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Table of Contents
EDITORIAL
Year : 2019  |  Volume : 2  |  Issue : 2  |  Page : 215-216

Management of bone and soft-tissue sarcomas: From state of practice to state of art


Musculoskeletal Oncology Division, Max Institute of Cancer Care, New Delhi, India

Date of Web Publication20-Dec-2019

Correspondence Address:
Akshay Tiwari
Musculoskeletal Oncology Division, Max Institute of Cancer Care, Saket, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CRST.CRST_107_19

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How to cite this article:
Tiwari A. Management of bone and soft-tissue sarcomas: From state of practice to state of art. Cancer Res Stat Treat 2019;2:215-6

How to cite this URL:
Tiwari A. Management of bone and soft-tissue sarcomas: From state of practice to state of art. Cancer Res Stat Treat [serial online] 2019 [cited 2020 Feb 26];2:215-6. Available from: http://www.crstonline.com/text.asp?2019/2/2/215/273671



Limb salvage surgery has been established as a standard of care for bone and soft-tissue sarcomas of the extremities, and the survival rates have been proven to be similar to what can be achieved by amputation. This issue of Cancer Research, Statistics, and Treatment brings two articles addressing the outcome of modern treatment modalities used for the management of bone and soft-tissue tumors in the Indian centers. As far as osteosarcoma is concerned, systemic treatment in the form of multi-agent chemotherapy combined with oncologically sound surgery is an integral part of multidisciplinary management of osteosarcoma, with 5-year survival rates varying from 60% to 70% in most series.[1],[2] While most of the recent data on osteosarcoma have been from the Western world, there have been a few Indian studies in recent years, which report the 5-year survival rates as somewhat inferior to the world literature, attributed largely to patients presenting late with larger tumors.[3],[4],[5] However, most of these are studies from large referral centers from metropolitan cities. Similarly, several studies on the outcome of management of soft-tissue sarcoma in Indian patients have been published.[6],[7],[8]

The article by Ankalkoti et al. reports the outcome of multidisciplinary osteosarcoma management from a 'rural' tertiary cancer center, thereby bridging a gap in the understanding of the feasibility and outcome of comprehensive osteosarcoma treatment beyond the boundaries of the bigger cities.[9] This is a retrospective analysis of 41 patients with osteosarcoma undergoing limb salvage surgery with multi-agent chemotherapy. At a median follow-up of 84.4 ± 11.01 months, the 5-year overall survival was 58.5% ± 7.7% and 5-year relapse-free survival was 56.1% ± 7.8% (95% confidence interval, 53.7–58.5). The estimated 5-year survival of prosthesis was 55.6% (less than the reported prosthetic survival reported by other workers), which takes into account implant removal for both local recurrence and infection, besides aseptic loosening. The use of a non-methotrexate (MTX)-based chemotherapy and a custom-made mega prosthesis rather than a modular prosthesis represents a balanced approach in a resource-limited setting and has given outcomes mostly at par with other studies. This adds to the large body of the existing evidence of noninferiority of non-MTX-based chemotherapy to an MTX-based one.[10] Whether only MTX-based chemotherapy is to be taken as state-of-the-art management is still controversial.[11] It is a study that represents the penetration of modern osteosarcoma treatment beyond just the metropolitan cities in India. The treatment and the follow-up have been carried out at the same center with the same team, making it a reproducible dataset. However, it is a retrospective study with a limited number of patients. Only patients having undergone limb-sparing surgery are included in this study, and the exclusion of patients undergoing amputation (who would likely have presented with locally and/or systemically advanced disease) may not be a true representation of the outcome of osteosarcoma in the Indian population.

The article by Pareekutty et al. from the same center studies the outcome of soft-tissue sarcoma in the Indian population and underlines very well the still prevalent problem of an unplanned excision of soft-tissue sarcomas.[12] Unplanned excisions result in repeat surgeries, often with greater postoperative morbidity, wound complications, and the requirement of flaps.[13] In the present study, 43.13% of the patients underwent planned excision, while 56.86% in the study group underwent unplanned excisions in peripheral hospitals. After unplanned excisions, 75.9% of the patients had positive margins and 56.2% of the patients had residual tumors at the operated site. Interestingly, the mean overall survival was 80.36 ± 10.76 months in the planned group and 104.52 ± 5.09 months in the unplanned group. As per the authors, this may have resulted from a better tumor profile in the unplanned excision group. Whether the smaller soft-tissue sarcomas have a higher chance of undergoing an unplanned excision would be interesting to explore.

It is a well-analyzed cohort of patients who underwent planned versus unplanned excisions of soft-tissue sarcomas. While the authors concluded that unplanned excisions do equally well if managed with timely re-excision echoes the outcome of many others,[14] there has been some discussion about a wait-and-watch policy rather than an active intervention for unplanned excision of soft-tissue sarcoma in the absence of residual disease on imaging.[15] The limitations of this study (small number of patients included, retrospective nature, and lack of information regarding functional outcomes) contribute to the differences in subgroups not reaching statistical differences. The study, however, does well to add to the existing Indian data on soft tissue-sarcoma.

Access to sarcoma care remains a challenge across the globe, more so in low- and middle-income countries.[16],[17] The impact of socioeconomic factors including the availability of infrastructure and expertise is undeniable[18] and improving access to care is a low-hanging fruit in the quest to bridge the gap that exists between the 'state of art' and the 'state of practice'.



 
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Poudel RR, Tiwari V, Kumar VS, Bakhshi S, Gamanagatti S, Khan SA, et al. Factors associated with local recurrence in operated osteosarcomas: A retrospective evaluation of 95 cases from a tertiary care center in a resource challenged environment. J Surg Oncol 2017;115:631-6.  Back to cited text no. 4
    
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Tiwari A, Jain S, Mehta S, Kumar R, Kapoor G, Kumar K. Limb salvage surgery for osteosarcoma: Early results in Indian patients. Indian J Orthop 2014;48:266-72.  Back to cited text no. 5
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Tiwari A, Shah S, Sharma AK, Mehta S, Batra U, Sharma SK, et al. Prognostic factors in Indian patients operated for soft tissue sarcomas-a retrospective cross-sectional analysis. Indian J Surg Oncol 2017;8:128-35.  Back to cited text no. 7
    
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Iqbal N, Shukla NK, Deo SV, Agarwala S, Sharma DN, Sharma MC, et al. Prognostic factors affecting survival in metastatic soft tissue sarcoma: An analysis of 110 patients. Clin Transl Oncol 2016;18:310-6.  Back to cited text no. 8
    
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Ankalkoti B, Pareekutty NM, Kattepur AK, Kumbakara R, Vazhayil R, Balasubramanian S. Life and limb after limb salvage surgery for osteosarcoma in an Indian tertiary cancer center. Cancer Res Stat Treat 2019;2:145-51.  Back to cited text no. 9
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Bajpai J, Chandrasekharan A, Simha V, Talreja V, Karpe A, Pandey N, et al. Outcomes in treatment-naïve patients with metastatic extremity osteosarcoma treated with ogs-12, a novel non-high-dose methotrexate-based, dose-dense combination chemotherapy, in a tertiary care cancer center. J Glob Oncol 2018;4:1-10.  Back to cited text no. 11
    
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Pareekutty NM, Kattepur AK, Alapett JJ, Satheesan B. Unplanned excision in soft-tissue sarcomas – Is it the unkindest cut of all? Cancer Res Stat Treat 2019;2:152-7.  Back to cited text no. 12
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13.
Grimer R, Parry M, James S. Inadvertent excision of malignant soft tissue tumours. EFORT Open Rev 2019;4:321-9.  Back to cited text no. 13
    
14.
Zaidi MY, Ethun CG, Liu Y, Poultsides G, Howard JH, Mogal H, et al. The impact of unplanned excisions of truncal/extremity soft tissue sarcomas: A multi-institutional propensity score analysis from the US sarcoma collaborative. J Surg Oncol 2019;120:332-9.  Back to cited text no. 14
    
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Decanter G, Stoeckle E, Honore C, Meeus P, Mattei JC, Dubray-Longeras P, et al. Watch and wait approach for re-excision after unplanned yet macroscopically complete excision of extremity and superficial truncal soft tissue sarcoma is safe and does not affect metastatic risk or amputation rate. Ann Surg Oncol 2019;26:3526-34.  Back to cited text no. 15
    
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