1. Clinical variables, pathological factors, and molecular markers for enhanced soft tissue sarcoma prognostication G. Lahat, B. Wang, D. Tuvin, DA. Anaya, C. Wei, B. Bekele, KD. Smith, AJ. Lazar, PW. Pisters, RE. Pollock, D. Lev Sarcoma Research Center UT MD Anderson Cancer Center Houston, TX U.S.A.

2. Current STS staging systems have several important shortcomings The TNM and grade criteria do not reflect the heterogeneity of STS Available nomograms are not universally applicable No current STS staging system includes molecular predictors of outcome Patient I- 6cm high grade extremity UPS Patient II- 25cm retroperitoneal dedifferentiated LPS Both are AJCC Stage III patients!

3. Purpose To identify clinical, pathological, and molecular descriptors of STS clinical behavior for inclusion in revised staging systems

4. Methods UTMDACC STS prospective database Univariate and multivariate statistical analyses Clinically annotated STS tissue microarray

5. Local recurrence only 474 Primary & Metastatic 435 Metastatic disease only 350 UTMDACC STS Database 1996-2007 6,702 patients Definitive treatment 3,717 Primary disease only 2,458 Surgical treatment of primary tumor 1,442 Study cohort 1,091 Second opinion 2,985 R2 resection and non-specific histologies 351 Non- surgical treatment 1,016

6. Patient and tumor characteristics Male: 52%; Female: 48% Median age (range): 54.5 years (15-91) Median follow-up: 53.3 months Extremity 58% Intra thoracic 6% Intra abdominal 26% Superficial trunk 6% Head and neck 2.5%

7. Non-extremity location is associated with increased STS-specific mortality Non-extremity (n= 464; 42%) Extremity (n= 627; 58%) p<0.0001

8. A T3 category may be added to the AJCC STS staging system p<0.0001 Tumor size>15cm (n= 230; 21%) Tumor size 5-10cm (n=336; 31%) Tumor size 10-15cm (n= 202; 19%) Tumor size< 5cm (n= 309; 29%)

9. High grade is associated with increased STS-specific mortality p<0.0001 High grade (n=737; 67.6%) Low/intermediate grade (n=354; 32.2%)

10. Interaction between variables: tumor size and grade effects on STS-specific mortality p<0.0001 High grade, size>15cm High grade, size 5-15cm High grade, size<5cm Low/intermediate grade

11. Low /intermediate grade, negative margins Low/intermediate grade, positive margins High grade, negative margins High grade, positive margins Interaction between variables: margin positivity and grade effects on STS- specific mortality p<0.0001

12. Multivariate Cox Proportional Hazard Models for STS-specific mortality VariableLevelsHRP value Microscopic marginsPositive vs. negative5.9<0.0001 Primary siteNon-extremity vs. extremity3.19<0.0001 Tumor size5-15cm vs. <5cm >15cm vs. <5cm 2.98 7.45 <0.0001 Disease gradeHigh grade vs. low/intermediate grade2.06<0.0001 HistologyUPS vs. WD Dedifferentiated liposarcoma vs. WD Others vs. WD 8.07 4.02 2.98 0.001 0.005 <0.0001

13. Multivariate Cox Proportional Hazard Models for STS local recurrence free survival VariableLevelsHRP value AgeContinuous in 10 years increment1.26<0.0001 Primary siteNon-extremity vs. extremity1.84<0.0001 Margin positivityPositive vs. negative margins2.39<0.0001 Disease gradeHigh grade vs. low/intermediate grade1.900.001 GenderMale vs. female1.540.01

14. Conclusions Ann Surg Oncol 2008; 15:2739-48 STS size, site, grade, histology, and microscopic margin status should be included in a revised staging system Can we further improve and individualize prognostication?

15. Every STS is “unique” Cure Distant metastasis followed by death 6cm, extremity, HG, UPS, R0 resection 6cm, extremity, HG, UPS, R0 resection Patient APatient B Clinical and pathological prognostic factors are not enough!

16. Molecular markers are important potential prognostic factors High throughput assays Detection of DNA, RNA, and protein targets Simultaneous analysis of large tumor sets Correlation with clinical data

17. TMA (n=205) Growth and metastasis Ki-67 Apoptosis/survival P53 MDM2 Bcl2 Bcl-x Cytokines/receptors/signaling EGFR VEGF β-Catenin Extracellular matrix MMP2 MMP9

18. High MMP2 expression correlates with decreased STS-specific survival 72% 46% Disease specific survival time (months) Percent MMP2 pos ≤ 10% Percent MMP2 pos > 10%

19. Multivariate Cox Proportional Hazard Models for disease specific survival (TMA cohort) VariableLevelsHRP value Primary siteNon-extremity vs. extremity2.950.001 Disease gradeHigh grade vs. low/intermediate grade2.50.02 AgeContinuous in 10 years increment1.62<0.0001 MMP2 expression> 10% vs. ≤ 10%1.740.04

20. Multivariate Cox Proportional Hazard Models for local recurrence (TMA cohort) VariableLevelsHRP value AgeContinuous in 10 years increment 1.510.008 Primary siteNon-extremity vs. extremity4.090.005 MMP2 expression> 10% vs. ≤ 10%6.280.006

21. Matrix metalloproteinases (MMP2) and STS Number of patientsCorrelation with outcome Maguire PD, et al (Oncology, 2000)12Negative Benassi MS, et al (Ann Oncol, 2001)73Positive; grade, DFS Previous series

22. Conclusions High MMP2 expression may be an adverse independent predictor of outcome in STS Inclusion as a molecular prognostic factor in future STS staging systems, pending large scale validation Individualized therapeutic strategy Should be further studied as potential targets for therapy

23. Acknowledgments Vision and direction: Insights and teamwork: Sarcoma Research Center University of Texas MD Anderson Cancer Center Dina Lev, MDDaniel Tuvin, MD Raphael Pollock, MD, PhDDaniel Anaya, MD Peter Pisters, MDKerrington Smith, MD Alex Lazar, MD, PhD Nebiyou Bekele, PhD Kevin Coombs, PhD Caimiao Wei, PhD

24. Thank you for your attention!

25. TMA Tumor characteristics Extremity 86% Size> 5cm (76%) HG (75%) UPS 78% Negative margins (70%)