Surgical management of soft tissue sarcoma in patients over 80 years

https://doi.org/10.1016/j.ejso.2006.05.016Get rights and content

Abstract

Aims

To report outcome on patients over 80 years of age with soft tissue sarcoma (STS), with respect to surgical treatment, co-morbidity, complications and survival.

Methods

From a prospective database of 3400 patients with STS presenting over a 13-year period, all patients over 80 years of age were identified and reviewed, with respect to tumour characteristics morbidity, mortality and outcome.

Results

128 patients over 80 years were treated for STS with 63 referred for treatment of primary disease, of whom 50 underwent resectional surgery. The remaining 65 patients were treated for recurrent or incompletely excised disease. Of the 50 patients treated primarily with surgery, 56% of tumours where high grade and 56% were greater than 10 cm in diameter. The overall complication rate was 34%, with a 30-day mortality of 4%. Two- and 5-year survival rates were 56% and 46%, with a local recurrence rate of 22% at a mean follow-up of 22 months.

Conclusion

This patient group presented with poor prognosis tumours that were associated with poor outcomes in the medium to long term. Age need not be considered a contra-indication to radical surgery with curative intent.

Introduction

There has been little data reported on surgical outcomes for soft tissue sarcoma (STS) in the elderly, with the two largest series reporting outcomes in 25 and 21 patients over 65 and 70 years of age, respectively.1, 2 There is no reported data in patients over 80 years of age. However, as the general population ages and anaesthetic and perioperative management improves, more elderly patients are likely to undergo surgery for STS.3

The Royal Marsden Hospital (RMH) Sarcoma Unit is a tertiary referral centre with a substantial sarcoma referral base, treating approximately 400 new patients with STS each year. We identified all patients over 80 years who were treated for STS and analysed the outcome of those patients, with particular focus on tumour characteristics, co-morbidities, surgical outcome, and long-term survival in patients undergoing surgery for primary localised disease. This report comprises the largest series of elderly patients undergoing surgery for STS in one single institution.

Section snippets

Patient selection

A prospective sarcoma database has been kept at RMH since 1990. From this, patients aged 80 years or older who were referred to, or treated by the unit were identified. Patient information, including primary tumour characteristics, treatment, morbidity and outcome were obtained from a combination of the hospital computerised records, multi-disciplinary meetings and patient notes. Supplementary information was obtained, when required, from other sources including general practitioners and

Patient demographics

One hundred and twenty-eight patients aged 80 years or older presenting to our unit between April 1990 and November 2003 were identified and included in the study group. The median age was 84 years (range 80–94). Of the 128 patients referred, 65 had undergone some form of resectional surgery at other institutions. These patients were referred for management of positive margins after this initial operation or for management of subsequent recurrence of the primary tumour. Although many of these

Discussion

The risk of developing STS is maximal at 40–60 years but a significant proportion of STS will present in a more elderly age group.9 Over the last 13 years at RMH the number of patients aged over 80 years referred for treatment has increased fourfold, from 6 in 1990–1991 to 24 in 2002–2003. It is doubtful that this is entirely due to changes in population demographics; more likely, it is due to patient choice and clinicians' awareness that elderly patients can successfully undergo large resectional

References (13)

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    Several studies have shown relative lack of improvement in clinical outcomes in the AYA population compared with their older and younger counterparts (4, 7) and poorer disease-specific survival of the elderly patients compared to the younger counterparts [8]. With the increasing referrals for treatment of elderly patients with STS, as well as the lack of improvement in the AYA population, further evaluation of factors influencing outcome for the different age groups might help in the decision-making regarding treatment strategies for the different patient groups [4,7,9,10]. Therefore, the primary aim of this study is to evaluate differences in overall survival (OS) and disease progression among age groups of patients with a primary high-grade eSTS treated with a curative intent.

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    Further, older age was identified as a significant independent adverse prognostic factor, and this trend was suggested to be caused by undertreatment in this population [7,8]. Some reports have described surgical outcomes for STS in older patients [6,8,9], but few reports have compared the clinical outcomes of both conservative treatment and surgical resection in STS patients aged 80 years or older. In the present study, we assessed the clinical outcomes of both conservative treatment and surgical resection in STS patients aged 80 years or older, and examined the association between older age (≥85 years) and surgical outcome.

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    Seventeen percent of Japanese citizens were 70 years and older in 2011, which is the highest percentage of elderly people in the world (Ministry of Internal Affairs and Communications, 2011). The incidence of soft tissue sarcoma (STS) in senior citizens is increasing,1 although STS is a rare malignancy compared with other types of cancer, and it mainly affects younger adults aged between 40 and 60 years.2 Complete resection can be a curative option for STS, and surgery is often combined with radiotherapy and/or systemic chemotherapy, especially in the treatment of advanced STS.

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