ADVANCES IN RADIOTHERAPY AND TARGETED AGENTS TO …€¦ · OF EXTREMITY AND BODYWALL. None...
Transcript of ADVANCES IN RADIOTHERAPY AND TARGETED AGENTS TO …€¦ · OF EXTREMITY AND BODYWALL. None...
Dian Wang, MD., Ph.D.
Professor of Radiation Oncology
Adjunct Professor of Urology
Rush University Medical Center
ADVANCES IN RADIOTHERAPY
AND TARGETED AGENTS TO
TREAT SOFT TISSUE SARCOMA
OF EXTREMITY AND BODYWALL
None
Conflict of Interest
PRESENTED BY: DIAN WANG, MD., PH.D., RUSH UNIV. MED. CENTER
LEARNING OBJECTIVES
PRESENTED BY: DIAN WANG, MD., PH.D., RUSH UNIVERSITY MEDICAL CENTER
Following this presentation, the participant should have improved knowledge of:
•Advances in Radiation Therapy (RT) technology for the treatment of soft tissue sarcoma (STS)
•Evidence to support adjunctive RT for STS including both pre- and post – operative RT
•Recent combination studies on RT and targeted agents for STS
SOFT TISSUE SARCOMA
PRESENTED BY: DIAN WANG, MD., PH.D., RUSH UNIV. MED. CENTER
Annual incidence: approximately15000
Author Lower Extr Upper Extr H & N Trunk*
Abbas et al 1981 81 42 24 90
Potter el al 1985 152 59 12 84
Torosian et al 1988 208 81 21 182
Lawrence el al 1987 2110 594 406 1440
MDACC 1965-1987 340 136 66 158
TOTAL 2891 (46%) 912 (15%) 529 (8%) 1954 (31%)
*about ½ are retroperitoneal
PRESENTED BY: DIAN WANG, MD., PH.D., RUSH UNIVERSITY MEDICAL CENTER
• Many Types!
• ~25 major categories of
malignant/borderline STS
• ~60 types when all
subcategories are
considered
• ~>300 synonyms for these
60 types!
• Grade is Critical!
• A Major Factor in Staging
• Strongly Correlates with
Metastatic Risk
• Some Histologic Types
Almost Always Low Grade
• Some Histologic Types
Almost Always High Grade
HISTOPATHOLOGY AND GRADE
PRESENTED BY: DIAN WANG, MD., PH.D., RUSH UNIV. MED. CENTER
A group of heterogeneous soft tissue malignancy
that is mainly arising from embryonic
mesodermal origin
SOFT TISSUE SARCOMAS
2018 AJCC STAGING SYSTEM, 8TH ED
• Grade: WD (G1), MD (G2), PD (G3)
• Size: T1≤ 5 cm, T2 > 5 cm, T3 > 10 cm, T4 >15 cm
• Extent: Nodes (N0-1) and Distant mets (M0-1)
• Variables not accounted for: Location, histology
stage
IA T1;N0;M0;G1
IB T2, T3, T4; N0; M0; G1
II T1;N0;M0; G2/3
IIIA T2;N0M0;G2/3
IIIB T3,T4;N0;M0;G2/3
PRESENTED BY: DIAN WANG, MD., PH.D., RUSH UNIVERSITY MEDICAL CENTER
CATES AJCC 8TH ED
N1 or M1
QUESTION 1
When compared to staging soft tissue sarcoma in
the AJCC 7th edition, staging in the AJCC 8th
edition NO LONGER includes the following:
A. T1-4 is based on tumor size
B. T1-4 is based on tumor depth
C. Grade is important
D. N1 or M1 is equally considered for stage IV
PRESENTED BY:
Is N1 Vs M1 Different?
Ashamalla et al 2019
NCDB database 2004-2014: of 82,987, 55,417 met inclusion criteria
PRESENTED BY: DIAN WANG
Conclusion
Ashamalla et al 2019
In adult STS, including those of the trunk and
extremity, OS is superior with N1M0 compared
with N0-1M1 disease. These results suggest
that the AJCC 8th edition grouping of N1 and
M1 patients into stage IV may obscure the
more favorable prognosis of patients with
N1M0 disease.
MANAGEMENT OF LOCALIZED, EXTREMITY STS -
MODALITIES
PRESENTED BY: DIAN WANG, MD., PH.D., RUSH UNIV. MED. CENTER
• Surgery
• Radiation
• Chemotherapy: Role Still Debated
• Neoadjuvant
• Concurrent or interdigitated
• Adjuvant
SURGICAL OPTIONS
PRESENTED BY: DIAN WANG, MD., PH.D., RUSH UNIV. MED. CENTER
amputation
Compartmental
resection
Wide resection
Marginal
resectionIntra-capsular
excision
Generally
Unnecessary
Standard of care in combination
with RT
Usually
Inadequate
SARCOMA RADIOTHERAPY
ACCUMULATED EVIDENCE SUPPORTING
PERIOPERATIVE RT
• Landmark Studies supporting postop RT
• Rosenberg et al., Ann Surg 1982
• Pisters et al., JCO 1996
• Yang et al., JCO, 1998
• Landmark Studies supporting preop RT
• O’Sullivan et al., Lancet 2002
• O’Sullivan et al., Cancer 2013
• Wang et al., JCO 2015
PREOP VS. POSTOP RT
PRESENTED BY: DIAN WANG, MD., PH.D., RUSH UNIV. MED. CENTER
• Preop and postop RT are options for extremity STS
• Preop RT associated with acute wound complications
• IMRT, especially pre-op, significantly reduces late morbidity (joint stiffness, lymphedema, fibrosis et al)
• Smaller RT volume and reduced RT dose
• Might facilitate resection and reduce the risk for tumor seeding during the surgery
• Reserve Resection & postop RT
• Uncertain histology after initial biopsy if info critical for systemic treatment
• Lower extremity STS in pts with co-morbidities, at high risk for wound complications poor healing.
• Very small tumor & expectation that No RT will be required
QUESTION 2
The DRAWBACK for preoperative radiation for
extremity soft tissue sarcoma, when compared to
postoperative radiation, is the following:
A. More LATE toxicities such as fibrosis, joint stiffness,
and lymphedema.
B. Higher radiation dose.
C. Larger radiation target volumes.
D. More ACUTE wound complications.
T1 T2
CONVERSION OF PSEUDOCAPSULE TO REAL CAPSULE AFTER PRE RT
PRESENTED BY: DIAN WANG, MD., PH.D., RUSH UNIV. MED. CENTER
T1 T2T1T2
T2T1
MRI STS, pre-RT (left), post-RT (right)
PREOP RT TARGET VOLUME DEFINITIONS
PRESENTED BY:
TARGET DEFINITIONS FOR PRE-OP RT OF
EXTREMITY STS
• WANG D, Bosch W, Roberge D, et al. IJROBP 81(4), e525-8. 2011.
• RTOG Website Core lab Contouring Atlas
• WANG D, Bosch W, Kirsch D, et al. IJROBP 81(5), e775-780, 2011.
• Bahig H, Roberge D, Bosch W…..Wang D. IJROBP 2013 Jun 1; 86(2):298-303. doi: 10.1016/j.ijrobp.2013.01.032. Epub 2013 Mar 6. PMID:23474110
• Li XA, Chen X, Zhang Q, Kirsch DG, ………Wang D. PRO, 2015
GTV: MRI T1 or CT with contrast (MRI preferred)
CTV: For T2G2-3, GTV plus 1.5 cm radial margin and 3 cm
longitudinal margin, CTV is required to cover suspicious
peritumor edema.
For others, GTV plus 1 cm radial margin and 2 cm
longitudinal margin, CTV is required to cover suspicious
peritumor edema.
PTV: 0.5 cm with daily IGRT vs. 1.5 cm without daily IGRT
QUESTION 3 In RTOG 0630 (phase II image guided radiotherapy of
extremity soft tissue sarcoma), the recommended
definitions for GTV, CTV and PTV for large high-grade
tumor includes the following:
A. The GTV is defined as the gross tumor volume noted on
physical exam.
B. The CTV is an expansion of the GTV using the following
dimensions: 1.5 cm radial and 3 cm superior and inferior.
C. The CTV is and expansion of the GTV using the
following dimensions: 2 cm radial and 4 cm superior and
inferior.
D. The PTV is 10 mm expansion of the CTV when daily
pretreatment IGRT is used.
TARGET DEFINITIONS:
REPRESENTATIVE GTV, CTV, PTV
PRESENTED BY: DIAN WANG, MD., PH.D., RUSH UNIV. MED. CENTER
Wang D et al., ASCO Expert
Education Book 2014
GTV→←CTV
Wang et al. RTOG Website Core lab Contouring Atlas for soft tissue sarcoma
TARGET DEFINITIONS FOR POST-OP RT OF
EXTREMITY STS
• Haas RLM, DeLaney TF, O'Sullivan B, Keus RB, LePechoux C, Poulsen JP, Seddon B,
Fairchild A, Wang D. Radiotherapy in the management of extremity soft tissue sarcomas:
Why, when, and where? IJROBP 2012, 84(3): 572-80 . PMID:22520481.
• UK 2006: Randomized trial of Volume of post-operative
radiotherapy given to adult patients with eXtremity soft tissue
sarcoma (VORTEX)
PRIMARY ENDPOINT: LIMB FUNCTIONALITY AND LOCAL
RECURRENCE
STS
Conventional two-phase RT 66 Gy/33 fx
(Control arm, 200 pts)
Single phase to only phase-2 volume of
control arm 66 Gy/33 fx (tailored field, 200pts) resection
COMBINATION OF NEW AGENTS AND
MODERN RT TO TREAT STS
FUTURE PRIORITY
PRESENTED BY: DIAN WANG, MD., PH.D., RUSH UNIV. MED. CENTER
STRATEGIC VISION OF NCI-NRG ONCOLOGY
SARCOMA WORKING GROUP
Wong P….Wang D. JNCI 2014
COG-NRG PAZOPANIB SOFT TISSUE SARCOMA
TRIAL
PRESENTED BY: DIAN WANG, MD., PH.D., RUSH UNIV. MED. CENTER
• Pazopanib: Inhibitor of
VEGF receptors 1-3,
PDGF alpha and beta,
and cKIT
ARST1321: Pazopanib Neoadjuvant Trial In Non-
Rhabdomyosarcoma Soft Tissue Sarcomas (PAZNTIS): A
Phase II/III Randomized Trial of Preoperative
Chemoradiation or Preoperative Radiation +/- Pazopanib
PALETTE: PHASE IIIR MET STS
PRESENTED BY:
Van Der Graaf WT, Lancet 2012
PRESENTED BY: DIAN WANG, MD., PH.D., RUSH UNIVERSITY MEDICAL CENTER
FIRST EVER COLLABORATIVE STUDY CO-
DEVELOPED, WRITTEN AND CONDUCTED BY BOTH A
PEDIATRIC AND ADULT CANCER COOPERATIVE
GROUP
30Aaron Weiss
PURPOSE
• To improve treatment for intermediate and high
risk NRSTS by adding pazopanib to standard
therapy
• Highest risk patients with chemosensitive histologies: preop chemo RT
+/- pazopanib
• Intermediate to high risk patients not receiving chemotherapy: preop RT
+/- pazopanib
• A unique opportunity to advance treatment of
pediatric and adult NRSTS and collect large
specimens for biomarker/gene profiling
SCHEMA
PRESENTED BY: DIAN WANG, MD., PH.D., RUSH UNIV. MED. CENTER
Chemotherapy cohort
“chemosensitive” STS
Non-chemotherapy cohort
“Non chemosensitive” STS
PRIMARY OBJECTIVES
• Determine feasibility of pazopanib + radiation or chemoradiation
(phase II)
• Compare rates of complete pathologic response in patients
receiving radiation or chemoradiation ± pazopanib (phase II)
3
3Aaron Weiss
PREOPERATIVE CHEMORADIATION +/-
PAZOPANIB IN NON-RHABDOMYOSARCOMA
SOFT TISSUE SARCOMA (NRSTS): A
REPORT FROM CHILDREN'S ONCOLOGY
GROUP (COG) AND NRG ONCOLOGY
Aaron R. Weiss1, Yen-Lin Chen1, Thomas Scharschmidt1, Yueh-Yun Chi, Jennifer O. Black, Julie
Fanburg-Smith, Eduardo Zambrano, Edwin Choy, Jessica L. Davis, Mark Kayton, Lynn Million, Scott
H. Okuno, Andrew Ostrenga, R. Lor Randall, Joel Sorger, Jing Tian, Stephanie A. Terezakis, Douglas
S. Hawkins2, Sheri L. Spunt2, Dian Wang2
Oral presentation iat 2019 ASCO
1Study Co-Chairs 2Study Co-Senior Leadership
Pathologic Response at Week 13 Regimen A (n=42) Regimen B (n=39) p-value
≥ 90% 14 (58.3%) 4 (22.2%) 0.021
< 90% 10 (41.7%) 14 (77.8%)
1Chi-square test
DISEASE RESPONSE
Aaron WeissCorrelation of Pathologic Necrosis with Survival Outcome: pending
Regimen A: Preop ChemoRT + Pazopanib
Regimen B: Preop ChemoRT
WANG ET AL. ASCO 2017
Key Scientific Findings
pCR is associated with improved
survival outcomes in STS pts treated
with either neoadjuvant RT or CT-RT
from long-term update of these two
multicenter prospective studies
Local failure rate was 0% in pts with
pCR vs. 5-year 11.7% and 9.1% for
pts with <pCR in 9514 and 0630,
respectively.
Leiomyosarcoma, myxoid/round cell
liposarcoma, and myxofibrosarcoma
are associated with better OS while
liposarcoma/myxofibrosarcoma are
associated with better DFS
A PHASE IB TRIAL OF NEOADJUVANT AMG-232
CONCURRENT WITH PREOPERATIVE RADIOTHERAPY IN
WILD-TYPE P53 SOFT TISSUE SARCOMA
Meng Welliver MD, Ph.D., Peter Houghton Ph.D., David Kirsch MD, Ph.D., Gary Schwartz, MD, Raphael Pollock MD, Ph.D., John Kane, MD, Steve Jiang, Ph.D., Brian Van Tine MD, Ph.D, Jeffrey
Sklar, MD, Ph.D, Michelle Rudek, Pharm.D., Ph.D., Paul Wakely, MD, Qiang Zhang, Ph.D., Dian Wang, MD, Ph.D.
NCI-NRG Study Protocol (PTMA AWARD)
Trino S et al. Front. Pharmacol., 2016
P53-MDM2 Pathway
MDM2 inhibitors
( Nutlin-3A, AMG232,
RG7388)
PRECLINICAL DATA: MDM2 INHIBITORS POTENTIATE RT IN (A) P53
WT RH18 EMBRYONAL RHABDOMYOSARCOMA XENOGRAFTS
PHELPS, D. ET AL PEDIATR BLOOD CANCER 2015
PI: MENG WELLIVER AND CO-PI DIAN WANG, NRG DT 001
PI: MENG WELLIVER AND CO-PI DIAN WANG, NRG DT 001
HYPOTHESIS AND OBJECTIVES:
• Biologic Hypothesis: AMG-232 and radiotherapy will have additive or synergistic anti-tumor
activity in p53 WT STS.
• Clinical Hypothesis: Preoperative AMG-232 +radiotherapy is safe/well tolerated and shows
preliminary efficacy in STS.
• Primary objectives:
• To evaluate the safety and tolerability of AMG-232 in combination with standard-dose
radiotherapy in STS in two separate cohorts;
• To determine the MTD/RP2D of AMG-232 in combination with radiotherapy.
• DLT includes all grade 3-5 toxicities up to 4 weeks after AMG-232+RT treatment.
• Secondary Objectives:
• To determine % necrosis and pCR in final surgical resection specimen;• To determine % LC, PFS and OS at 2 years;• To determine PD effects of AMG-232 when combined with radiotherapy by
assessing serial serum Macrophage Inhibitory Cytokine (MIC)-1 levels; • To correlate AMG-232 exposure-response relationships (PD, toxicity, and
efficacy).
SARC83
PRESENTED BY:
CONCLUSIONS
PRESENTED BY: DIAN WANG, MD., PH.D., RUSH UNIV. MED. CENTER
• Perioperative RT is required for many soft tissue sarcoma of extremity
• Both preop RT and postop RT are equivalent in clinical outcomes
• Preop RT, esp. IG-IMRT late toxicities, but acute wound complications mainly in low extremity
• Co-administration of angiogenesis inhibitor Pazopanib enhances pCR rate in patients with high grade STS treated with neoadjuvant chemoRT
• Correlation of pCR with survival outcomes: pending
• Future priority on RT for STS: Identification of new targeted agents in combination with modern RT
• Participation in the clinical studies such as NRG DT 001b STS trial is highly recommended.
ACKNOWLEDGEMENTS
PRESENTED BY: DIAN WANG, MD., PH.D., RUSH UNIV. MED. CENTER
• NRG/RTOG
• NRG/RTOG Sarcoma Working Group
• RUMC Sarcoma Program
PRESENTED BY:
Thank you!
PRESENTED BY: DIAN WANG, MD., PH.D., RUSH UNIVERSITY MEDICAL CENTER
RETROPERITONEAL SARCOMA: EVOLVING ROLE OF RADIATION?
Krisha Howell, MD
Fox Chase Cancer Center
Philadelphia, PA
ACRO 28h 2020
CONFLICTS OF INTEREST
• Employment – Spouse: Medtronic
• Stock: Medtronic
• Introduction – Soft Tissue Sarcoma• Introduction – Retroperitoneal Sarcoma
• Staging• Histology• Pathology• Question #1
• Treatment Support• Radiation • Question #2• Chemotherapy
• Radiation Guidance• Current Interests/Advancements
OVERVIEW
POLL – QUESTION #1
• How many retroperitoneal sarcomas do you see in consultation for radiation therapy in a year?
• 1. > 25 a year
• 2. 10 - 25 a year
• 3. 5 - 10 a year
• 4. 1 - 5 a year
• 5. never
INTRO – SOFT TISSUE SARCOMAS
• Soft-tissue tumors are mesenchymal neoplasms that can arise anywhere in the body
• Retroperitoneal sarcomas occur deep in the abdomen and pelvis, behind the peritoneum
Gray’s Anatomy, Plate 1126
D.S. Strayer Rubin’s Pathology Ch 30, 2020
INTRODUCTION – RETROPERITONEAL SARCOMA
• Retroperitoneal sarcomas (RPS) have a risk of local recurrences (LR).
• Extrapolating from extremity data, RT is employed to limit LR.
HD Suit et al. Cancer. 1975;35(5):1478RD Lindberg. Cancer. 1981;47(10):2391.
T Category T Criteria
TX Cannot be assessed
T0 No evidence of primary tumor
T1 Tumor <5cm in greatest dimension
T2 Tumor > 5cm - <10cm
T3 Tumor >10cm - <15cm
T4 Tumor >15cm
Nodal Disease:N0 vs N1
Metastatic Disease:M0 vs M1
Primary Tumor:
Grade Grade Definition
GX Cannot be assessed
G1 Total differentiation, mitotic count & necrosis score of 2 or 3
G2 Total differentiation, mitotic count & necrosis score of 4 or 5
G3 Total differentiation, mitotic count & necrosis score of 6, 7, or 8
Group Staging dependent on both T, N, M and GradeAJCC manual 8th ed. Retroperitoneal sarcoma
0
100
200
300
400
500
600
700
FibrosarcomaLeiomyosarcomaLiposarcomaMPNSTUPSMyxofibrosarcomaSynovial SarcomaGIST
Brennan at al. 2013
PATHOLOGY – RETROPERITONEAL SARCOMA
• Common histologies:• Liposarcoma: All types may show lipoblasts
• Well-differentiated liposarcoma (WD)/Atypical lipomatous tumor (ALT)
• Dedifferentiated liposarcoma
• Pleomorphic liposarcoma
• Myxoid- (inclusive of round-cell) liposarcoma
• Leiomyosarcoma• Undifferentiated Pleomorphic Sarcoma (UPS)/Undifferentiated or
Unclassified SarcomasDS Strayer. Rubin’s Pathology Ch 30, 2020CDM Fletcher. WHO Classification, 2013
Well-differentiated liposarcoma (WD):A locally aggressive neoplasm composed of mature adipocytic proliferation with variation in cell size and at least focal nuclear atypia in adipocytes and stromal cells.
100x 400x
Lipoma-like appearance
Fibrous bands with atypical hyperchromatic cells
Source: Dr. Jian Fu, FCCC
Dedifferentiated liposarcoma: WD liposarcoma showing progression, either in the primary or in a recurrence, to (usually non-lipogenic) sarcoma of variable histological grade. In most cases there is substantial amplification of MDM2. A well-differentiated component may not be identifiable. Rarely, the high-grade component may be lipogenic.
100x 400x
Source: Dr. Jian Fu, FCCC
Leiomyosarcoma: Malignant neoplasm showing pure smooth-muscle differentiation. Common location is the retroperitoneum. May arise in large blood vessels, most commonly the inferior vena cava.
Source: Dr. Jian Fu, FCCC
Leiomyosarcoma 400x- intersecting
fascicles of spindle cells
- Tumor necrosis- Increased mitotic
activity
RETROPERITONEAL SARCOMA
• Well-differentiated liposarcoma and G1- G2 de-differentiated liposarcoma, the 2 most common histological subtypes originating at this site, predominantly fail locally
• High grade dedifferentiated liposarcoma and leiomyosarcoma are characterized by a high metastatic risk, which portends a dismal prognosis, with a risk of death of > 70% at 5 yrs
MCB Tan. Ann Surg 2016; 263: 593A Gronchi. Ann Surg 2016; 263: 1002
RECAP:
A dedifferentiated liposarcoma (DDLPS):Has the histological hallmark of a transition from ALT/well-differentiated liposarcoma to non-lipogenic sarcoma, which, in most cases, is of high grade. In addition, DDLPS most often has ring or giant marker chromosomes wherein MDM2 is consistently amplified and over-expressed.
TREATMENT
Source: Dr. Jeffrey Farma, FCCC
TREATMENT - RADIATION
• Preop RT for RPS is well tolerated
KS Mak. PRO 2016 Sept-Oct 6(5):360
STRASS I
STRASS I - STUDY DESIGN
266 patients accrued
During or after surgery
STRASS I –PRIMARY ENDPOINT:ABDOMINAL RECURRENCE FREE SURVIVAL
(ARFS)
STRASS 1 – PRIMARY ENDPOINTARFS
Median f/u 43 mos
STRASS I –PRIMARY ENDPOINT:ABDOMINAL RECURRENCE FREE SURVIVAL
(ARFS)
STRASS I – ARFS: IDMC SENSITIVITY ANALYSIS
Median f/u 43 mos
Local progression on RT NOT regarded as a primary endpoint event for the patients who subsequently achieve a complete
surgical resection
STRASS I – IDMC SENSITIVITY ANALYSIS: LIPOSARCOMA SUBGROUP
Median f/u 43 mos
RECAP:
With a median follow up of 43 months, the primary endpoint tested in STRASS I:
Was not significant for the primary endpoint, abdominal recurrence free survival (ARFS), although on further subgroup sensitivity analysis, ARFS was significantly better after preoperative RT in the liposarcoma subgroup.
POLL – QUESTION #2
• Do you routinely consider chemotherapy for retroperitoneal sarcomas?
• 1. yes
• 2. no
• 3. I don’t know
CHEMOTHERAPY SENSITIVITIES
VERY SENSITIVERhabdomyosarcoma
Synovial sarcomaAngiosarcoma
Myxoid liposarcoma
LOW SENSITIVITYExtra skeletal myxoid chondrosarcoma
FibrosarcomaEpithelioid sarcoma
Malignant peripheral nerve sheath tumorHemangiopericytoma/solitary fibrous
tumor
AVERAGE SENSITIVITYLeiomyosarcoma
High grade undifferentiated sarcomaDediff/pleomorphic liposarcomaDesmoplastic round cell tumor
RESISTANTGIST
Alveolar soft part sarcomaClear cell sarcoma
TREATMENT - CHEMOTHERAPY?
STRASS 2: RANDOMIZED PHASE III STUDY OF NEOADJUVANT CHEMO FOLLOWED BY SURGERY
VS SURGERY ALONE FOR HIGH RISK RETROPERITONEAL SARCOMA
• Systemic chemo has the potential to address the metastatic risk and improve relapse free survival and overall survival
• The neoadjuvant setting is preferable as it allows assessment of drugefficacy, immediately address the systemic risk, and study tumor biology
STRASS 1 & STRASS 2 SUMMARY
• "STRASS [1] included all "adult-type" primary RPS, without distinguishing those with a high loco-regional risk from those with a more pronounced systemic risk. This is the main reason why the study failed to show a benefit of neoadjuvant radiation in the whole RPS family" - STRASS 2
CONTOURING AND TREATMENT RECOMMENDATIONS
ADVANCES IN RADIATION OF RETROPERITONEAL SARCOMAS
ADVANCES IN RADIATION OF RETROPERITONEAL SARCOMAS
• Trial NCT01659203/Mass Gen’l Hospital: Phase I/II Trial of Pre-Operative Image Guided Intensity Modulated Proton Radiation Therapy (IMPT) or Photon (IMRT) With Simultaneously Integrated Boost to the High Risk Margin for Retroperitoneal Sarcomas
• Boosting the region of proposed positive/close surgical margins.
THANK YOU
• Fox Chase Cancer Center Sarcoma Group:
• Dr. Margaret von Mehren
• Dr. Jeffrey Farma
• Dr. Jian Fu
• Dr. Sanjay Reddy
• Dr. Stephanie Greco
• Dr. John Abraham
ADDITIONAL REFERENCES:
• Question #1:AJCC manual 8th ed.• Question #2:
• 1. A. Paolo Dei Tos. Bone and Soft Tissue Pathology: Ch 4 – Adipocytic Tumors, Elsevier 2010, pgs 97-118.
• 2. J.D.R. Reimann and C.D.M. Fletcher. The Molecular Basis of Cancer (4th Ed.): Ch 44 - Soft Tissue Sarcomas, Elsevier 2015, pg 609 – 620.
• 3. D.M. Fletcher, K. Krishnan Unni, F. Mertens. WHO Classification: Tumours of Soft Tissue and Bone. IARC Press: Lyon 2013
• Question #3: Source: ASCO slides – STRASS 1
QUESTIONS FOR CME CREDIT:
Which statement is true in regards to staging (per AJCC Manual v.
8th ed, 2017) of retroperitoneal sarcomas:
1. The current AJCC staging manual generalizes all sarcomas sites into 1 staging system.
2. Retroperitoneal staging does NOT include grade in the group staging.
3. The manual lumps abdominal and thoracic visceral organ sarcomas with that of
retroperitoneal sarcomas.
4. The staging system breaks up the T-stage of the sarcoma based upon size of greatest
dimension (every 5cm increments from </= 5cm for T1 up to >15cm for T4). *
Harvard Medical School
RADIATION THERAPY FORSOFT TISSUE SARCOMAS
Thomas F. DeLaney, M.D. Chief, Sarcoma Service, Department of Radiation OncologyAssociate Medical Director, Francis H. Burr Proton Therapy CenterMassachusetts General HospitalAndres Soriano Professor of Radiation OncologyHarvard Medical School
Harvard Medical School
DISCLOSURES
Author/editor: Elsevier (honorarium); UpToDate (honoraria), Inc; Wolters, Kluwer Health, Inc., (royalties)
Educational Conference Speaker: AO Spine (honorarium)
Educational Video Speaker: Oakstone Medical Publishing (honoraria)
Consulting: RBC Consulting(honorarium); Gerson Lehman (honoraria)
Medical Advisory Board: Chordoma Foundation (no remuneration)
Harvard Medical School
TAKE AWAY LESSONS: EXTREMITY STS
• Pre-Op RT preferred for upper extremity lesions• Postop RT preferred for myxofibrosarcomas• Lower extremity
• Balance higher rate of acute wound healing complications vs lower risk of late effects with preop RT
• Preop RT target volumes per RTOG 0630 guidelines• GTV defined on the T1, post-gado images• If G2, 3, T >8 cm: CTV 1.5 cm radial, 3 cm prox/distal to GTV +
edema• Others: CTV 1 cm radial, 2 cm prox/distal to GTV + edema• PTV expansion 0.5 cm if using image guidance
Harvard Medical School
TAKE AWAY LESSONS: EXTREMITY STS
• Preop RT target volumes• Subcutaneous tissue overlying tumor deep to the
fascia is not target• Princess Margaret reduced acute wound healing
complications when they were able to spare flap of tissue overlying the target (Griffin et al, IJROBP 2007)
• Adjuvant systemic therapy for high risk patients• Between a fielder’s choice and a single
• New agents being tested included pazopanib, AMG-232 (MDM2 inhibitor, pembrolizumab (immune checkpoint inhibitor)
Harvard Medical School
Toronto Preop/Postop 50 Gy Study
Harvard Medical School
HISTOLOGY-DRIVEN RADIATION TREATMENT
• DOREMY Study: DOSE REDUCTION OP PREOPERATIVE RADIOTHERAPY IN MYXOID LIPOSARCOMAS
• Phase II Study• Reduction of preoperative radiotherapy from 50 Gy/25 fractions
(standard) to 36 Gy/18 fractions.• Primary endpoint: pathologic response• Target accrual : 80 patients
Harvard Medical School
Prospective Hypofractionated Pre-op Radiotherapy for Extremity/Truck STS
• 272 pts Warsaw, Poland (1/2006-6/2011)• 5 Gy x 5 fx preop->Surgery 3-7 days after RT• Neoadjuvant chemoRx in high risk pts (61 – 22.4%)• LC 81%: worse size > 10 cm, G3, R1• ChemoRx no significant impact on OS• 114 patients (42%) had Rx toxicity, most with
tumors located on lower limbs. 7% (21) of pts required surgery for Rx of complications
Kosella-Paterczyk et al., Eur J Surg Oncol. 2014 Dec;40(12):1641-7
Harvard Medical School
Harvard Medical School
IMRT vs. Brachytherapy• MSKCC - Retrospective• 134 pts with soft tissue sarcoma
– 71 pts postop brachy (45 Gy) (1995-2003)
– 63 pts IMRT pre or postop (50-63Gy) (2002-2006)
• More IMRT pts had <1 mm margins, large tumors (>10 cm), and bone or nerve stripping/resection
• 5 yr Local control: 92% (IMRT) vs. 81% (brachy), p=0.04
• Multivariate: IMRT retained significance as independent predictor of improved LC
Alektiar et al, Cancer, 2011
Harvard Medical School
Pooled multicenter analysis: 259 patientsR0: 71% R1: 29% 5 year LC: 86%
Limb preservation and good functional outcome were achieved in 95% and 81% of patients.
Harvard Medical School
Stereotactic Body Radiotherapy for Lung Metastases from Sarcomas
• 52 pts: SBRT 50 Gy in 5 fractions• Local control 82% at 3 years• Median overall survival
– 2.1 years (0.8 to 15 years) SBRT versus 0.5 for no SBRT
– Consider for pts who are not surgical candidates, have had prior surgery, or decline surgery
• ---Dhakal et al, IJROBP 2011
Harvard Medical School
RETROPERITONEAL SARCOMA• Only proven treatment modality for RPS is surgery
– Local control only ~50% at 5 years with surgery•Hard to achieve (-) margins: Tumor size and adjacent organs• Compartmental resection may reduce LR to 30-40% (Bonvalot 2009)
• Local recurrence more common with liposarcoma• If RT to be used, should be done pre-op• STRASS I study suggests potential benefit for preop RT
for patients with liposarcoma– STRASS II study to assess role of chemoRx for high grade
dediff liposarcoma and leiomyosarcoma
Harvard Medical School
If RT is to be used, preoperative RT is preferred
MSKCC: No Impact of (+) Margins on RPS LR• 2084 pts who underwent sarcoma resection at MSKCC
– (+) margins: RPS: 45% Head/Neck: 30% Extremity 19%– Risk for local recurrence: RPS: HR=3.1 (highest risk), P<.001– For the majority of sarcoma anatomic sites and histologies, (+) margins
were a significant risk factor for local recurrence (LR)
• 229 pts with retroperitoneal sarcomas• No significant difference in risk of LR with (+) margins
– Relative risk of LR only 1.2 with (+) vs (-)…p> 0.05 (NS)• This suggests that although margins were nominally (-) in 55% of
patients, many may have had undetected (+) margins.Stojadinovic A et al, Ann Surg 2002:235;424-34
Harvard Medical School
Local Control, STS, all sites, (+) margins, by RT Dose
86% at 5 years
66% at 5 years
Harvard Medical School
RPS Dose-escalated, Dose-Painted Pre-op RT
Patients with retroperitoneal
sarcoma
IMRT/IMPT 50.4 Gy/ 28 fx to Lower
Risk CTV1
SIB 60.2/61.6/63 Gy/ 28 fx to high risk CTV2
margins
Resection 4-8 weeks after IMRT/IMPT
Phase I/II Preop Intensity Modulated Photons (IMRT)
Phase I/II Preop Intensity Modulated Protons (IMPT)
for Retroperitoneal Sarcoma:
Neoadjuvant chemoRxallowed
Phase I IMPT Cohort66 y.o. female with grade 2/3 dedifferentiated liposarcoma; NED 58 months after start of intensity modulated proton RT
CTV1 50.4 GyRBE,CTV2 63 GyRBE/28 fx