1. Primary thoracic sarcomas: prognostic factors and outcome in a series of patients treated at a single institution Leonardo Duranti T horacic Surgery

2. Soft tissues sarcomas of trunk wall French Sarcoma Group Database 343 patients Overall survival 5 and 10 year 60,4% and 53,7% Local recurrence-free survival 5 and 10 year 58,4% and 55,5% Metastasis-free survival 5 and 10 year 68,9% and 66,4%

3. Thoracic chest wall sarcomas Limited series with significant disease recurrence rates

4. From 1/1980 to 3/2012 Methods Our analysis is limited to : Primary sarcoma First Local recurrence We excluded from this analysis: Systemic disease Pulmonary, pleural,mediastinal or chest wall metastases from peripheral sarcomas Bone sarcomas, Ewing sarcomas, alveolar/embrional rabdomyosarcomas and desmoids 343 patients

5. No.% Sex Female13539.8 Male20860.2 Age, yr Mean (SD)50.8 (16.7) Median (IQ range)52.9 (38.1-64.1) Presentation Primary31290.8 Recurrence319.2 Grading G17522.3 G25616.6 G320661.1 Patients characteristics

6. No.% - Histological subtypes UPS13439.8 Lipo3811.3 Leio319.2 Syno4613.6 SFT339.8 MPNST4011.9 Other154.4 Margins R026177.4 R16419.0 R2123.6 CT No19559.3 Yes13440.7 RT No16048.6 Yes16951.4 Patients characteristics

7. Methods Type of resectionsProcedures Soft tissues resections 233 pts Muscles, skin and subcutaneous tissue without chest wall Chest wall resections 36 Skeleton of the chest, sometimes with soft tissue and lung and pericardium and or diaphragm Mediastinal resection 17 Mediastinal masses without great vessels, and without major pulmonary resections Extended resections 32 Mediastinal masses en bloc with complex chest wall(*), great vessels (**) and/or myocardial resection (***), extrapleural pneumonectomy, thoraco- pneumonectomy, diaphragm and vertebral resections(****) Pleural masses 9 Pleural fibrous tumors not en-bloc with major pulmonary parenchyma or chest wall resections. Lung resections 16 Pulmonary anatomical resections * 2 thoraco-pneumonectomies, which consist in the removal of an entire hemithorax: 12 ribs, hemi- sternum, lung, hemi-diaphragm, pericardium and prosthetic reconstruction of the skeleton and the pericardium **3 superior vena cava replacements with PTFE prosthesis between anonimous veins and right auricle, 1 replacement of the carotid artery and 3 prosthetic replacements of subclavian artery and vein, and 1 jugular and subclavian vein replacement. ***5 atrial resections, and 1 myocardial ECC maximal cardiac surgery ****2 hemi-laminectomies and 2 body vertebral resections.

8. Post-operative outcome Major Complications Minor Complications 10 % 2 % Postoperative mortality 0,6 %

9. Survival

10. Survival by prognostic factors p<0,0001 Survival analysis according to margins Survival analysis according to phase p=0,0002 p<0,0001

11. Survival by grade Comparative analysis o overall survival between primary tumors operated before and after the specified time Panel A (Log-rank test p=0.03) p=0,0005 p<0,0001 Survival analysis according to grade Distant Metastases–free Survival and grade

12. Survival by histotype Log-rank test p=0.04 Panel A (Log-rank test p=0.03) Survival according to histotypes p=0,05 p=0,003 Distant Metastases–free Survival and histotypes

13. Survival by calendar time Overall Survival Superficial STSCentral STS Log-rank test p=0.004 Log-rank test p=0.04

14. Significant predictors of survival Phase (primary/recurrence) Margins Grading Tumor size Calendar time Multivariate analysis for survival Significant predictors of local recurrence Tumor size (> 8 cm) Margins Radiotherapy Calendar time Significant predictors of distant metastases Tumor size (> 8 cm) Grading Margins

15. Chest Wall Reconstruction Three-step process ( approximately 20 minutes) 1. polyester multifilament knitted mesh 2. acrylic resin modeled over the mesh 3. the prosthesis is further reinforced by dripping and modeling methyl methacrylate resin

16. Chest Wall Reconstruction

17. Superior vena cava

18. Quality of surgery is the most important treatment in STS and correlates with overall survival, risk of recurrences and distant metastases. Quality of surgery in STS also means extended surgery/ /multivisceral resections. The prognosis depends on biology (grading), on early diagnosis (size) and ability to perform an optimal surgical resection at presentation (phase and margins). Integrated multidisciplinary treatment is warranted. Tertiary referral centers are needed, particularly for these specific site. Conclusions