1. Institut Bergonié 1 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

2. Institut Bergonié 2 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 – dependentor  Pathologist - dependent

3. Institut Bergonié 3 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

4. Institut Bergonié 4 Individual appreciation of quality of surgery is not appropriate!  Surgeons overestimate excision  Almost large  German registry (Junginger 2001):  Extremity sarcoma82% R0  Retroperitoneal sarcoma64% R0  Local recurrences remain elevated  Pathologists underestimate excision  Retraction of tissue  Negative specimen after re-excision in 50%

5. Institut Bergonié 5 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.

6. Institut Bergonié 6 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% R0 Local recurrence:8%( P < 0,01) 19% R1 Negative predictive value of R0: 97% 5. Actual study: multicentric evaluation

7. Institut Bergonié 7 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: Bordeaux88 Villejuif52 Lyon52 Lausanne24 Nancy22 0ther centers64

8. Institut Bergonié 8 Patients’ characteristics  M/F:150/152 pts.  Localizations:  Shoulder girdle 12 4%  Upper extremity 3612%  Trunk wall 3110%  Pelvic girdle 24 8%  Lower extremity19966%

9. Institut Bergonié 9 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%

10. Institut Bergonié 10 Pathology  Histological subtypes:  Liposarcoma70 (23%)  Leiomyosarcoma46 (15%)  MFH44 (15%)  Synovialosarcoma25 (8%)  MPNST + RhabdoS.15 (5%)  Unclassified S.39 (13%)  Others + NP63 (21%)  Grade I: 17% II: 34% III: 45% NP: 5%

11. Institut Bergonié 11 Treatments  302 operated patients:  First-line surgery:83%  Resection types : R0220 (73%) R1 68 (22%) R2 14 (5%)  Radiotherapy:62%  Chemotherapy:40%

12. Institut Bergonié 12 Treatment results R0 213  CR:272 (90%) R1 54 R2 5  Survivors:240 (80%) actuarial 65%  LR:crude 34 (13%) actuarial 21%

13. Institut Bergonié 13 Overall survival TSURV 60483624120 Survie cumulée 1,0,9,8,7,6,5,4,3,2,1 0,0

14. Institut Bergonié 14 Resection-type according to center (NS) CenterNR0 Bordeaux8873% Villejuif5273% Lyon5264% Lausanne2483% Nancy2264% Others6480%

15. Institut Bergonié 15 Resection type according to localization (NS) Localization NR0 Shoulder girdle 1275% Upper extremity 3656% Trunk wall 3171% Pelvic girdle 2467% Lower extremity19977%

16. Institut Bergonié 16 Local recurrence-free interval TRLOC 60544842363024181260 Survie cumulée 1,0,9,8,7,6,5,4,3,2,1 0,0

17. Institut Bergonié 17 Local recurrence according to R P = 0,004 R0 R1 + R2

18. Institut Bergonié 18 Local recurrence according to grade P = 0,019 Grade 1 + 2 Grade 3

19. Institut Bergonié 19 Local recurrence according to T3 (1979 UICC classification) P = 0,049 T1 + T2 T3

20. Institut Bergonié 20 Local recurrence according to stage AJC/UICC 1979 P = 0,0045

21. Institut Bergonié 21 Local recurrence according to stage AJC/UICC 2002 P = 0,042

22. Institut Bergonié 22 Prognostic factors/LR VariableRL Np R R020213 0,004 R1+R214 59 Grade 1 3 46 0,02 2 7 92 323122 T T1 +T223218 0,05 T3 8 37 Histotype, Size (+/- 5 cm), Localization, Depth, Center, Radiotherapy:NS

23. Institut Bergonié 23 Independent prognostic factors for local recurrence VariablespRRCI No R00,0033,061,47 - 6,38 Grade 30,0043,351,48 - 7,55

24. Institut Bergonié 24 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.