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MULTICENTRIC EVALUATION OF THE FRENCH SURGICAL SYSTEM IN SOFT TISSUE SARCOMA (STS).
E. Stoeckle, S. Bonvalot, JY Blay, L. Guillou, J. Fraisse, JL.
Verhaeghe, JM. Coindre, BN Bui
From the French Sarcoma Group
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Why another classification?
Surgery is no more the only treatment for STS: Formerly, subjectivity of surgeon-based definitions of quality of
surgery had no impact on treatment modalities: wait and see Actually, multimodality treatment needs to know: -
who will recur - to whom give additional treatment and how
Furthermore, homogenous treatment reporting is needed
However, quality of surgery remains subjective: Surgeon – dependent or Pathologist - dependent
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The UICC classification
The UICC recommends the R - classification in STS: R0: resection in sano R1: microscopic residual disease R2: macroscopic residual disease
But it does not give instructions how to determine R!
Usually, Enneking’s classification is transposed into the R - classification
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Individual appreciation of quality of surgery is not
appropriate!
Surgeons overestimate excision Almost large German registry (Junginger 2001):
Extremity sarcoma 82% R0 Retroperitoneal sarcoma 64% R0
Local recurrences remain elevated Pathologists underestimate excision
Retraction of tissue Negative specimen after re-excision in 50%
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The FSG system (I)
1. 1995: OP reports review in 8 participating centers: missing information
2. 1995 - 1996: multicentric feasibility study of items for OP reporting:
Only describe Important issues: tumor seen?
tumor rupture?3. 1998: Recommendations for pathology
reporting (Ghnassia).4. Determination of resection type (UICC R
system) by surgeon and pathologist.
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The FSG system (II)
4. 1996 - 1999: prospective validation in a single center (Bordeaux):
109 consecutive patients with trunk wall + extremity, conservative surgery, 68% R0 , 56 months FU:
3% R0Local recurrence:8% (P < 0,01)
19% R1
Negative predictive value of R0: 97%
5. Actual study: multicentric evaluation
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Methods
Methods: FSG data base - multivariate prognostic factor analysis
Patients’ selection: resection type (R) informed: 423 pts. 325 pts. with
trunk wall or extremity STS 302 pts. N0 M0 Inclusion and follow-up:
1995 - 2002, FU: 21 months (1 – 104 months) Accrual by center: Bordeaux 88
Villejuif 52 Lyon 52 Lausanne 24 Nancy 22 0ther centers 64
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Patients’ characteristics
M/F: 150/152 pts. Localizations:
Shoulder girdle 12 4% Upper extremity 36 12% Trunk wall 31 10% Pelvic girdle 24
8% Lower extremity 199 66%
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Tumor extension
Superficial tumors: 56 pts. (18,5%) Median size : 9 cm (1 – 26 cm) Multifocality: 31 pts. (10,3%) Vasc./nerve involvement: 47 pts. (15,6%) AJC/UICC stage 1979:
I: 14% II: 28% III: 33% IV: 15% NP: 10% AJC/UICC stage 2002:
IA: 15% IB: 35% IIA: 13% IIB: 2% III: 29% NP: 5%
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Pathology
Histological subtypes: Liposarcoma 70 (23%) Leiomyosarcoma 46 (15%) MFH 44 (15%) Synovialosarcoma 25 (8%) MPNST + RhabdoS. 15 (5%) Unclassified S. 39 (13%) Others + NP 63 (21%)
Grade I: 17% II: 34% III: 45% NP: 5%
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Treatments
302 operated patients: First-line surgery: 83% Resection types :
R0 220 (73%)R1 68 (22%)
R2 14 (5%) Radiotherapy: 62% Chemotherapy: 40%
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Treatment results
R0 213
CR: 272 (90%) R1 54
R2 5
Survivors: 240 (80%) actuarial 65%
LR: crude 34 (13%) actuarial 21%
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Overall survival
TSURV
60483624120
Sur
vie
cum
ulée
1,0
,9
,8
,7
,6
,5
,4
,3
,2
,1
0,0
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Resection-type according to center (NS)
Center N R0
Bordeaux 88 73%Villejuif 52 73%Lyon 52 64%Lausanne 24 83%Nancy 22 64%Others 64 80%
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Resection type according to localization (NS)
Localization N R0
Shoulder girdle 12 75%Upper extremity 36 56%Trunk wall 31 71%Pelvic girdle 24 67%Lower extremity 199 77%
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Local recurrence-free interval
TRLOC
60544842363024181260
Su
rvie
cu
mu
lée
1,0
,9
,8
,7
,6
,5
,4
,3
,2
,1
0,0
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Local recurrence according to R
0
0,1
0,2
0,3
0,4
0,5
0,6
0,7
0,8
0,9
1
0 12 24 36 48 60 72
R0
R1+R2
P = 0,004
R0
R1 + R2
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Local recurrence according to grade
0
0,1
0,2
0,3
0,4
0,5
0,6
0,7
0,8
0,9
1
0 12 24 36 48 60 72
grade1 et2
grade3
P = 0,019
Grade 1 + 2
Grade 3
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19Local recurrence according to T3 (1979 UICC
classification)
0
0,1
0,2
0,3
0,4
0,5
0,6
0,7
0,8
0,9
1
0 12 24 36 48 60 72
T1T2
T3
P = 0,049
T1 + T2
T3
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Local recurrence according to stage AJC/UICC 1979
0
0,1
0,2
0,3
0,4
0,5
0,6
0,7
0,8
0,9
1
0 12 24 36 48 60 72
stade I ajc
stade 2 ajc
stade3 ajc
stade4 ajc
P = 0,0045
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Local recurrence according to stage AJC/UICC 2002
0
0,1
0,2
0,3
0,4
0,5
0,6
0,7
0,8
0,9
1
0 12 24 36 48 60 72
stade IA2002
stade IB2002
Stade II 2002
Stade3 2002
P = 0,042
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Prognostic factors/LR
Variable RL N p
R R0 20 213 0,004R1+R2 14 59
Grade 1 3 46 0,022 7 923 23 122
T T1 +T2 23 218 0,05T3 8 37
Histotype, Size (+/- 5 cm), Localization,Depth, Center, Radiotherapy: NS
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Independent prognostic factors for local recurrence
Variables p RR CI
No R0 0,003 3,06 1,47 - 6,38
Grade 3 0,004 3,35 1,48 - 7,55
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Conclusion
Resection type (R) as defined by FSG predicts independently local recurrence
FSG criteria are reproducible and can
be used in a multicentric setting Treatment results in the multicenter
study are lower than in the single center: progress still needed.