Progress in the management of sarcomas: Three questions for Dr Sylvie Bonvalot

What do you think are the major findings of the past 10 years in terms of sarcoma management?

The main findings include percutaneous micro-biopsy as soon as sarcoma is suspected, the expertise of radiologists, and progress in anatomopathology as well as molecular biology, which can both produce diagnoses on small samples. These allow for the most appropriate type of surgery to be chosen from the outset, which is vital to limit the risk of recurrence. Radiotherapy is more precise and has made enormous progress. Intensity-modulated radiation therapy, for example, helps save tissues close to the tumor when its location is complicated. Sarcoma surgery has made great improvements, demonstrated by the drop in local recurrence of sarcomas in the limbs from 25% 15 years ago to less than 10% five years ago. It also does a better job of preserving limbs, with amputations falling from 15% to less than 1%. In terms of medical treatments, new targeted therapies such as imatinib have proven significantly effective in metastatic sarcomas, or in addition to surgery in certain high-risk cases.

Are sarcomas currently being well managed?

The analysis of the French sarcoma group shows us that medical management of soft tissue sarcomas at the metastatic phase is good in France, and meets the requirements of the ESMO* in 90% of cases. However, at the stage where the disease has not metastasized and is therefore curable, surgery is inappropriate in 50% of cases. Why is that? The appropriate strategy, which involves micro-biopsy and extensive surgery at the outset, is not followed from the beginning. The solution is clear: seeking care from an expert sarcoma center in the event of the slightest doubt following imaging exams. If inappropriate surgery has been performed because the diagnostic strategy was not properly implemented, the patient must be redirected as soon as possible to an expert center. Bone sarcomas are overall easier to diagnose than soft tissue sarcomas, since orthopedic specialists are more likely to refer patients with bone tumors, which are easy to detect via X-rays, to a specialist department.

How does surgical management affect the treatment and prognosis of the disease?

Sarcoma surgery is technically complex, since the tumor must be removed in a single block, leaving a margin of healthy tissue wide enough to prevent recurrence. If a sarcoma is indeed diagnosed via the biopsy, it is necessary. If inappropriate surgery has already been performed, recovery is possible, but will be difficult. When the diagnosis and treatment are carried out appropriately, the prognosis for the sarcoma is greatly improved. If the sarcoma is discovered before metastasis occurs, the overall survival rate for all sarcoma cases is around 75% at five years. The notable differences between the types of sarcoma, however, lead to differences in the additional treatments, which must be discussed at the multi-disciplinary meetings.

* European Society for Medical Oncology.