Repeated and Aggressive Pulmonary Resections for Leiomyosarcoma Metastases Extends Survival

doi:10.1016/j.athoracsur.2011.05.052

The Annals of Thoracic Surgery

Volume 92, Issue 4, October 2011, Pages 1202-1207

https://doi.org/10.1016/j.athoracsur.2011.05.052 Get rights and content

Background

Sarcoma frequently metastasizes to the lungs, and pulmonary metastasectomy is the only treatment modality that can provide a cure for these patients. We attempted to determine the clinicopathologic features and survival determinants of a common subset of patients who undergo pulmonary metastasectomy for leiomyosarcoma.

Methods

All patients undergoing pulmonary metastasectomy at The Brigham and Women's Hospital from 1989 to 2004 were reviewed retrospectively. Analyzed variables included number, size, pathology, and location of metastases, age, gender, location of primary tumor, disease-free interval (DFI), surgical approach, margin status, adjuvant therapy, recurrence, number of metastasectomies, and disease-free and overall survival.

Results

Eighty-two patients underwent pulmonary metastasectomy for metastases from sarcoma. Leiomyosarcoma was the most common histologic finding (n = 31; 38%). Fifteen patients with leiomyosarcoma (48%) underwent repeated pulmonary metastasectomy. Patients with leiomyosarcoma were more commonly female (77% versus 43%; p = 0.031), less frequently received chemotherapy for their primary tumor (48% versus 71%, p = 0.041), and presented with fewer number of pulmonary metastases than did patients with nonleiomyosarcoma metastases (1.9 ± 1.5 standard deviation [SD] versus 3.6 ± 4.4; p = 0.033). Although there was no difference in disease-free survival, patients with leiomyosarcoma demonstrated improved overall survival compared with those with nonleiomyosarcoma metastases (70 versus 24 months; p = 0.049). In multivariate analyses, the DFI from primary tumor resection to pulmonary metastases and the DFI from pulmonary metastasectomy to second pulmonary recurrence were identified as independent predictors of survival.

Conclusions

Leiomyosarcoma is a common subset of sarcomatous pulmonary metastases that behave more indolently compared with other pulmonary metastases from sarcoma. Long-term survival is achievable with an aggressive approach toward pulmonary metastasectomy and repeated pulmonary metastasectomy.

Section snippets

Material and Methods

All patients undergoing pulmonary metastasectomy at The Brigham and Women's Hospital from 1989 to 2004 were reviewed retrospectively following institutional review board approval with waived individual consent. Standardized data collection forms were completed prospectively by the Division of Thoracic Surgery at preoperative, operative, and postoperative interaction points and were recorded in a computerized database. To be included in this series, subjects had to have undergone pulmonary

Results

From 1989 to 2004, 509 pulmonary metastasectomy were performed at The Brigham and Women's Hospital. Eighty-two patients underwent pulmonary metastasectomy for metastases from sarcoma. Of these patients, 31 (38%) had LMS metastases, which was the most common sarcoma histology (Table 1). Compared to patients with non-LMS metastases, patients with LMS metastases were slightly but nonsignificantly older (52 versus 47 years; p = 0.059) and were represented by a greater number of females (77% versus

Comment

Among patients with soft tissue sarcoma that develop pulmonary metastases, the most common histologic findings include malignant fibrous histiocytoma (MFH), synovial sarcoma, and LMS [6, 8, 9]. At our institution, the majority of patients with pulmonary metastases from sarcoma treated with pulmonary metastasectomy had an LMS primary tumor. This cohort of patients appeared to have a modest but significant overall survival advantage (median survival, 69.9 months) compared to patients with other

References (34)

N. Penel et al.
Factors affecting the outcome of patients with metastatic leiomyosarcoma treated with doxorubicin-containing chemotherapy
Ann Oncol
(2010)
D. Gossot et al.
Resection of pulmonary metastases from sarcoma: can some patients benefit from a less invasive approach?
Ann Thorac Surg
(2009)
D. Jablons et al.
Metastasectomy for soft tissue sarcomaFurther evidence for efficacy and prognostic indicators
J Thorac Cardiovasc Surg
(1989)
R. Smith et al.
Factors associated with actual long-term survival following soft tissue sarcoma pulmonary metastasectomy
Eur J Surg Oncol
(2009)
M.F. Brennan
Management of extremity soft-tissue sarcoma
Am J Surg
(1989)
J.Y. Blay et al.
Advanced soft-tissue sarcoma: a disease that is potentially curable for a subset of patients treated with chemotherapy
Eur J Cancer
(2003)
M. Anraku et al.
Pulmonary metastases from uterine malignancies: results of surgical resection in 133 patients
J Thorac Cardiovasc Surg
(2004)
C. Levenback et al.
Resection of pulmonary metastases from uterine sarcomas
Gyn Onc
(1992)
J.F. Huth et al.
Pulmonary resection for metastatic sarcoma
Am J Surg
(1980)
L.A. Lanza et al.
Response to chemotherapy does not predict survival after resection of sarcomatous pulmonary metastases
Ann Thorac Surg
(1991)

G.A. Porter et al.

Cost-effectiveness of pulmonary resection and systemic chemotherapy in the management of metastatic soft tissue sarcoma: a combined analysis from the University of Texas M. D. Anderson and Memorial Sloan-Kettering Cancer Centers

J Thorac Cardiovasc Surg

(2004)

H.W. Pogrebniak et al.

Reoperative pulmonary resection in patients with metastatic soft tissue sarcoma

Ann Thorac Surg

(1991)

M.R. Weiser et al.

Repeat resection of pulmonary metastases in patients with soft-tissue sarcoma

J Am Coll Surg

(2000)

M.T. Jaklitsch et al.

Sequential thoracic metastasectomy prolongs survival by re-establishing local control within the chest

J Thorac Cardiovasc Surg

(2001)

K.G. Billingsley et al.

Multifactorial analysis of the survival of patients with distant metastasis arising from primary extremity sarcoma

Cancer

(1999)

M.A. Gadd et al.

Development and treatment of pulmonary metastases in adult patients with extremity soft tissue sarcoma

Ann Surg

(1993)

M. Van Glabbeke et al.

Prognostic factors for the outcome of chemotherapy in advanced soft tissue sarcoma: an analysis of 2,185 patients treated with anthracycline-containing first-line regimens–a European Organization for Research and Treatment of Cancer Soft Tissue and Bone Sarcoma Group Study

J Clin Oncol

(1999)

Cited by (66)

Surgical treatment of recurrent retroperitoneal sarcoma in its different patterns: A 15-years’ two-centers experience
2023, Surgeon
There is limited data available regarding the role of surgery in the treatment of retroperitoneal sarcoma (RPS) recurrences. We herein report the short- and mid-term outcomes of patients who underwent surgical treatment of RPS recurrences at two Italian centers over a 15-years’ experience.
From January 2005 to January 2020, 33 patients underwent surgical treatment of isolated locally recurrent RPS (LR group), locally recurrent RPS associated with the presence of distant recurrence (LR + DM group), and distant-only recurrent RPS (DM group). Only procedures performed to obtain a macroscopically radical treatment with curative intent were included. Data regarding pre-, intra-, post-operative course, and follow-up, collected in an Institutional database, were retrospectively analyzed, and compared.
LR-group was composed of 15 patients, LR + DM group of 9 patients, and DM group of 9 patients. During the follow-up, 78.5% of the LR group, 77.8% of the DM group and 100% of the LR + DM group (p = 0.244) experienced a second recurrence. 7/11 (63.6%) patients in the LR group, 2/7 (28.5%) patients in the DM-group, and 0/9 (0.0%) patients in the LR + DM group underwent to almost one further local treatments of their recurrences (p = 0.010). No differences in the mean disease-free survival (p = 0.127), overall survival (OS) (p = 0.165) was reported among the three groups. Repeated surgery was an independent factor affecting survival in multivariate analysis (p = 0.01).
A surgical treatment of RPS recurrences should always be taken into consideration, also in metastatic patients and/or in those who have already undergone surgery for previous RPS recurrence, because this approach may offer survival benefits.
Risk-adjusted hazard analysis of survival after pulmonary metastasectomy for uterine malignancies in 319 cases
2023, JTCVS Open
There is little evidence of the outcome of pulmonary metastasectomy for uterine tumors when comparing different histologies. This study aimed to delineate the primary histology that leads to more favorable outcomes after pulmonary metastasectomy.
The database of the Metastatic Lung Tumor Study Group of Japan for 1984 to 2016 was used to analyze the outcomes of patients with gynecologic malignancies who underwent pulmonary metastasectomy. Prognostic factors and long-term outcomes were compared according to the histology of the primary uterine tumors, specifically adenocarcinoma, squamous cell carcinoma, and sarcoma. The adjusted hazard risks according to disease-free intervals (DFIs) and the number and maximum size of resected tumors were also analyzed to delineate the pattern of risk trends.
A total of 319 patients were included in the analysis (122 with adenocarcinomas, 113 with squamous cell carcinomas, 46 with sarcomas, and 38 with other types). The 5-year survival rate was 66.5% for the entire cohort, 71.6% for the patients with adenocarcinoma, 61.3% for those with squamous cell carcinoma, and 55.4% for those with sarcoma. Multivariate analyses identified the positive prognostic factors as DFI ≥12 months in adenocarcinoma and sarcoma and the primary site (corpus) of uterine tumors in adenocarcinoma. The nonlinear adjusted hazard risks indicated that a shorter DFI was associated with an elevated risk of death in patients with adenocarcinoma and sarcoma.
The survival outcome after pulmonary metastasectomy varies according to primary tumor histology, and the prognostic factors differ among histologic subtypes. Surgical indications should be determined based on the prognostic factors for each histology.
Sarcoma Pulmonary Metastatic Disease: Still a Chance for Cure
2022, Surgical Clinics of North America
Italian consensus conference on management of uterine sarcomas on behalf of S.I.G.O. (Societa’ italiana di Ginecologia E Ostetricia)
2020, European Journal of Cancer
Uterine sarcomas are very rare tumours with different histotypes, molecular features and clinical outcomes; therefore, it is difficult to carry out prospective clinical trials, and this often results in heterogeneous management of patients in the clinical practice.
We planned to set up an Italian consensus conference on these diseases in order to provide recommendations on treatments and quality of care in our country.
Early-stage uterine sarcomas are managed by hysterectomy + bilateral salpingo-oophorectomy according to menopausal status and histology; lymphadenectomy is not indicated in patients without bulky nodes, and morcellation must be avoided. The postoperative management is represented by observation, even though chemotherapy can be considered in some high-risk patients. In early-stage low-grade endometrial stromal sarcoma and adenosarcomas without sarcomatous overgrowth, hormonal adjuvant treatment can be offered based on hormone receptor expression. In selected cases, external beam radiotherapy ± brachytherapy can be considered to increase local control only.
Patients with advanced disease involving the abdomen can be offered primary chemotherapy (or hormonal therapy in the case of low-grade endometrial stromal sarcoma and adenosarcoma without sarcomatous overgrowth), even if potentially resectable in the absence of residual disease in order to test the chemosensitivity (or hormonosensitivity); debulking surgery can be considered in patients with clinical and radiological response. Chemotherapy is based on anthracyclines ± ifosfamide or dacarbazine. Palliative radiotherapy can be offered for symptom control, and stereotactic radiotherapy can be used for up to five isolated metastatic lesions.
Treatment of uterine sarcoma should be centralised at referral centres and managed in a multidisciplinary setting.
Current Indications for Pulmonary Metastasectomy
2020, Surgical Oncology Clinics of North America
Stereotactic Body Radiotherapy Versus Metastasectomy in Patients With Pulmonary Metastases From Soft Tissue Sarcoma
2020, Clinical Oncology
The lung is the preferred site of metastasis from soft tissue sarcoma (STS). This systematic review aims to evaluate the outcomes of stereotactic body radiotherapy (SBRT) and metastasectomy (MTS) for the treatment of lung metastases from STS. A systematic review was carried out according to the PRISMA protocol. PubMed, Medline, EMBASE, Cochrane Library, Ovid and Web of Knowledge databases were searched for English-language articles to December 2018 using a predefined strategy. Retrieved studies were independently screened and rated for relevance. Data were extracted by two researchers. In total, there were 1306 patients with STS: 1104 underwent MTS and 202 had SBRT. The mean age ranged from 40 to 55.8 years in the MTS group and from 47.9 to 64 years in the SBRT group. The cumulative death rate was 72% (95% confidence interval 59–85%) in the MTS group and 56% (38–74%) in the SBRT group. The cumulative mean overall survival time was 46.7 months (36.4–57.0%) in the MTS group and 47.6 months (33.7–61.5%) in the SBRT group. The cumulative rate of patients alive with disease was 5% (2–9%) in the MTS group and 15% (6–36%) in the SBRT group. Finally, the cumulative rate of patients alive without disease in the two groups was 19% (9–29%) and 20% (10–50%), respectively. Our study showed that local treatment of pulmonary metastases from STS with SBRT, compared with surgery, was associated with a lower cumulative overall death rate and similar overall survival time and survival rates without disease. By contrast, SBRT was associated with a higher survival rate with disease than MTS. Large randomised trials are necessary to confirm these findings and to establish whether SBRT may be a reliable option for early stage disease.

View all citing articles on Scopus

View full text

Original articleGeneral thoracicRepeated and Aggressive Pulmonary Resections for Leiomyosarcoma Metastases Extends Survival

Background

Methods

Results

Conclusions

Section snippets

Material and Methods

Results

Comment

Ann Oncol

Ann Thorac Surg

J Thorac Cardiovasc Surg

Eur J Surg Oncol

Am J Surg

Eur J Cancer

J Thorac Cardiovasc Surg

Gyn Onc

Am J Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Am Coll Surg

J Thorac Cardiovasc Surg

Multifactorial analysis of the survival of patients with distant metastasis arising from primary extremity sarcoma

Cancer

Development and treatment of pulmonary metastases in adult patients with extremity soft tissue sarcoma

Ann Surg

Prognostic factors for the outcome of chemotherapy in advanced soft tissue sarcoma: an analysis of 2,185 patients treated with anthracycline-containing first-line regimens–a European Organization for Research and Treatment of Cancer Soft Tissue and Bone Sarcoma Group Study

J Clin Oncol

Original article
General thoracic
Repeated and Aggressive Pulmonary Resections for Leiomyosarcoma Metastases Extends Survival