|LETTER TO EDITOR
|Year : 2020 | Volume
| Issue : 1 | Page : 120-121
Raising the bar – Sarcoma management in India
Srinath Gupta, Ashish Gulia
Department of Surgical Oncology, Tata Memorial Hospital, HBNI, Mumbai, Maharashtra, India
|Date of Submission||14-Jan-2020|
|Date of Acceptance||16-Jan-2020|
|Date of Web Publication||24-Feb-2020|
Department of Surgical Oncology, Tata Memorial Hospital, HBNI, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Gupta S, Gulia A. Raising the bar – Sarcoma management in India. Cancer Res Stat Treat 2020;3:120-1
Bone and soft-tissue sarcomas are aggressive malignancies requiring a multimodality approach. Ankalkoti et al. have discussed the management of osteosarcoma, while Pareekutty et al. have described in detail about a very common community hazard, i.e. 'Whoops excision' and its management. However, we would like to raise few queries and mention some shortcomings.
Ankalkoti et al. mentioned that 19.5% of their patients had the Enneking Stage III disease with a 5-year overall survival of 25%. A mention about the number of patients with lung metastasis, and the intent of treatment (inclusion/exclusion criteria) was missing. Having more details about the number of patients with metastasis and their individual outcomes would be interesting. Under the material and methods section, the authors have mentioned about prosthetic reconstruction, whereas the results talk about biological reconstruction as well. The size of the tumor is another important prognostic factor; a comparison between the size and outcomes would have been preferred. The functional evaluation was done using the Musculoskeletal Tumor Society (MSTS) scoring system which is universally accepted. However, the parameters described are wrong. The scoring system is different for the upper limb and the lower limb. The original article mentions 6 parameters with 5 points for each and a maximum score of 30. MSTS scores recorded at the time of the last date of follow-up and evaluation by the treating surgeon would have been ideal. There is no mention about the margins of resection and their comparison with oncological outcomes, which would have made for a compelling analysis. With a 17% lost to follow-up, the oncological outcomes recorded may be low if we considered all of them or at least half of them dead. The paper talks about the outcomes of limb salvage but does not describe the outcomes of those who underwent amputation. However, this was good attempt to generate Indian data on this complex disease.
Unplanned excisions in soft-tissue sarcomas are very common in our country. Widespread education of the surgical fraternity is required regarding the hazards of this. The methodology and results of Pareekutty et al., are in line with the published literature which have described similar or better outcomes in unplanned excision groups which can be attributed to their smaller size and location (superficial). An analysis between the grade and outcomes would have been preferred. With no mention of the local recurrence-free survival and a 23% lost to follow-up, the results are incomplete. Eighteen cases of 'Whoops excision' were excluded from the final analysis; including them would have had an impact on the final results. As the literature mentions better outcomes within 12 weeks of re-resection, mention of the same would have made it a complete paper.
Imaging modalities used during the follow-up are a bit controversial. Imaging in the form of plain radiographs of the chest + lower limb in cases of bone sarcomas and radiograph of chest + ultrasound of the draining lymph nodes in a case of soft-tissue sarcoma have shown similar outcomes compared to those who were followed up with a computed tomography (CT) scan of the chest. Hence, avoiding a CT scan in a resource-constrained setting like India is suggested.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Tiwari A. Management of bone and soft-tissue sarcomas: From state of practice to state of art. Cancer Res Stat Treat 2019;2:215. [Full text]
Ankalkoti B, Pareekutty N, Kattepur A, 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. [Full text]
Pareekutty N, Kattepur A, Alapatt J, Satheesan B. Unplanned excision in soft-tissue sarcomas – Is it the unkindest cut of all?. Cancer Res Stat Treat 2019;2:152.
Matsubara E, Mori T, Koga T, Shibata H, Ikeda K, Shiraishi K, et al
. Metastasectomy of Pulmonary Metastases from Osteosarcoma: Prognostic Factors and Indication for Repeat Metastasectomy. J Respir Med 2015;2015:1-5.
Puri A, Byregowda S, Gulia A, Crasto S, Chinaswamy G. A study of 853 high grade osteosarcomas from a single institution-are outcomes in Indian patients different? J Surg Oncol 2018;117:299-306.
Enneking WF, Dunham W, Gebhardt MC, Malawar M, Pritchard DJ. A system for the functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system. Clin Orthop Relat Res 1993;286:241-6.
Funovics PT, Vaselic S, Panotopoulos J, Kotz RI, Dominkus M. The impact of re-excision of inadequately resected soft tissue sarcomas on surgical therapy, results, and prognosis: A single institution experience with 682 patients. J Surg Oncol 2010;102:626-33.
Puri A, Ranganathan P, Gulia A, Crasto S, Hawaldar R, Badwe RA. Does a less intensive surveillance protocol affect the survival of patients after treatment of a sarcoma of the limb? Updated results of the randomized TOSS study. Bone Joint J 2018;100-B: 262-8.