Catton C N, O'Sullivan B, Kotwall C, Cummings B, Hao Y, Fornasier V
Department of Radiation Oncology, Princess Margaret Hospital, Toronto, Canada.
Int J Radiat Oncol Biol Phys. 1994 Jul 30;29(5):1005-10. doi: 10.1016/0360-3016(94)90395-6.
To retrospectively evaluate the outcome of treatment and identify factors prognostic for survival and locoregional and distant disease control for patients with retroperitoneal soft tissue sarcoma.
The records of 104 patients with retroperitoneal soft tissue sarcoma (RSTS) managed with surgery and irradiation at Princess Margaret Hospital between 1975 and 1988 were retrospectively reviewed. Univariate log-rank analysis was used to evaluate potential prognostic factors.
Presentation was new primary disease, 74; primary recurrence, 20; metastases, 10. Pathology was liposarcoma for 42, leiomyosarcoma for 22, malignant fibrous histiocytoma for 19, and 21 with other histologies. Grade was low for 36, high for 35, and 33 were not graded. Median tumor size was 17 cm. Grossly complete surgical excision was achieved for 45 (43%), of whom 6 (6%) also had clear surgical margins. Adjuvant postoperative irradiation was administered to 36 patients to a median dose of 40 Gy/20 fractions/4 weeks and 16 received adjuvant chemotherapy. Nine patients received no adjuvant postoperative radiotherapy. Gross residual tumor was present postoperatively in 57 patients. The overall 5- and 10-year survival rates were 36% and 14%, respectively. The locoregional relapse free rate (RFR) was 28% at 5 years and 9% at 10 years, and the distant RFR was 76% at 5 years and 60% at 10 years. For the 45 patients treated with complete excision, survival was 55% and 22% at 5 and 10 years, and locoregional RFR was 50% and 18% at 5 and 10 years. Univariate analysis demonstrated that complete surgical removal was the only factor significant for improved survival, locoregional RFR, and distant RFR. Liposarcoma histology predicted for improved survival (p = 0.02), and leiomyosarcoma histology for a lower distant RFR, compared to other histologies (p = 0.003). Patients under 62 years had an improved survival (p = 0.002) and local RFR (p = 0.02), and patients presenting with recurrent disease had improved survival (p = 0.03). Sex, tumor size, or grade, or the use of adjuvant chemotherapy were not predictive for any of the endpoints tested. Those who received adjuvant irradiation following gross surgical clearance experienced a prolonged median locoregional RFR over those who did not, and this approached statistical significance for those receiving radiation doses > 35 Gy. (103 months vs. 30 months, p = 0.06). Statistical significance was reached (p = 0.02) if only the infield RFR was considered.
This study demonstrates that failure to achieve local control is the primary cause of treatment failure for patients with RSTS, and that postoperative irradiation in doses > 35 Gy after complete surgery delayed, but did not prevent local recurrence. Improvements in outcome for patients with RSTS will require alternate treatment strategies, and preoperative irradiation with an aggressive surgical attempt at complete excision is currently under investigation.
回顾性评估腹膜后软组织肉瘤患者的治疗结果，并确定影响生存、局部区域和远处疾病控制的预后因素。
回顾性分析了1975年至1988年间在玛格丽特公主医院接受手术和放疗的104例腹膜后软组织肉瘤（RSTS）患者的记录。采用单因素对数秩分析评估潜在的预后因素。
初诊为新发原发性疾病74例，原发性复发20例，转移10例。病理类型为脂肪肉瘤42例，平滑肌肉瘤22例，恶性纤维组织细胞瘤19例，其他组织学类型21例。分级为低级别36例，高级别35例，33例未分级。肿瘤中位大小为17 cm。45例（43%）实现了大体完全手术切除，其中6例（6%）手术切缘也为阴性。36例患者接受了辅助术后放疗，中位剂量为40 Gy/20次/4周，16例接受了辅助化疗。9例患者未接受辅助术后放疗。57例患者术后存在大体残留肿瘤。总体5年和10年生存率分别为36%和14%。局部区域无复发生存率（RFR）5年时为28%，10年时为9%；远处无复发生存率5年时为76%，10年时为60%。对于45例接受完全切除的患者，5年和10年生存率分别为55%和22%，局部区域无复发生存率5年和10年时分别为50%和18%。单因素分析表明，完全手术切除是改善生存、局部区域无复发生存率和远处无复发生存率的唯一显著因素。与其他组织学类型相比，脂肪肉瘤组织学类型提示生存改善（p = 0.02），平滑肌肉瘤组织学类型提示远处无复发生存率较低（p = 0.003）。62岁以下患者生存改善（p = 0.002）且局部无复发生存率改善（p = 0.02），复发疾病患者生存改善（p = 0.03）。性别、肿瘤大小、分级或辅助化疗的使用对所测试的任何终点均无预测价值。在大体手术切除后接受辅助放疗的患者，其局部区域无复发生存期的中位数长于未接受放疗的患者，对于接受放疗剂量> 35 Gy的患者，这接近统计学意义（103个月对30个月，p = 0.06）。若仅考虑野内无复发生存率，则达到统计学意义（p = 0.02）。
本研究表明，未能实现局部控制是RSTS患者治疗失败的主要原因，完全手术后放疗剂量> 35 Gy可延迟但不能预防局部复发。改善RSTS患者的治疗结果需要替代治疗策略，目前正在研究术前放疗并积极手术尝试完全切除。
