrane review evaluating randomized trials that compared doxorubicin and combination chemotherapy regimens, response rates varied from 14% for doxorubicin in combination with streptomycin to 34% for doxorubicin and ifosfamide. Most trials did not show a significant benefit for combination therapies when compared to doxorubicin alone.⁴³ Mean survival with doxorubicin or doxorubicin and ifosfamide is 12 months. High rates of recurrence highlight the need for additional chemotherapy regimens.

The newest approved agent is olaratumab, a monoclonal antibody that binds platelet-derived growth factor receptor alpha and prevents receptor activation. A phase 1-b and phase 2 trial evaluated patients with locally advanced and metastatic STS and randomly assigned them to either olaratumab and doxorubicin or doxorubicin alone.⁴⁶ Progression-free survival for olaratumab/doxorubicin was 6.6 months (95% CI 4.1 to 8.3) compared to 4.1 months (95% CI 2.8 to 5.4) for doxorubicin alone. The objective response rate was 18.2% (95% CI 9.8 to 29.6) for olaratumab/doxorubicin compared to 7.5% (95% CI 2.5 to 6.6) for doxorubicin alone. Furthermore, the median overall survival for olaratumab plus doxorubicin was 26.5 months (95% CI 20.9 to 31.7) compared to 14.7 months for doxorubicin alone (95% CI 5.5 to 26.0). Impressively, this improved response was notable across histological types. Furthermore, patients who had previously been treated with more than 1 regimen and those who were treatment naïve had similar response rates.⁴⁶

• What are second-line treatment options?

Doxorubicin has been used in combination with several other agents including dacarbazine (DTIC) as well as DTIC and ifosfamide (MAID). Borden et al evaluated patients with metastatic STS and randomly assigned the patients to either doxorubicin or doxorubicin and DTIC. Combination therapy demonstrated better tumor response than doxorubicin alone: 30% complete or partial response for combination therapy and 18% for doxorubicin alone.⁴⁷ However, Omura et al

 

found similar rates of efficacy between doxorubicin and combination doxorubicin and DTIC in women with recurrent or nonresectable uterine sarcomas.⁴⁸ MAID has never been directly compared in a randomized trial to doxorubicin alone. In a study that compared MAID to doxorubicin and DTIC (AD) in patients with unresectable or metastatic sarcomas, MAID had superior response rates (32% versus 17%), but there was no difference with regards to overall survival (mean survival of 12.5 months).⁴⁹

Several additional regimens have undergone evaluation in metastatic and recurrent STSs. Gemcitabine has been used both as a single agent and as part of combination therapy in many studies. Studies with gemcitabine in combination with either docetaxel or DTIC have been the most efficacious. In a phase 2 trial, patients with metastatic STS were randomly assigned to either gemcitabine alone or gemcitabine and docetaxel. Combination therapy had a higher response rate (16% versus 8%) and longer overall survival (17.9 months versus 11.5 months) than gemcitabine alone.⁵⁰ Furthermore, a phase 2 trial of gemcitabine and docetaxel in patients with unresectable leiomyosarcoma showed an overall response rate of 56%, with 3 complete and 15 partial responses among the 34 patients enrolled in the study.⁵¹

A phase 2 trial randomly assigned patients with unresectable or metastatic STS to either DTIC or combination gemcitabine and DTIC.⁵² Gemcitabine-DTIC had a superior progression-free survival at 3 months (56% [95% CI 43% to 69%]) as compared to DTIC alone (37% [95% CI 23.5% to 50%]). Furthermore, mean progression-free survival and overall survival were improved in the gemcitabine-DTIC group (4.2 months and 16.8 months) as compared to the DTIC group (2.0 months and 8.2 months).⁵² DTIC has a single-agent response rate of 16%, but has been shown to be particularly effective in the setting of leiomyosarcomas.⁴⁹

• Does response to treatment regimens differ by histologic subtype?

The majority of STS trials include many different histologic subtypes. Given the rarity of sarcomas as a whole, many trials have had difficulty recruiting adequate numbers of patients to have sufficient power to definitely determine if the treatment under investigation has clinical benefit. Furthermore, the patients recruited have been heterogeneous with regard to subtype. Many older studies hypothesized that the efficacy of chemotherapeutic agents vary based on histologic subtype; however, for most subtypes the number of individuals included in those trials was too low to evaluate efficacy based on subtype.

Some exceptions exist, however. For example, both gemcitabine-DTIC and gemcitabine-docetaxel have been found to be particularly effective in the treatment of leiomyosarcomas.^50,52 Additionally, a retrospective study found a 51% overall response rate for patients with myxoid liposarcomas treated with trabectedin.⁵³ Studies of patients with angiosarcoma treated with paclitaxel have demonstrated response rates of 43% and 53%.^54,55

• What are the newest approved and investigational agents?

A recently approved agent is trabectedin, a tris tetrahydroisoquinoline alkaloid isolated from ascidians that binds to the minor groove of DNA and causes disruptions in the cell cycle. Samuels et al reported data from a single-arm, open-label expanded access trial that evaluated patients with advanced metastatic sarcomas.⁵⁶ In this study, patients with liposarcomas and leiomyosarcomas had an objective response rate of 6.9% (95% CI 4.8 to 9.6) as compared to a rate of 5.9% (95% CI 4.4 to 7.8) for all assessable patients. Median survival was 11.9 months for all patients, with improved median survivals for liposarcoma and leiomyosarcomas of 16.2 months (95% CI 14.1 to 19.5) compared to 8.4 months (95% CI 7.1 to 10.7 months) for other subtypes.⁵⁶

Schöffski et al evaluated eribulin, a chemotherapeutic agent that affects microtubule dynamics, in a phase 2 trial of patients with progressive or high-grade STS with progression on previous chemotherapy. They found a median progression-free survival of 2.6 months (95% CI 1.7 to 6.2) for adipocytic sarcoma, 2.9 months (95% CI 2.4 to 4.6) for leiomyosarcoma, 2.6 months (95% CI 2.3 to 4.3) for synovial sarcoma, and 2.1 months (95% CI 1.4 to 2.9) for other sarcomas.⁵⁷

Van der Graaf and colleagues randomly assigned patients with metastatic nonadipocytic STS to pazopanib or placebo in a phase 3 trial. Pazopanib is a small-molecule endothelial growth factor inhibitor with activity against vascular endothelial growth factors 1, 2, and 3 as well as platelet-derived growth factors. Median progression-free survival was 4.6 months (95% CI 3.7 to 4.8) with pazopanib compared to 1.6 months (95% CI 0.9 to 1.8) with placebo.⁵⁸ Adipocytic sarcomas (liposarcomas) were excluded from the trial because phase 2 trials had found a lower rate of progression-free survival (26%) for them compared to other subtypes.

 

• What are the most common toxicities associated with the approved and investigational chemotherapeutic agents?

Toxicities were seen with each of the regimens studied and were common in the randomized trials, with higher rates of toxicities in the combination chemotherapy regimens. The most common toxicities are myelosuppression, nausea, and vomiting. In the doxorubicin trials, the most common toxicities were myelosuppression, nausea, and vomiting.⁴⁴

Ifosfamide both as an individual agent and in combination with doxorubicin has higher rates and higher grades of toxicity than doxorubicin alone. Myelosuppression is the most common toxicity associated with ifosfamide, and the most commonly affected cell line is leukocytes.⁴⁴ Combination doxorubicin and ifosfamide also had high rates of nausea and vomiting (95%) and alopecia (100%).³⁵

Neutropenia is the most common toxicity associated with gemcitabine and dacarbazine, while their most common nonhematologic toxicities are fatigue and nausea.^52,59 Trabectedin’s most common toxicities are nausea (29%), neutropenia (24%), and fatigue (23%). It has also been shown to cause increased alkaline phosphatase (20%) and alanine aminotransferase (19%) levels.⁵⁶ In a phase 2 study of eribulin, 50% of patients had neutropenia, and other toxicities included fatigue, alopecia, nausea, sensory neuropathy, and thrombocytopenia.⁵⁷ Pazopanib is generally well tolerated; the most common toxicities are fatigue (65%), diarrhea (58%), nausea (54%), and hypertension (41%).⁵⁸ Higher rates of neutropenia, mucositis, nausea, vomiting, diarrhea, and transfusion reactions were seen with olaratumab and doxorubicin compared to doxorubicin alone in phase 1b and 2 studies.⁴⁶

CASE CONCLUSION

Given his poor prognosis with unresectable metastatic undifferentiated liposarcoma, the patient considers a clinical trial prior to undergoing combined therapy with doxorubicin and ifosfamide. He tolerates therapy well with stable disease at 6 months.

CONCLUSION

STSs are a heterogeneous collection of rare tumors. Low-grade, localized tumors have the best prognosis, and patients who undergo complete resection have the best long-term survival. Due to the rarity of STSs, trials often have limited enrollment, and little progress has been made with regards to treatment and survival rates for metastatic and unresectable disease. All patients should be evaluated and treated at specialized sarcoma centers. This case highlights the need for continued research and clinical trials to improve overall survival of patients with sarcoma.

INTRODUCTION

Soft tissue sarcomas (STSs) are rare adult tumors, with 3.4 new cases per 100,000 persons or 12,310 expected new cases in 2016.¹ Sarcomas are a heterogeneous collection of tumors that affect fat, muscle, nerve, nerve sheath, vascular, and connective tissues. There are more than 50 histological subtypes that comprise this diverse category of tumors. Treatment varies by stage, with limb-sparing surgery representing the mainstay of curative-intent treatment. Radiation and chemotherapy may also be considered depending on the size, grade, and location of the tumor. Survival rates have been stagnant until recently, with a disease-specific survival hovering around 65%.¹ Given the complexity of these cases, all patients ideally should be evaluated and treated by a multidisciplinary team at an institution with extensive experience treating STS.²

EPIDEMIOLOGY AND CLASSIFICATION

The most common STS subtypes are gastrointestinal stromal tumor (GIST), undifferentiate pleomorphic sarcoma (previously referred to as malignant fibrous histiocytoma), liposarcoma, leiomyosarcoma, synovial sarcoma, malignant peripheral nerve sheath tumor, rhabdomyosarcoma, and unclassified sarcoma.³ Liposarcoma is one of the most common subtypes, comprising 20% of all STSs; it is subdivided into well-differentiated/dedifferentiated liposarcomas, myxoid/round cell liposarcomas, and pleomorphic liposarcomas. Well-differentiated liposarcomas tend to occur in the retroperitoneum and limbs, while both myxoid and round cell as well as pleomorphic liposarcomas more commonly originate on the limbs. Histology varies based on subtype and ranges from mature-appearing adipocytes and fibroblasts to undifferentiated cells with minimal lipogenic differentiation.⁴

Leiomyosarcomas are smooth muscle tumors and are usually located in the retroperitoneum, but have also been associated with peripheral soft tissue and vasculature. Typical histology ranges from well-defined areas of spindle-shaped cells to poorly differentiated anaplastic spindle cells.^5,6 Synovial sarcomas are a distinct type of STS that can show epithelial differentiation and account for 5% of adult STSs. The extremities are the most common presenting location (90%).⁷

Rhabdomyosarcomas are skeletal muscle tumors and are further subdivided into embryonal, alveolar, and pleomorphic subtypes. Embryonal histology ranges from primitive mesenchymal-appearing cells to highly differentiated muscle cells. Alveolar rhabdomyosarcoma has the worst prognosis of the subtypes and consists of round cells with high nuclear-to-chromatin ratios that form “glandular-like” or “alveolar” spaces.⁸ Pleomorphic rhabdomyosarcomas are composed of rhabdomyoblasts that can affect many different locations, but most commonly present on the lower extremities.⁹

Malignant peripheral nerve sheath tumor (MPNST) comprises 5% to 10% of all STSs. These tumors are associated with neurofibromatosis type 1 (NF-1), with 25% to 50% of tumors occurring in NF-1 patients. Additionally, most patients have a truncating lesion in the NF1 gene on chromosome 17.¹⁰ Anghileri et al in their single institution analysis of 205 patients with MPNSTs found the 2 most common presenting sites were the trunk and extremities. Histologically, these tumors have dense fascicles of spindle cells.¹⁰

GISTs are the most common STS of the gastrointestinal (GI) tract. Previously, GISTs were classified as smooth muscle tumors and were not accounted for in the literature as a separate entity distinct from leiomyomas, leiomyoblastomas, and leiomyosarcomas.¹¹ GISTs are found throughout the GI tract: the most common sites are the stomach (60%) and small intestine (30%). Less common sites include duodenum (4%–5%), esophagus (1%), rectum (1%–2%), and appendix (< 0.2%).¹² GISTs can be spindle cell, epithelioid, or mesenchymal tumors. Immunohistochemically, GISTs are KIT (CD117) positive. Other cell markers that are also commonly positive include CD34 (60%–70%) and smooth muscle actin (SMA) (25%).¹¹ The majority of GISTs (80%) have an activating c-KIT gene mutation. The most common mutation site is exon 11, with less common c-KIT gene mutations also occurring at exon 9 or 13. Not all GISTs have KIT mutations. The second most common mutation is the PDGFRA mutation (5%–10% of GISTs).² A minority of GISTs are negative for both KIT and PDGFRA mutations. These tumors were previously called wild-type, but as the majority have either a succinate dehydrogenase (SDH) loss of function or loss of SDHB protein expression, they are now referred to as SDH-deficient GISTs.² GISTs vary in aggressiveness from incidental to aggressive. Typically, small intestine and rectal GISTs are more aggressive than gastric GISTs. Both size and mitotic rate help to predict the metastatic potential of the tumor. Tumors less than 2 cm in size and having a mitotic rate of less than 5 per 50 high-power fields (hpf) have the lowest risk of metastases, while tumors greater than 5 cm and with more than 5 mitoses per 50 hpf have the highest rates of metastases.¹²

 

Angiosarcomas are rare tumors comprising 4% of all STSs. Although they can occur in any site, the majority are cutaneous and occur most frequently in the head and neck regions. These tumors are either of vascular or lymphatic origin and are comprised of abnormal, pleomorphic, malignant endothelial cells. The most useful immunohistochemical markers include von Willebrand factor, CD31, and Ulex europaeus agglutinin 1. The majority of these tumors occur sporadically; however, radiation exposure, chronic lymphedema, and certain toxins including vinyl chloride and thorium dioxide are known risk factors.¹³

Undifferentiated sarcomas have no specific features and typically consist of primitive mesenchymal cells.

CLINICAL EVALUATION

CASE PRESENTATION

Initial Presentation and History

A 55-year-old man presents to his primary care physician with a painless mass in his anterior thigh. The mass has been present for the past 3 months and he believes that it is enlarging. The patient has a history of well-controlled hypertension and hyperlipidemia. His medications include atorvastatin and hydrochlorothiazide. He has no known drug allergies. Family history is notable for diabetes and hypertension. He drinks 4 to 5 alcoholic drinks a week and he is a former smoker. He quit smoking in his 30s and only smoked intermittently prior to quitting. He denies any illicit drug use. He works as a high school principal. Currently, he feels well. His review of systems is otherwise noncontributory.

Physical Examination

On physical exam, he is afebrile with a blood pressure of 132/75 mm Hg, respiratory rate of 10 breaths/min, and oxygen saturation of 99% on room air. He is a well appearing, overweight male. His head and neck exam is unremarkable. Lung exam reveals clear breath sounds, and cardiac exam reveals a regular rate and rhythm. His abdomen is obese, soft, and without hepatosplenomegaly. There is a large, fixed mass on the anterior lateral aspect of his right thigh. He has no appreciable lymphadenopathy. His neurological exam is unremarkable.

• What are risk factors for sarcoma?

There are few known risk factors for sarcoma. Established risks factors include prior radiation therapy, chronic lymphedema, viruses, and genetic cancer syndromes including Li-Fraumeni syndrome, hereditary retinoblastoma, and NF-1. Other environmental exposures include phenoxyacetic acids and chlorophenols.¹⁴ The majority of cases are sporadic, with only a minority of patients having one of these known risk factors.¹⁵ Up to one third of sarcomas have a specific translocation and are driven by fusion oncogenes (Table 1).

table1_hpho_sarcoma_010117.jpg

• What is the typical presentation for sarcomas?

A painless mass is the most typical presenting symptom. Size at presentation varies based on location, with extremity and head and neck locations typically presenting at smaller sizes than retroperitoneal tumors.¹⁴ Patients may experience pain and numbness as the mass enlarges and impinges on surrounding structures including nerves and vasculature. The vast majority of patients are without systemic symptoms.

• How is sarcoma staged?

The American Joint Committee on Cancer (AJCC) staging system is the most widely used staging system in the United States. The latest AJCC manual was updated in 2010 to include a 3-tiered grading system where the tumor is classified according to tumor size, lymph node involvement, metastases, and grade at time of diagnosis (Table 2 and Table 3). Additionally, tumor depth in relation to deep fascia is also taken into account, with superficial tumors being assigned a designation of “a” and deep tumors a designation of “b.”

table2_hpho_sarcoma_010117.jpg

table3_hpho_sarcoma_010117.jpg

Previously, 2 of the most widely used grading systems were the National Cancer Institute (NCI) and French Federation of Cancer Centers Sarcoma Group (FNCLCC) systems, both 3-tier grading systems. The main components that determine the NCI grade are the tumor’s histologic type and location and the amount of tumor necrosis. The FNCLCC system evaluation focuses on tumor differentiation, mitotic rate, and amount of tumor necrosis. A study that compared the NCI and FNCLCC grading systems found that FNCLCC was a better predictor of mortality and distant metastasis.¹⁶ Previously, the AJCC was a 4-tier grading system, but the 2010 version was updated to the 3-tier FNCLCC grading system. Additionally, the AJCC system has reclassified single lymph node disease as stage III as it confers better survival than metastatic disease.¹⁷ It is important that pathology be evaluated by a sarcoma specialist as disagreements with regard to histologic subtype and grade are common.^18,19

• What are the most important prognostic factors?

Prognostic factors include grade, size, and presence of metastases at presentation. Best survival is associated with low-grade, small tumors with no metastases at time of diagnosis.¹⁴

 

• What imaging should be considered?

Imaging should be undertaken to help differentiate between benign and malignant lesions. Ideally, it should be undertaken before a biopsy is planned as the imaging can be used to plan biopsy as well as provide invaluable prognostic information. There are several imaging modalities that should be considered during the preliminary work-up and staging of STSs. Conventional imaging includes magnetic resonance imaging (MRI) of the original tumor site; computed tomography (CT) to evaluate for pulmonary metastases and, depending on location, liver metastases; and in the case of small, low-grade tumors, chest radiography. MRI is considered the test of choice for soft tissue masses and can help delineate benign masses such as hematomas, lipomas, and hemangiomas from sarcomas.²⁰ It is difficult to compare the accuracy of positron emission tomography (PET)/CT to CT and MRI because most studies have evaluated PET/CT in parallel with CT and MRI.²¹ Tateishi et al compared the accuracy of conventional imaging, PET/CT, and PET/CT combined with conventional imaging at determining the TNM staging for 117 patients. They found that conventional imaging correctly classified 77% of patients, PET alone correctly classified 70%, PET/CT correctly classified 83%, and PET/CT combined with conventional imaging correctly staged 87%.²²

• Which subtypes are most likely to metastasize?

Although the vast majority of sarcomas spread hematogenously, 3 have a propensity to spread lymphogenously: epithelioid sarcoma, rhabdomyosarcoma, and clear-cell sarcoma. Additionally, certain subtypes are more likely to metastasize: leiomyosarcomas, synovial sarcomas, neurogenic sarcomas, rhabdomyosarcomas, and epithelioid sarcomas.²³ Sarcomas metastasize to the lungs more frequently than to the liver. The metastatic pattern is defined primarily by sarcoma subtype and site of primary tumor. Sarcomas rarely metastasize to the brain (~1%).

MANAGEMENT

CASE CONTINUED

The patient undergoes an ultrasound to better visualize the mass. Given the heterogeneous character of the mass, he is referred for an MRI to evaluate the mass and a CT scan of the chest, abdomen, and pelvis to evaluate for distant metastases. MRI reveals a 5.1 cm × 4.6 cm heterogeneous mass invading the superficial fascia of the rectus femoris muscle. No suspicious lymph nodes or other masses are identified on imaging. The patient next undergoes an image-guided core needle biopsy. Pathology from that procedure is consistent with a stage III, T2bNxMx, grade 3, dedifferentiated liposarcoma.

• What is the best management approach for this patient?

SURGERY

Surgery is the mainstay of treatment for STS. Patients with the best prognosis are those who undergo complete resection with negative surgical margins.^24,25 Goal tumor-free margin is 1 to 3 cm.²⁶ Complete resection confers the best long-term survival. Both local and metastatic recurrence is higher in patients with incomplete resection and positive margins.^24,25 In a study that analyzed 2084 localized primary STSs, patients with negative margins had a local recurrence rate of 15% versus a rate of 28% in patients with positive margins. This translated into higher 5-year local recurrence-free survival for patients with negative surgical margins (82%) compared to patients with positive margins (65%).²⁷ Another study similarly found that patients with negative margins at referral to their institution who underwent postoperative radiation had high local control rates of 93% (95% confidence interval [CI] 87% to 97%) at 5, 10, and 15 years.²⁶ Although radiation improves local control, neither preoperative or postoperative radiation has been shown to improve progression-free or overall survival.²⁸ Other factors that are associated with risk of recurrence are tumor location, history of previous recurrence, age of patient, histopathology, tumor grade, and tumor size. Approximately 40% to 50% of patients with high-grade tumors (defined as size > 5 cm, deep location, and high grade) will develop distant metastases.²⁹

Zagars et al found that positive or uncertain resection margin had a relative risk of local recurrence of 2.0 (95% CI 1.3 to 3.1; P = 0.002), and presentation with locally recurrent disease (vs new tumor) had a relative risk of local recurrence of 2.0 (95% CI 1.2 to 3.4; P = 0.013).²⁶ Patients with STS of head and neck and deep trunk have higher recurrence rates than those with superficial trunk and extremity STS. A single-institution retrospective review demonstrated that patients with completely resectable retroperitoneal sarcomas have longer median survival (103 months) compared to patients with incompletely resected abdominal sarcomas (18 months).²⁵

 

Rosenberg and colleagues compared amputation to limb-sparing surgery and radiation.²⁴ Their prospective analysis of 65 patients found no difference in disease-free and overall survival between the 2 treatment groups.The limb-sparing treatment group had higher rates of local recurrence, which was highly correlated with positive surgical margins on pathology.²⁴ Evidence from this and similar studies has resulted in radical amputations being replaced by conservative limb-sparing procedures and radiation therapy. In those found to have positive margins, re-resection is an option for some. Patients who undergo re-resection have higher local control rates than patients with positive margins who do not undergo re-resection. The 5-year control rate for patients who undergo re-resection is 85% (95% CI 80% to 89%) compared to 78% (95% CI 71% to 83%) for those who do not undergo re-resection. Similarly, patients who undergo re-resection have lower rates of metastases at 5, 10, and 15 years as well as higher 5-, 10-, and 15-year disease-free survival rates.²⁶

CASE CONTINUED

The patient is referred for limb-sparing surgery after presentation at a multidisciplinary tumor board. Prior to undergoing resection of the tumor, he is also referred to radiation-oncology to discuss the risks and benefits of combination radiotherapy and surgery as opposed to surgical resection alone.

• What is the evidence for radiation therapy?

RADIATION THERAPY

Radiation therapy is used in the preoperative, intraoperative, and postoperative settings to reduce the risk of local recurrence. There are several options for radiation, including external beam radiation therapy (EBRT), intraoperative radiation, and brachytherapy. A newer strategy, intensity-modulated radiation therapy (IMRT), utilizes 3-dimensional modeling to reduce radiation dosages. Overall there are no differences in overall survival or local recurrence rates between preoperative and postoperative radiation in STS.²⁸

The rationale behind preoperative radiation is that it reduces seeding of tumor cells, especially at the time of surgery.³⁰ Additionally, for EBRT, preoperative radiation has smaller field sizes and lower radiation doses. It can also help to reduce the size of the tumor prior to resection. Intraoperative radiation is often paired with preoperative radiation as a boost dose given only to the area of residual tumor.

Suit et al reviewed patients treated at a single institution with limb-sparing surgery and different radiation strategies. Local control rates between preoperative and postoperative radiation groups were not statistically significant. Local recurrence was linked to grade and size of the tumor in both groups. The authors did note, however, that the preoperative radiation group tended to have larger tumor sizes at baseline compared to the patients who received postoperative radiation.³⁰ A study that compared 190 patients who received preoperative and postoperative EBRT or brachytherapy (primary end point was wound complications, and local control was a secondary end point) showed a trend towards greater local control with preoperative radiation; however, the preoperative radiation group had significantly more wound complications compared to the postoperative radiation group.³¹

Yang et al found that postoperative EBRT decreases rates of local recurrence compared to surgery alone in high-grade extremity sarcomas.³² However, there were no differences in rates of distant metastases and overall survival between the 2 treatment groups. Similarly, in patients with low-grade sarcoma, there were fewer local recurrences in those who received EBRT and surgery as compared to surgery alone.³² Another study that evaluated 164 patients who received either adjuvant brachytherapy or no further therapy after complete resection found that brachytherapy reduced local recurrence in high-grade sarcomas. No difference in local recurrence rates was found in patients with low-grade sarcomas, nor was a significant difference found in the rates of distant metastases and overall survival between the 2 treatment groups.³³ With regards to IMRT, a single institution cohort experience with 41 patients who received IMRT following limb-sparing surgery had similar local control rates when compared to historical controls.³⁴

CASE CONTINUED

After discussion of the risks and benefits of radiation therapy, the patient opts for preoperative radiation prior to resection of his liposarcoma. He receives 50 Gy of EBRT prior to undergoing resection. Resection results in R1 margin consistent with microscopic disease. He receives 16 Gy of EBRT as a boost after recovery from his resection.²

• What is the evidence for neoadjuvant and adjuvant chemotherapy for stage I tumors?

CHEMOTHERAPY

Localized Sarcoma

For localized sarcoma, limb-sparing resection with or without radiation forms the backbone of treatment. Studies have evaluated chemotherapy in both the neoadjuvant and adjuvant settings, with the vast majority of studies evaluating doxorubicin-based chemotherapy regimens in the adjuvant settings. Due to the rare nature of sarcomas, most studies are not sufficiently powered to detect significant benefit from chemotherapy. Several trials evaluating chemotherapy regimens in the neoadjuvant and adjuvant settings needed to be terminated prematurely due to inadequate enrollment into the study. ^35,36

 

For stage IA (T1a-Tb, N0, M0, low grade) tumors, no additional therapy is recommended after limb-sparing surgery with appropriate surgical margins. For stage IB (T2a-2b, N0, M0, low grade) tumors with insufficient margins, re-resection and radiation therapy should be considered, while for stage IIA (T1a-1b, N0, M0, G2-3) tumors preoperative or postoperative radiation therapy is recommended.² Studies have not found benefit of adjuvant chemotherapy in these low-grade, stage I tumors in terms of progression-free survival and overall survival.³⁷

• At what stage should chemotherapy be considered?

For stage IIb and stage III tumors, surgery and radiation therapy again form the backbone of therapy; however, neoadjuvant and adjuvant chemotherapy are also recommended as considerations. Anthracycline-based chemotherapy with either single-agent doxorubicin or doxorubicin and ifosfamide in combination are considered first-line chemotherapy agents in locally advanced STS.^2,29,37

Evidence regarding the efficacy of both neoadjuvant and adjuvant chemotherapy regimens in the setting of locally advanced high-grade STS has been mixed. The Sarcoma Meta-analysis Collaboration evaluated 14 trials of doxorubicin-based adjuvant chemotherapy and found a trend towards overall survival in the treatment groups that received chemotherapy.³⁷ All trials included in the meta-analysis compared patients with localized resectable soft-tissue sarcomas who were randomized to either adjuvant chemotherapy or no adjuvant chemotherapy after limb-sparing surgery with or without radiation therapy. None of the individual trials showed a significant benefit, and all trials had large confidence intervals; however, the meta-analysis showed significant benefit in the chemotherapy treatment groups with regard to local recurrence, distant recurrence, and progression-free survival. No significant difference in overall survival was found.³⁷ Pervais et al updated the Sarcoma Meta-analysis Collaboration’s 1997 meta-analysis with the inclusion of 4 new trials that evaluated doxorubicin combined with ifosfamide and found that both patients who received doxorubicin-based regimens or doxorubicin with ifosfamide had significant decreases in distant and overall recurrences. Only the trials that utilized doxorubicin and ifosfamide had an improved overall survival that was statistically significant (hazard ratio 0.56 [95% CI 0.36 to 0.85]; P = 0.01).²⁹ Although no significant heterogeneity was found among the trials included in either meta-analysis, a variety of sarcomas were included in each clinical trial evaluated. Given the extremely small number of each sarcoma subtype present in each trial, subgroup analysis is difficult and prone to inaccuracies. As a result, it is not known if certain histological subtypes are more or less responsive to chemotherapy.^37–39

One randomized controlled trial evaluated neoadjuvant chemotherapy in high-risk sarcomas defined as tumors greater than 8 cm or grade II/III tumors. This study evaluated doxorubicin and ifosfamide and found no significant difference in disease-free and overall survival in the neoadjuvant therapy group compared to the control group.³⁵ There remains controversy in the literature with regards to adjuvant chemotherapy. Many oncologists offer adjuvant chemotherapy to patients with certain stage III subtypes. Examples of subtypes that may be offered adjuvant therapy include myxoid liposarcomas, synovial sarcomas, and leiomyosarcomas.² With regards to how many cycles of chemotherapy should be considered, a noninferiority study compared 3 cycles of epirubicin and ifosfamide to 5 cycles of epirubicin and ifosfamide in patients with high-risk locally advanced adult STSs. Three cycles of preoperative epirubicin and ifosfamide was found to be noninferior to 5 cycles with regards to overall survival.³⁸

• What is this patient’s risk for recurrence?

The patient is at intermediate risk for recurrence. Numerous studies have demonstrated that tumor size, grade, and location are the most important factors to determine risk of recurrence, with larger size, higher grades, and deeper locations being associated with higher risk of recurrence. In an analysis of 1041 patients with STS of the extremities, high grade was the most important risk factor for distant metastases.³⁹ The highest risk of recurrence is within the first 2 years. Given that the patient’s initial tumor was located in the extremity, he is more likely to have a distant metastasis as his site of recurrence; individuals with retroperitoneal tumors and visceral tumors are more likely to recur locally.⁴⁰ For STSs of the extremity, distant metastases determine overall survival, whereas patients with retroperitoneal sarcomas can die from complications of local metastases.⁴¹ Once a patient develops distant metastases, the most important prognostic factor is the size of the tumor, with tumors larger than 10 cm having a relative risk of 1.5 (95% CI 1.0 to 2.0).³⁹

• What are the recommendations for surveillance?

Surveillance recommendations are based on the stage of the sarcoma. Stage I tumors are the least likely to recur either locally or distally. As a result, it is recommended that stage I tumors be followed with history and physical exam every 3 to 6 months for the first 2 to 3 years, and then annually after the first 2 to 3 years. Chest x-rays should be considered every 6 to 12 months.² For stage II–IV tumors, history and physical exam is recommended every 3 to 6 months for the first 2 to 3 years. Chest and distant metastases imaging should also be performed every 3 to 6 months during this time frame. For the next 2 years, history and physical exam and imaging are recommended every 6 months. After the first 4 to 5 years, annual follow-up is recommended.²

 

A study that followed 141 patients with primary extremity STSs for a median interval of 49 months found that high-grade tumors were most likely to recur during the first 2 years, with 20% of their patients recurring locally and 40% recurring distally. Chest x-rays performed during surveillance follow-up found distant lung metastases in 36 asymptomatic patients and had a positive predictive value of 92%, a negative predictive value of 97%, and a quality-adjusted life-year of $30,000.^40,41 No laboratory testing was found to aid in detection of recurrence.

CASE CONTINUED

The patient does well for 1 year. With physical therapy, he regains most of the strength and coordination of the lower extremity. He is followed every 3 months with chest x-rays and a MRI of the thigh for the first year. On his fourth follow-up clinic visit, he describes increased dyspnea on exertion over the previous few weeks and is found to have multiple lung metastases in both lungs on chest x-ray. He undergoes further evaluation for metastases and is not found to have any other metastatic lesions. Bronchoscopy and biopsy of 1 of the lung nodules confirms recurrent dedifferentiated liposarcoma.

• Should this patient undergo metastectomy?

An analysis of 3149 patients with STS treated at Memorial Sloan-Kettering who developed lung metastases found that patients with pulmonary metastases have survival rates of 25%. The most important prognostic factor for survival was complete resection of all metastases.⁴² For stage IV disease, surgery is used only in certain instances. In instances where tumor is more localized or limited, removal of metastases or metastectomy can play a role in management.²

CASE CONTINUED

Because the patient’s metastases are limited to the lungs, he is referred for metastectomy. He undergoes wedge resection for definitive diagnosis but it is not possible to completely resect all of the metastases. He is thus referred to a medical oncologist to discuss his treatment options.

• What are treatment options for unresectable or metastatic disease?

Metastatic Disease

Unlike local and locally advanced disease, chemotherapy forms the backbone of treatment in stage IV disease. Doxorubicin and olaratumab or doxorubicin and ifosfamide in combination are considered first line in metastatic disease. Response rates for single-agent doxorubicin range from 16% to 27%, while phase 2 and phase 3 studies of doxorubicin and ifosfamide have found response rates ranging from 18% to 36%.⁴³ In addition, the effectiveness of doxorubicin and ifosfamide phase 2 and 3 trials varied. Edmonson et al found a tumor regression rate of 34% for doxorubicin and ifosfamide as compared to 20% for doxorubicin alone.⁴⁴ In comparison, Santoro et al found a response rate of 21.3% for doxorubicin alone and 25.2% for doxorubicin and ifosfamide.⁴⁵ Neither study found increased survival benefit for doxorubicin and ifosfamide when compared to doxorubicin alone. In a Cochrane review evaluating randomized trials that compared doxorubicin and combination chemotherapy regimens, response rates varied from 14% for doxorubicin in combination with streptomycin to 34% for doxorubicin and ifosfamide. Most trials did not show a significant benefit for combination therapies when compared to doxorubicin alone.⁴³ Mean survival with doxorubicin or doxorubicin and ifosfamide is 12 months. High rates of recurrence highlight the need for additional chemotherapy regimens.

The newest approved agent is olaratumab, a monoclonal antibody that binds platelet-derived growth factor receptor alpha and prevents receptor activation. A phase 1-b and phase 2 trial evaluated patients with locally advanced and metastatic STS and randomly assigned them to either olaratumab and doxorubicin or doxorubicin alone.⁴⁶ Progression-free survival for olaratumab/doxorubicin was 6.6 months (95% CI 4.1 to 8.3) compared to 4.1 months (95% CI 2.8 to 5.4) for doxorubicin alone. The objective response rate was 18.2% (95% CI 9.8 to 29.6) for olaratumab/doxorubicin compared to 7.5% (95% CI 2.5 to 6.6) for doxorubicin alone. Furthermore, the median overall survival for olaratumab plus doxorubicin was 26.5 months (95% CI 20.9 to 31.7) compared to 14.7 months for doxorubicin alone (95% CI 5.5 to 26.0). Impressively, this improved response was notable across histological types. Furthermore, patients who had previously been treated with more than 1 regimen and those who were treatment naïve had similar response rates.⁴⁶

• What are second-line treatment options?

Doxorubicin has been used in combination with several other agents including dacarbazine (DTIC) as well as DTIC and ifosfamide (MAID). Borden et al evaluated patients with metastatic STS and randomly assigned the patients to either doxorubicin or doxorubicin and DTIC. Combination therapy demonstrated better tumor response than doxorubicin alone: 30% complete or partial response for combination therapy and 18% for doxorubicin alone.⁴⁷ However, Omura et al

 

found similar rates of efficacy between doxorubicin and combination doxorubicin and DTIC in women with recurrent or nonresectable uterine sarcomas.⁴⁸ MAID has never been directly compared in a randomized trial to doxorubicin alone. In a study that compared MAID to doxorubicin and DTIC (AD) in patients with unresectable or metastatic sarcomas, MAID had superior response rates (32% versus 17%), but there was no difference with regards to overall survival (mean survival of 12.5 months).⁴⁹

Several additional regimens have undergone evaluation in metastatic and recurrent STSs. Gemcitabine has been used both as a single agent and as part of combination therapy in many studies. Studies with gemcitabine in combination with either docetaxel or DTIC have been the most efficacious. In a phase 2 trial, patients with metastatic STS were randomly assigned to either gemcitabine alone or gemcitabine and docetaxel. Combination therapy had a higher response rate (16% versus 8%) and longer overall survival (17.9 months versus 11.5 months) than gemcitabine alone.⁵⁰ Furthermore, a phase 2 trial of gemcitabine and docetaxel in patients with unresectable leiomyosarcoma showed an overall response rate of 56%, with 3 complete and 15 partial responses among the 34 patients enrolled in the study.⁵¹

A phase 2 trial randomly assigned patients with unresectable or metastatic STS to either DTIC or combination gemcitabine and DTIC.⁵² Gemcitabine-DTIC had a superior progression-free survival at 3 months (56% [95% CI 43% to 69%]) as compared to DTIC alone (37% [95% CI 23.5% to 50%]). Furthermore, mean progression-free survival and overall survival were improved in the gemcitabine-DTIC group (4.2 months and 16.8 months) as compared to the DTIC group (2.0 months and 8.2 months).⁵² DTIC has a single-agent response rate of 16%, but has been shown to be particularly effective in the setting of leiomyosarcomas.⁴⁹

• Does response to treatment regimens differ by histologic subtype?

The majority of STS trials include many different histologic subtypes. Given the rarity of sarcomas as a whole, many trials have had difficulty recruiting adequate numbers of patients to have sufficient power to definitely determine if the treatment under investigation has clinical benefit. Furthermore, the patients recruited have been heterogeneous with regard to subtype. Many older studies hypothesized that the efficacy of chemotherapeutic agents vary based on histologic subtype; however, for most subtypes the number of individuals included in those trials was too low to evaluate efficacy based on subtype.

Some exceptions exist, however. For example, both gemcitabine-DTIC and gemcitabine-docetaxel have been found to be particularly effective in the treatment of leiomyosarcomas.^50,52 Additionally, a retrospective study found a 51% overall response rate for patients with myxoid liposarcomas treated with trabectedin.⁵³ Studies of patients with angiosarcoma treated with paclitaxel have demonstrated response rates of 43% and 53%.^54,55

• What are the newest approved and investigational agents?

A recently approved agent is trabectedin, a tris tetrahydroisoquinoline alkaloid isolated from ascidians that binds to the minor groove of DNA and causes disruptions in the cell cycle. Samuels et al reported data from a single-arm, open-label expanded access trial that evaluated patients with advanced metastatic sarcomas.⁵⁶ In this study, patients with liposarcomas and leiomyosarcomas had an objective response rate of 6.9% (95% CI 4.8 to 9.6) as compared to a rate of 5.9% (95% CI 4.4 to 7.8) for all assessable patients. Median survival was 11.9 months for all patients, with improved median survivals for liposarcoma and leiomyosarcomas of 16.2 months (95% CI 14.1 to 19.5) compared to 8.4 months (95% CI 7.1 to 10.7 months) for other subtypes.⁵⁶

Schöffski et al evaluated eribulin, a chemotherapeutic agent that affects microtubule dynamics, in a phase 2 trial of patients with progressive or high-grade STS with progression on previous chemotherapy. They found a median progression-free survival of 2.6 months (95% CI 1.7 to 6.2) for adipocytic sarcoma, 2.9 months (95% CI 2.4 to 4.6) for leiomyosarcoma, 2.6 months (95% CI 2.3 to 4.3) for synovial sarcoma, and 2.1 months (95% CI 1.4 to 2.9) for other sarcomas.⁵⁷

Van der Graaf and colleagues randomly assigned patients with metastatic nonadipocytic STS to pazopanib or placebo in a phase 3 trial. Pazopanib is a small-molecule endothelial growth factor inhibitor with activity against vascular endothelial growth factors 1, 2, and 3 as well as platelet-derived growth factors. Median progression-free survival was 4.6 months (95% CI 3.7 to 4.8) with pazopanib compared to 1.6 months (95% CI 0.9 to 1.8) with placebo.⁵⁸ Adipocytic sarcomas (liposarcomas) were excluded from the trial because phase 2 trials had found a lower rate of progression-free survival (26%) for them compared to other subtypes.

 

• What are the most common toxicities associated with the approved and investigational chemotherapeutic agents?

Toxicities were seen with each of the regimens studied and were common in the randomized trials, with higher rates of toxicities in the combination chemotherapy regimens. The most common toxicities are myelosuppression, nausea, and vomiting. In the doxorubicin trials, the most common toxicities were myelosuppression, nausea, and vomiting.⁴⁴

Ifosfamide both as an individual agent and in combination with doxorubicin has higher rates and higher grades of toxicity than doxorubicin alone. Myelosuppression is the most common toxicity associated with ifosfamide, and the most commonly affected cell line is leukocytes.⁴⁴ Combination doxorubicin and ifosfamide also had high rates of nausea and vomiting (95%) and alopecia (100%).³⁵

Neutropenia is the most common toxicity associated with gemcitabine and dacarbazine, while their most common nonhematologic toxicities are fatigue and nausea.^52,59 Trabectedin’s most common toxicities are nausea (29%), neutropenia (24%), and fatigue (23%). It has also been shown to cause increased alkaline phosphatase (20%) and alanine aminotransferase (19%) levels.⁵⁶ In a phase 2 study of eribulin, 50% of patients had neutropenia, and other toxicities included fatigue, alopecia, nausea, sensory neuropathy, and thrombocytopenia.⁵⁷ Pazopanib is generally well tolerated; the most common toxicities are fatigue (65%), diarrhea (58%), nausea (54%), and hypertension (41%).⁵⁸ Higher rates of neutropenia, mucositis, nausea, vomiting, diarrhea, and transfusion reactions were seen with olaratumab and doxorubicin compared to doxorubicin alone in phase 1b and 2 studies.⁴⁶

CASE CONCLUSION

Given his poor prognosis with unresectable metastatic undifferentiated liposarcoma, the patient considers a clinical trial prior to undergoing combined therapy with doxorubicin and ifosfamide. He tolerates therapy well with stable disease at 6 months.

CONCLUSION

STSs are a heterogeneous collection of rare tumors. Low-grade, localized tumors have the best prognosis, and patients who undergo complete resection have the best long-term survival. Due to the rarity of STSs, trials often have limited enrollment, and little progress has been made with regards to treatment and survival rates for metastatic and unresectable disease. All patients should be evaluated and treated at specialized sarcoma centers. This case highlights the need for continued research and clinical trials to improve overall survival of patients with sarcoma.

INTRODUCTION

Soft tissue sarcomas (STSs) are rare adult tumors, with 3.4 new cases per 100,000 persons or 12,310 expected new cases in 2016.¹ Sarcomas are a heterogeneous collection of tumors that affect fat, muscle, nerve, nerve sheath, vascular, and connective tissues. There are more than 50 histological subtypes that comprise this diverse category of tumors. Treatment varies by stage, with limb-sparing surgery representing the mainstay of curative-intent treatment. Radiation and chemotherapy may also be considered depending on the size, grade, and location of the tumor. Survival rates have been stagnant until recently, with a disease-specific survival hovering around 65%.¹ Given the complexity of these cases, all patients ideally should be evaluated and treated by a multidisciplinary team at an institution with extensive experience treating STS.²

EPIDEMIOLOGY AND CLASSIFICATION

The most common STS subtypes are gastrointestinal stromal tumor (GIST), undifferentiate pleomorphic sarcoma (previously referred to as malignant fibrous histiocytoma), liposarcoma, leiomyosarcoma, synovial sarcoma, malignant peripheral nerve sheath tumor, rhabdomyosarcoma, and unclassified sarcoma.³ Liposarcoma is one of the most common subtypes, comprising 20% of all STSs; it is subdivided into well-differentiated/dedifferentiated liposarcomas, myxoid/round cell liposarcomas, and pleomorphic liposarcomas. Well-differentiated liposarcomas tend to occur in the retroperitoneum and limbs, while both myxoid and round cell as well as pleomorphic liposarcomas more commonly originate on the limbs. Histology varies based on subtype and ranges from mature-appearing adipocytes and fibroblasts to undifferentiated cells with minimal lipogenic differentiation.⁴

Leiomyosarcomas are smooth muscle tumors and are usually located in the retroperitoneum, but have also been associated with peripheral soft tissue and vasculature. Typical histology ranges from well-defined areas of spindle-shaped cells to poorly differentiated anaplastic spindle cells.^5,6 Synovial sarcomas are a distinct type of STS that can show epithelial differentiation and account for 5% of adult STSs. The extremities are the most common presenting location (90%).⁷

Rhabdomyosarcomas are skeletal muscle tumors and are further subdivided into embryonal, alveolar, and pleomorphic subtypes. Embryonal histology ranges from primitive mesenchymal-appearing cells to highly differentiated muscle cells. Alveolar rhabdomyosarcoma has the worst prognosis of the subtypes and consists of round cells with high nuclear-to-chromatin ratios that form “glandular-like” or “alveolar” spaces.⁸ Pleomorphic rhabdomyosarcomas are composed of rhabdomyoblasts that can affect many different locations, but most commonly present on the lower extremities.⁹

Malignant peripheral nerve sheath tumor (MPNST) comprises 5% to 10% of all STSs. These tumors are associated with neurofibromatosis type 1 (NF-1), with 25% to 50% of tumors occurring in NF-1 patients. Additionally, most patients have a truncating lesion in the NF1 gene on chromosome 17.¹⁰ Anghileri et al in their single institution analysis of 205 patients with MPNSTs found the 2 most common presenting sites were the trunk and extremities. Histologically, these tumors have dense fascicles of spindle cells.¹⁰

GISTs are the most common STS of the gastrointestinal (GI) tract. Previously, GISTs were classified as smooth muscle tumors and were not accounted for in the literature as a separate entity distinct from leiomyomas, leiomyoblastomas, and leiomyosarcomas.¹¹ GISTs are found throughout the GI tract: the most common sites are the stomach (60%) and small intestine (30%). Less common sites include duodenum (4%–5%), esophagus (1%), rectum (1%–2%), and appendix (< 0.2%).¹² GISTs can be spindle cell, epithelioid, or mesenchymal tumors. Immunohistochemically, GISTs are KIT (CD117) positive. Other cell markers that are also commonly positive include CD34 (60%–70%) and smooth muscle actin (SMA) (25%).¹¹ The majority of GISTs (80%) have an activating c-KIT gene mutation. The most common mutation site is exon 11, with less common c-KIT gene mutations also occurring at exon 9 or 13. Not all GISTs have KIT mutations. The second most common mutation is the PDGFRA mutation (5%–10% of GISTs).² A minority of GISTs are negative for both KIT and PDGFRA mutations. These tumors were previously called wild-type, but as the majority have either a succinate dehydrogenase (SDH) loss of function or loss of SDHB protein expression, they are now referred to as SDH-deficient GISTs.² GISTs vary in aggressiveness from incidental to aggressive. Typically, small intestine and rectal GISTs are more aggressive than gastric GISTs. Both size and mitotic rate help to predict the metastatic potential of the tumor. Tumors less than 2 cm in size and having a mitotic rate of less than 5 per 50 high-power fields (hpf) have the lowest risk of metastases, while tumors greater than 5 cm and with more than 5 mitoses per 50 hpf have the highest rates of metastases.¹²

 

Angiosarcomas are rare tumors comprising 4% of all STSs. Although they can occur in any site, the majority are cutaneous and occur most frequently in the head and neck regions. These tumors are either of vascular or lymphatic origin and are comprised of abnormal, pleomorphic, malignant endothelial cells. The most useful immunohistochemical markers include von Willebrand factor, CD31, and Ulex europaeus agglutinin 1. The majority of these tumors occur sporadically; however, radiation exposure, chronic lymphedema, and certain toxins including vinyl chloride and thorium dioxide are known risk factors.¹³

Undifferentiated sarcomas have no specific features and typically consist of primitive mesenchymal cells.

CLINICAL EVALUATION

CASE PRESENTATION

Initial Presentation and History

A 55-year-old man presents to his primary care physician with a painless mass in his anterior thigh. The mass has been present for the past 3 months and he believes that it is enlarging. The patient has a history of well-controlled hypertension and hyperlipidemia. His medications include atorvastatin and hydrochlorothiazide. He has no known drug allergies. Family history is notable for diabetes and hypertension. He drinks 4 to 5 alcoholic drinks a week and he is a former smoker. He quit smoking in his 30s and only smoked intermittently prior to quitting. He denies any illicit drug use. He works as a high school principal. Currently, he feels well. His review of systems is otherwise noncontributory.

Physical Examination

On physical exam, he is afebrile with a blood pressure of 132/75 mm Hg, respiratory rate of 10 breaths/min, and oxygen saturation of 99% on room air. He is a well appearing, overweight male. His head and neck exam is unremarkable. Lung exam reveals clear breath sounds, and cardiac exam reveals a regular rate and rhythm. His abdomen is obese, soft, and without hepatosplenomegaly. There is a large, fixed mass on the anterior lateral aspect of his right thigh. He has no appreciable lymphadenopathy. His neurological exam is unremarkable.

• What are risk factors for sarcoma?

There are few known risk factors for sarcoma. Established risks factors include prior radiation therapy, chronic lymphedema, viruses, and genetic cancer syndromes including Li-Fraumeni syndrome, hereditary retinoblastoma, and NF-1. Other environmental exposures include phenoxyacetic acids and chlorophenols.¹⁴ The majority of cases are sporadic, with only a minority of patients having one of these known risk factors.¹⁵ Up to one third of sarcomas have a specific translocation and are driven by fusion oncogenes (Table 1).

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• What is the typical presentation for sarcomas?

A painless mass is the most typical presenting symptom. Size at presentation varies based on location, with extremity and head and neck locations typically presenting at smaller sizes than retroperitoneal tumors.¹⁴ Patients may experience pain and numbness as the mass enlarges and impinges on surrounding structures including nerves and vasculature. The vast majority of patients are without systemic symptoms.

• How is sarcoma staged?

The American Joint Committee on Cancer (AJCC) staging system is the most widely used staging system in the United States. The latest AJCC manual was updated in 2010 to include a 3-tiered grading system where the tumor is classified according to tumor size, lymph node involvement, metastases, and grade at time of diagnosis (Table 2 and Table 3). Additionally, tumor depth in relation to deep fascia is also taken into account, with superficial tumors being assigned a designation of “a” and deep tumors a designation of “b.”

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Previously, 2 of the most widely used grading systems were the National Cancer Institute (NCI) and French Federation of Cancer Centers Sarcoma Group (FNCLCC) systems, both 3-tier grading systems. The main components that determine the NCI grade are the tumor’s histologic type and location and the amount of tumor necrosis. The FNCLCC system evaluation focuses on tumor differentiation, mitotic rate, and amount of tumor necrosis. A study that compared the NCI and FNCLCC grading systems found that FNCLCC was a better predictor of mortality and distant metastasis.¹⁶ Previously, the AJCC was a 4-tier grading system, but the 2010 version was updated to the 3-tier FNCLCC grading system. Additionally, the AJCC system has reclassified single lymph node disease as stage III as it confers better survival than metastatic disease.¹⁷ It is important that pathology be evaluated by a sarcoma specialist as disagreements with regard to histologic subtype and grade are common.^18,19

• What are the most important prognostic factors?

Prognostic factors include grade, size, and presence of metastases at presentation. Best survival is associated with low-grade, small tumors with no metastases at time of diagnosis.¹⁴

 

• What imaging should be considered?

Imaging should be undertaken to help differentiate between benign and malignant lesions. Ideally, it should be undertaken before a biopsy is planned as the imaging can be used to plan biopsy as well as provide invaluable prognostic information. There are several imaging modalities that should be considered during the preliminary work-up and staging of STSs. Conventional imaging includes magnetic resonance imaging (MRI) of the original tumor site; computed tomography (CT) to evaluate for pulmonary metastases and, depending on location, liver metastases; and in the case of small, low-grade tumors, chest radiography. MRI is considered the test of choice for soft tissue masses and can help delineate benign masses such as hematomas, lipomas, and hemangiomas from sarcomas.²⁰ It is difficult to compare the accuracy of positron emission tomography (PET)/CT to CT and MRI because most studies have evaluated PET/CT in parallel with CT and MRI.²¹ Tateishi et al compared the accuracy of conventional imaging, PET/CT, and PET/CT combined with conventional imaging at determining the TNM staging for 117 patients. They found that conventional imaging correctly classified 77% of patients, PET alone correctly classified 70%, PET/CT correctly classified 83%, and PET/CT combined with conventional imaging correctly staged 87%.²²

• Which subtypes are most likely to metastasize?

Although the vast majority of sarcomas spread hematogenously, 3 have a propensity to spread lymphogenously: epithelioid sarcoma, rhabdomyosarcoma, and clear-cell sarcoma. Additionally, certain subtypes are more likely to metastasize: leiomyosarcomas, synovial sarcomas, neurogenic sarcomas, rhabdomyosarcomas, and epithelioid sarcomas.²³ Sarcomas metastasize to the lungs more frequently than to the liver. The metastatic pattern is defined primarily by sarcoma subtype and site of primary tumor. Sarcomas rarely metastasize to the brain (~1%).

MANAGEMENT

CASE CONTINUED

The patient undergoes an ultrasound to better visualize the mass. Given the heterogeneous character of the mass, he is referred for an MRI to evaluate the mass and a CT scan of the chest, abdomen, and pelvis to evaluate for distant metastases. MRI reveals a 5.1 cm × 4.6 cm heterogeneous mass invading the superficial fascia of the rectus femoris muscle. No suspicious lymph nodes or other masses are identified on imaging. The patient next undergoes an image-guided core needle biopsy. Pathology from that procedure is consistent with a stage III, T2bNxMx, grade 3, dedifferentiated liposarcoma.

• What is the best management approach for this patient?

SURGERY

Surgery is the mainstay of treatment for STS. Patients with the best prognosis are those who undergo complete resection with negative surgical margins.^24,25 Goal tumor-free margin is 1 to 3 cm.²⁶ Complete resection confers the best long-term survival. Both local and metastatic recurrence is higher in patients with incomplete resection and positive margins.^24,25 In a study that analyzed 2084 localized primary STSs, patients with negative margins had a local recurrence rate of 15% versus a rate of 28% in patients with positive margins. This translated into higher 5-year local recurrence-free survival for patients with negative surgical margins (82%) compared to patients with positive margins (65%).²⁷ Another study similarly found that patients with negative margins at referral to their institution who underwent postoperative radiation had high local control rates of 93% (95% confidence interval [CI] 87% to 97%) at 5, 10, and 15 years.²⁶ Although radiation improves local control, neither preoperative or postoperative radiation has been shown to improve progression-free or overall survival.²⁸ Other factors that are associated with risk of recurrence are tumor location, history of previous recurrence, age of patient, histopathology, tumor grade, and tumor size. Approximately 40% to 50% of patients with high-grade tumors (defined as size > 5 cm, deep location, and high grade) will develop distant metastases.²⁹

Zagars et al found that positive or uncertain resection margin had a relative risk of local recurrence of 2.0 (95% CI 1.3 to 3.1; P = 0.002), and presentation with locally recurrent disease (vs new tumor) had a relative risk of local recurrence of 2.0 (95% CI 1.2 to 3.4; P = 0.013).²⁶ Patients with STS of head and neck and deep trunk have higher recurrence rates than those with superficial trunk and extremity STS. A single-institution retrospective review demonstrated that patients with completely resectable retroperitoneal sarcomas have longer median survival (103 months) compared to patients with incompletely resected abdominal sarcomas (18 months).²⁵

 

Rosenberg and colleagues compared amputation to limb-sparing surgery and radiation.²⁴ Their prospective analysis of 65 patients found no difference in disease-free and overall survival between the 2 treatment groups.The limb-sparing treatment group had higher rates of local recurrence, which was highly correlated with positive surgical margins on pathology.²⁴ Evidence from this and similar studies has resulted in radical amputations being replaced by conservative limb-sparing procedures and radiation therapy. In those found to have positive margins, re-resection is an option for some. Patients who undergo re-resection have higher local control rates than patients with positive margins who do not undergo re-resection. The 5-year control rate for patients who undergo re-resection is 85% (95% CI 80% to 89%) compared to 78% (95% CI 71% to 83%) for those who do not undergo re-resection. Similarly, patients who undergo re-resection have lower rates of metastases at 5, 10, and 15 years as well as higher 5-, 10-, and 15-year disease-free survival rates.²⁶

CASE CONTINUED

The patient is referred for limb-sparing surgery after presentation at a multidisciplinary tumor board. Prior to undergoing resection of the tumor, he is also referred to radiation-oncology to discuss the risks and benefits of combination radiotherapy and surgery as opposed to surgical resection alone.

• What is the evidence for radiation therapy?

RADIATION THERAPY

Radiation therapy is used in the preoperative, intraoperative, and postoperative settings to reduce the risk of local recurrence. There are several options for radiation, including external beam radiation therapy (EBRT), intraoperative radiation, and brachytherapy. A newer strategy, intensity-modulated radiation therapy (IMRT), utilizes 3-dimensional modeling to reduce radiation dosages. Overall there are no differences in overall survival or local recurrence rates between preoperative and postoperative radiation in STS.²⁸

The rationale behind preoperative radiation is that it reduces seeding of tumor cells, especially at the time of surgery.³⁰ Additionally, for EBRT, preoperative radiation has smaller field sizes and lower radiation doses. It can also help to reduce the size of the tumor prior to resection. Intraoperative radiation is often paired with preoperative radiation as a boost dose given only to the area of residual tumor.

Suit et al reviewed patients treated at a single institution with limb-sparing surgery and different radiation strategies. Local control rates between preoperative and postoperative radiation groups were not statistically significant. Local recurrence was linked to grade and size of the tumor in both groups. The authors did note, however, that the preoperative radiation group tended to have larger tumor sizes at baseline compared to the patients who received postoperative radiation.³⁰ A study that compared 190 patients who received preoperative and postoperative EBRT or brachytherapy (primary end point was wound complications, and local control was a secondary end point) showed a trend towards greater local control with preoperative radiation; however, the preoperative radiation group had significantly more wound complications compared to the postoperative radiation group.³¹

Yang et al found that postoperative EBRT decreases rates of local recurrence compared to surgery alone in high-grade extremity sarcomas.³² However, there were no differences in rates of distant metastases and overall survival between the 2 treatment groups. Similarly, in patients with low-grade sarcoma, there were fewer local recurrences in those who received EBRT and surgery as compared to surgery alone.³² Another study that evaluated 164 patients who received either adjuvant brachytherapy or no further therapy after complete resection found that brachytherapy reduced local recurrence in high-grade sarcomas. No difference in local recurrence rates was found in patients with low-grade sarcomas, nor was a significant difference found in the rates of distant metastases and overall survival between the 2 treatment groups.³³ With regards to IMRT, a single institution cohort experience with 41 patients who received IMRT following limb-sparing surgery had similar local control rates when compared to historical controls.³⁴

CASE CONTINUED

After discussion of the risks and benefits of radiation therapy, the patient opts for preoperative radiation prior to resection of his liposarcoma. He receives 50 Gy of EBRT prior to undergoing resection. Resection results in R1 margin consistent with microscopic disease. He receives 16 Gy of EBRT as a boost after recovery from his resection.²

• What is the evidence for neoadjuvant and adjuvant chemotherapy for stage I tumors?

CHEMOTHERAPY

Localized Sarcoma

For localized sarcoma, limb-sparing resection with or without radiation forms the backbone of treatment. Studies have evaluated chemotherapy in both the neoadjuvant and adjuvant settings, with the vast majority of studies evaluating doxorubicin-based chemotherapy regimens in the adjuvant settings. Due to the rare nature of sarcomas, most studies are not sufficiently powered to detect significant benefit from chemotherapy. Several trials evaluating chemotherapy regimens in the neoadjuvant and adjuvant settings needed to be terminated prematurely due to inadequate enrollment into the study. ^35,36

 

For stage IA (T1a-Tb, N0, M0, low grade) tumors, no additional therapy is recommended after limb-sparing surgery with appropriate surgical margins. For stage IB (T2a-2b, N0, M0, low grade) tumors with insufficient margins, re-resection and radiation therapy should be considered, while for stage IIA (T1a-1b, N0, M0, G2-3) tumors preoperative or postoperative radiation therapy is recommended.² Studies have not found benefit of adjuvant chemotherapy in these low-grade, stage I tumors in terms of progression-free survival and overall survival.³⁷

• At what stage should chemotherapy be considered?

For stage IIb and stage III tumors, surgery and radiation therapy again form the backbone of therapy; however, neoadjuvant and adjuvant chemotherapy are also recommended as considerations. Anthracycline-based chemotherapy with either single-agent doxorubicin or doxorubicin and ifosfamide in combination are considered first-line chemotherapy agents in locally advanced STS.^2,29,37

Evidence regarding the efficacy of both neoadjuvant and adjuvant chemotherapy regimens in the setting of locally advanced high-grade STS has been mixed. The Sarcoma Meta-analysis Collaboration evaluated 14 trials of doxorubicin-based adjuvant chemotherapy and found a trend towards overall survival in the treatment groups that received chemotherapy.³⁷ All trials included in the meta-analysis compared patients with localized resectable soft-tissue sarcomas who were randomized to either adjuvant chemotherapy or no adjuvant chemotherapy after limb-sparing surgery with or without radiation therapy. None of the individual trials showed a significant benefit, and all trials had large confidence intervals; however, the meta-analysis showed significant benefit in the chemotherapy treatment groups with regard to local recurrence, distant recurrence, and progression-free survival. No significant difference in overall survival was found.³⁷ Pervais et al updated the Sarcoma Meta-analysis Collaboration’s 1997 meta-analysis with the inclusion of 4 new trials that evaluated doxorubicin combined with ifosfamide and found that both patients who received doxorubicin-based regimens or doxorubicin with ifosfamide had significant decreases in distant and overall recurrences. Only the trials that utilized doxorubicin and ifosfamide had an improved overall survival that was statistically significant (hazard ratio 0.56 [95% CI 0.36 to 0.85]; P = 0.01).²⁹ Although no significant heterogeneity was found among the trials included in either meta-analysis, a variety of sarcomas were included in each clinical trial evaluated. Given the extremely small number of each sarcoma subtype present in each trial, subgroup analysis is difficult and prone to inaccuracies. As a result, it is not known if certain histological subtypes are more or less responsive to chemotherapy.^37–39

One randomized controlled trial evaluated neoadjuvant chemotherapy in high-risk sarcomas defined as tumors greater than 8 cm or grade II/III tumors. This study evaluated doxorubicin and ifosfamide and found no significant difference in disease-free and overall survival in the neoadjuvant therapy group compared to the control group.³⁵ There remains controversy in the literature with regards to adjuvant chemotherapy. Many oncologists offer adjuvant chemotherapy to patients with certain stage III subtypes. Examples of subtypes that may be offered adjuvant therapy include myxoid liposarcomas, synovial sarcomas, and leiomyosarcomas.² With regards to how many cycles of chemotherapy should be considered, a noninferiority study compared 3 cycles of epirubicin and ifosfamide to 5 cycles of epirubicin and ifosfamide in patients with high-risk locally advanced adult STSs. Three cycles of preoperative epirubicin and ifosfamide was found to be noninferior to 5 cycles with regards to overall survival.³⁸

• What is this patient’s risk for recurrence?

The patient is at intermediate risk for recurrence. Numerous studies have demonstrated that tumor size, grade, and location are the most important factors to determine risk of recurrence, with larger size, higher grades, and deeper locations being associated with higher risk of recurrence. In an analysis of 1041 patients with STS of the extremities, high grade was the most important risk factor for distant metastases.³⁹ The highest risk of recurrence is within the first 2 years. Given that the patient’s initial tumor was located in the extremity, he is more likely to have a distant metastasis as his site of recurrence; individuals with retroperitoneal tumors and visceral tumors are more likely to recur locally.⁴⁰ For STSs of the extremity, distant metastases determine overall survival, whereas patients with retroperitoneal sarcomas can die from complications of local metastases.⁴¹ Once a patient develops distant metastases, the most important prognostic factor is the size of the tumor, with tumors larger than 10 cm having a relative risk of 1.5 (95% CI 1.0 to 2.0).³⁹

• What are the recommendations for surveillance?

Surveillance recommendations are based on the stage of the sarcoma. Stage I tumors are the least likely to recur either locally or distally. As a result, it is recommended that stage I tumors be followed with history and physical exam every 3 to 6 months for the first 2 to 3 years, and then annually after the first 2 to 3 years. Chest x-rays should be considered every 6 to 12 months.² For stage II–IV tumors, history and physical exam is recommended every 3 to 6 months for the first 2 to 3 years. Chest and distant metastases imaging should also be performed every 3 to 6 months during this time frame. For the next 2 years, history and physical exam and imaging are recommended every 6 months. After the first 4 to 5 years, annual follow-up is recommended.²

 

A study that followed 141 patients with primary extremity STSs for a median interval of 49 months found that high-grade tumors were most likely to recur during the first 2 years, with 20% of their patients recurring locally and 40% recurring distally. Chest x-rays performed during surveillance follow-up found distant lung metastases in 36 asymptomatic patients and had a positive predictive value of 92%, a negative predictive value of 97%, and a quality-adjusted life-year of $30,000.^40,41 No laboratory testing was found to aid in detection of recurrence.

CASE CONTINUED

The patient does well for 1 year. With physical therapy, he regains most of the strength and coordination of the lower extremity. He is followed every 3 months with chest x-rays and a MRI of the thigh for the first year. On his fourth follow-up clinic visit, he describes increased dyspnea on exertion over the previous few weeks and is found to have multiple lung metastases in both lungs on chest x-ray. He undergoes further evaluation for metastases and is not found to have any other metastatic lesions. Bronchoscopy and biopsy of 1 of the lung nodules confirms recurrent dedifferentiated liposarcoma.

• Should this patient undergo metastectomy?

An analysis of 3149 patients with STS treated at Memorial Sloan-Kettering who developed lung metastases found that patients with pulmonary metastases have survival rates of 25%. The most important prognostic factor for survival was complete resection of all metastases.⁴² For stage IV disease, surgery is used only in certain instances. In instances where tumor is more localized or limited, removal of metastases or metastectomy can play a role in management.²

CASE CONTINUED

Because the patient’s metastases are limited to the lungs, he is referred for metastectomy. He undergoes wedge resection for definitive diagnosis but it is not possible to completely resect all of the metastases. He is thus referred to a medical oncologist to discuss his treatment options.

• What are treatment options for unresectable or metastatic disease?

Metastatic Disease

Unlike local and locally advanced disease, chemotherapy forms the backbone of treatment in stage IV disease. Doxorubicin and olaratumab or doxorubicin and ifosfamide in combination are considered first line in metastatic disease. Response rates for single-agent doxorubicin range from 16% to 27%, while phase 2 and phase 3 studies of doxorubicin and ifosfamide have found response rates ranging from 18% to 36%.⁴³ In addition, the effectiveness of doxorubicin and ifosfamide phase 2 and 3 trials varied. Edmonson et al found a tumor regression rate of 34% for doxorubicin and ifosfamide as compared to 20% for doxorubicin alone.⁴⁴ In comparison, Santoro et al found a response rate of 21.3% for doxorubicin alone and 25.2% for doxorubicin and ifosfamide.⁴⁵ Neither study found increased survival benefit for doxorubicin and ifosfamide when compared to doxorubicin alone. In a Cochrane review evaluating randomized trials that compared doxorubicin and combination chemotherapy regimens, response rates varied from 14% for doxorubicin in combination with streptomycin to 34% for doxorubicin and ifosfamide. Most trials did not show a significant benefit for combination therapies when compared to doxorubicin alone.⁴³ Mean survival with doxorubicin or doxorubicin and ifosfamide is 12 months. High rates of recurrence highlight the need for additional chemotherapy regimens.

The newest approved agent is olaratumab, a monoclonal antibody that binds platelet-derived growth factor receptor alpha and prevents receptor activation. A phase 1-b and phase 2 trial evaluated patients with locally advanced and metastatic STS and randomly assigned them to either olaratumab and doxorubicin or doxorubicin alone.⁴⁶ Progression-free survival for olaratumab/doxorubicin was 6.6 months (95% CI 4.1 to 8.3) compared to 4.1 months (95% CI 2.8 to 5.4) for doxorubicin alone. The objective response rate was 18.2% (95% CI 9.8 to 29.6) for olaratumab/doxorubicin compared to 7.5% (95% CI 2.5 to 6.6) for doxorubicin alone. Furthermore, the median overall survival for olaratumab plus doxorubicin was 26.5 months (95% CI 20.9 to 31.7) compared to 14.7 months for doxorubicin alone (95% CI 5.5 to 26.0). Impressively, this improved response was notable across histological types. Furthermore, patients who had previously been treated with more than 1 regimen and those who were treatment naïve had similar response rates.⁴⁶

• What are second-line treatment options?

Doxorubicin has been used in combination with several other agents including dacarbazine (DTIC) as well as DTIC and ifosfamide (MAID). Borden et al evaluated patients with metastatic STS and randomly assigned the patients to either doxorubicin or doxorubicin and DTIC. Combination therapy demonstrated better tumor response than doxorubicin alone: 30% complete or partial response for combination therapy and 18% for doxorubicin alone.⁴⁷ However, Omura et al

 

found similar rates of efficacy between doxorubicin and combination doxorubicin and DTIC in women with recurrent or nonresectable uterine sarcomas.⁴⁸ MAID has never been directly compared in a randomized trial to doxorubicin alone. In a study that compared MAID to doxorubicin and DTIC (AD) in patients with unresectable or metastatic sarcomas, MAID had superior response rates (32% versus 17%), but there was no difference with regards to overall survival (mean survival of 12.5 months).⁴⁹

Several additional regimens have undergone evaluation in metastatic and recurrent STSs. Gemcitabine has been used both as a single agent and as part of combination therapy in many studies. Studies with gemcitabine in combination with either docetaxel or DTIC have been the most efficacious. In a phase 2 trial, patients with metastatic STS were randomly assigned to either gemcitabine alone or gemcitabine and docetaxel. Combination therapy had a higher response rate (16% versus 8%) and longer overall survival (17.9 months versus 11.5 months) than gemcitabine alone.⁵⁰ Furthermore, a phase 2 trial of gemcitabine and docetaxel in patients with unresectable leiomyosarcoma showed an overall response rate of 56%, with 3 complete and 15 partial responses among the 34 patients enrolled in the study.⁵¹

A phase 2 trial randomly assigned patients with unresectable or metastatic STS to either DTIC or combination gemcitabine and DTIC.⁵² Gemcitabine-DTIC had a superior progression-free survival at 3 months (56% [95% CI 43% to 69%]) as compared to DTIC alone (37% [95% CI 23.5% to 50%]). Furthermore, mean progression-free survival and overall survival were improved in the gemcitabine-DTIC group (4.2 months and 16.8 months) as compared to the DTIC group (2.0 months and 8.2 months).⁵² DTIC has a single-agent response rate of 16%, but has been shown to be particularly effective in the setting of leiomyosarcomas.⁴⁹

• Does response to treatment regimens differ by histologic subtype?

The majority of STS trials include many different histologic subtypes. Given the rarity of sarcomas as a whole, many trials have had difficulty recruiting adequate numbers of patients to have sufficient power to definitely determine if the treatment under investigation has clinical benefit. Furthermore, the patients recruited have been heterogeneous with regard to subtype. Many older studies hypothesized that the efficacy of chemotherapeutic agents vary based on histologic subtype; however, for most subtypes the number of individuals included in those trials was too low to evaluate efficacy based on subtype.

Some exceptions exist, however. For example, both gemcitabine-DTIC and gemcitabine-docetaxel have been found to be particularly effective in the treatment of leiomyosarcomas.^50,52 Additionally, a retrospective study found a 51% overall response rate for patients with myxoid liposarcomas treated with trabectedin.⁵³ Studies of patients with angiosarcoma treated with paclitaxel have demonstrated response rates of 43% and 53%.^54,55

• What are the newest approved and investigational agents?

A recently approved agent is trabectedin, a tris tetrahydroisoquinoline alkaloid isolated from ascidians that binds to the minor groove of DNA and causes disruptions in the cell cycle. Samuels et al reported data from a single-arm, open-label expanded access trial that evaluated patients with advanced metastatic sarcomas.⁵⁶ In this study, patients with liposarcomas and leiomyosarcomas had an objective response rate of 6.9% (95% CI 4.8 to 9.6) as compared to a rate of 5.9% (95% CI 4.4 to 7.8) for all assessable patients. Median survival was 11.9 months for all patients, with improved median survivals for liposarcoma and leiomyosarcomas of 16.2 months (95% CI 14.1 to 19.5) compared to 8.4 months (95% CI 7.1 to 10.7 months) for other subtypes.⁵⁶

Schöffski et al evaluated eribulin, a chemotherapeutic agent that affects microtubule dynamics, in a phase 2 trial of patients with progressive or high-grade STS with progression on previous chemotherapy. They found a median progression-free survival of 2.6 months (95% CI 1.7 to 6.2) for adipocytic sarcoma, 2.9 months (95% CI 2.4 to 4.6) for leiomyosarcoma, 2.6 months (95% CI 2.3 to 4.3) for synovial sarcoma, and 2.1 months (95% CI 1.4 to 2.9) for other sarcomas.⁵⁷

Van der Graaf and colleagues randomly assigned patients with metastatic nonadipocytic STS to pazopanib or placebo in a phase 3 trial. Pazopanib is a small-molecule endothelial growth factor inhibitor with activity against vascular endothelial growth factors 1, 2, and 3 as well as platelet-derived growth factors. Median progression-free survival was 4.6 months (95% CI 3.7 to 4.8) with pazopanib compared to 1.6 months (95% CI 0.9 to 1.8) with placebo.⁵⁸ Adipocytic sarcomas (liposarcomas) were excluded from the trial because phase 2 trials had found a lower rate of progression-free survival (26%) for them compared to other subtypes.

 

• What are the most common toxicities associated with the approved and investigational chemotherapeutic agents?

Toxicities were seen with each of the regimens studied and were common in the randomized trials, with higher rates of toxicities in the combination chemotherapy regimens. The most common toxicities are myelosuppression, nausea, and vomiting. In the doxorubicin trials, the most common toxicities were myelosuppression, nausea, and vomiting.⁴⁴

Ifosfamide both as an individual agent and in combination with doxorubicin has higher rates and higher grades of toxicity than doxorubicin alone. Myelosuppression is the most common toxicity associated with ifosfamide, and the most commonly affected cell line is leukocytes.⁴⁴ Combination doxorubicin and ifosfamide also had high rates of nausea and vomiting (95%) and alopecia (100%).³⁵

Neutropenia is the most common toxicity associated with gemcitabine and dacarbazine, while their most common nonhematologic toxicities are fatigue and nausea.^52,59 Trabectedin’s most common toxicities are nausea (29%), neutropenia (24%), and fatigue (23%). It has also been shown to cause increased alkaline phosphatase (20%) and alanine aminotransferase (19%) levels.⁵⁶ In a phase 2 study of eribulin, 50% of patients had neutropenia, and other toxicities included fatigue, alopecia, nausea, sensory neuropathy, and thrombocytopenia.⁵⁷ Pazopanib is generally well tolerated; the most common toxicities are fatigue (65%), diarrhea (58%), nausea (54%), and hypertension (41%).⁵⁸ Higher rates of neutropenia, mucositis, nausea, vomiting, diarrhea, and transfusion reactions were seen with olaratumab and doxorubicin compared to doxorubicin alone in phase 1b and 2 studies.⁴⁶

CASE CONCLUSION

Given his poor prognosis with unresectable metastatic undifferentiated liposarcoma, the patient considers a clinical trial prior to undergoing combined therapy with doxorubicin and ifosfamide. He tolerates therapy well with stable disease at 6 months.

CONCLUSION

STSs are a heterogeneous collection of rare tumors. Low-grade, localized tumors have the best prognosis, and patients who undergo complete resection have the best long-term survival. Due to the rarity of STSs, trials often have limited enrollment, and little progress has been made with regards to treatment and survival rates for metastatic and unresectable disease. All patients should be evaluated and treated at specialized sarcoma centers. This case highlights the need for continued research and clinical trials to improve overall survival of patients with sarcoma.