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The Influence of Age on Morbidity in Primary High Grade Sarcoma of
the Extremity
K. Alektiar, M. Brennan, S. Singer
Memorial Sloan-Kettering Cancer Center
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Introduction: STS & Age
Wibmer C et al. Ann Oncol 2009
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Local Recurrence & Age
Cahlon O et al. ASTRO 2008
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Use of RT and Older Age:MSKCC Data (n = 1459)
Odds Ratio 95% CI p value
Limb sparing surgery 13 7-25 < 0.001High grade 3.6 2.4-4.7 < 0.001 Deep tumor 2.5 1.8-3.4 < 0.001Size ≥ 5 cm 2.2 1.7-2.9 < 0.001Positive margin 1.6 1.2-2.1 0.004
Age ≥ 70 0.6 0.5-0.9 0.005
Ashman et al. ASTRO 2006
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Purpose
To determine whether older age, defined as ≥ 70 years, influences morbidity in pts with primary HG extremity STS who received adjuvant RT at MSKCC
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Patient Population
# of pts: 433 Period: 8/82- 02/06 Presentation: Primary, N0M0 Mean age: 53 (range: 16-89) Grade: High only Deep: 89% (n = 387) Size > 5 cm: 74% (n = 322) Lower extremity: 72% (n = 310)
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Extent of SurgeryAll pts had limb-sparing surgery at MSKCC
n %
Bone manipulation♠ 83 19
Nerve manipulation♦ 115 27
Tissue transfer 31 7
♠: Periosteal stripping/bone resection♦: Neurolysis/nerve resection
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RT TypeAll pts had their RT MSKCC
n (%) Dose (Gy)*
BRT 239 (55%) 45
EBRT 159 (37%) 63
BRT+EBRT 35 (8%) 20+45
Adjuvant chemotherapy: 139/433 (32%).
*: Median dose
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SexFemale Male
159 (47%)180 (53%)
41(44%)53 (56%)
0.5
Size (cm) ≤ 5 > 5
85 (25%)254 (75%)
26 (28%)68 (72%)
0.6
DepthSuperficialDeep
33 (10%)306 (90%)
13 (14%)81 (86%)
0.25
SiteUpper extremityLower extremity
94 (28%)245 (72%)
29 (31%)65 (69%)
0.5
Adjuvant CTYesNo
127 (38%)212 (62%)
12 (13%)82 (87%)
0.001
< 70 ≥ 70 p
Distribution of Variables
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Extent of Surgery & Age Groups
< 70 (n = 339) ≥ 70 (n = 94) p
Bone manipulation♠ 63 (18%) 20 (21%) 0.5
Nerve manipulation♦ 97 (29%) 18 (19%) 0.06
Tissue transfer 28 (8%) 3 (3%) 0.2
♠: Periosteal stripping/bone resection♦: Neurolysis/nerve resection
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RT Type & Age Groups:For the purpose of this analysis, BRT and
BRT+EBRT were combined
< 70 (n = 339) ≥ 70 (n = 94) p
BRT/BRT+EBRT 220 (65%) 54 (57%)
EBRT 119 (35%) 40 (43%)0.18
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RT “Conventional” Dose & Age GroupsConventional:
BRT 45 Gy EBRT 60-70 Gy
BRT+EBRT 15-20 and 45-50 Gy
< 70 (n = 339) ≥ 70 (n = 94) p
BRT* 200 (91%) 50 (93%) 0.15
EBRT 108 (91%) 35 (88%) 0.2
*: BRT and BRT+EBRT
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MorbidityMedian F/U: 53 months
n (%)
Wound re-operation 33 8
Fracture 17 4
Stiffness 51 12
Edema 46 11
Nerve Damage♠ 27 7
♠:Those with nerve resection were excluded
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Morbidity & Age
< 70 ≥ 70 p
Wound re-operation 7% 12% 0.09
Fracture 4% 3% 0.6
Stiffness 11% 15% 0.3
Edema 9% 18% 0.01
Nerve Damage♠ 8% 4% 0.13
♠:Those with nerve resection were excluded
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Joint Stiffness
n (%)
Grade 0 382 88
Grade 1 26 6
Grade 2 20 5
Grade 3 5 1
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Grade of Stiffness & Age Groups
< 70 (n = 339) ≥ 70 (n = 94)
Grade 0 302 (89%) 80 (85%)
Grade 1 19 (6%) 7 (7%)
Grade 2 14 (4%) 6 (6%)
Grade 3 4 (1%) 1 (1%)
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Edema
n (%)
Grade 0 387 89
Grade 1 17 4
Grade 2 24 6
Grade 3 5 1
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Grade of Edema & Age Groups
< 70 (n = 339) ≥ 70 (n = 94)
Grade 0 308 (91%) 79 (84%)
Grade 1 13 (4%) 4 (4%)
Grade 2 15 (4%) 9 (10%)
Grade 3 3 (1%) 2 (2%)
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Grade of Nerve Damage:(n = 377/433)♠
n (%)
Grade 0 350 93
Grade 1 11 3
Grade 2 7 1.5
Grade 3 1 0.5
Grade 4 8 2
♠:Those with nerve resection were excluded
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Grade of Nerve♠ Damage & Age Groups
< 70 (n = 291) ≥ 70 (n = 86)
Grade 0 267 (92%) 83 (97%)
Grade 1 9 (3%) 2 (2%)
Grade 2 6 (1.5%) 1 (1%)
Grade 3 1 (0.5%) 0 (0%)
Grade 4 8 (3%) 0 (0%)
♠:Those with nerve resection were excluded
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Conclusion
Older age (≥ 70 years) is not associated with increased morbidity from treatment with the exception of edema
Strategies to minimize the risk of edema are warranted
Withholding adjuvant RT solely based on older age, for fear of potential morbidity doesn’t seem to be justified
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Influence of Age on BRT Morbidity
< 70 ≥ 70 p
Wound re-operation 9% 11% 0.7
Fracture 2% 2% 0.8
Stiffness 5% 6% 0.8
Edema 6% 11% 0.2
Nerve Damage♠ 8% 2% 0.2
♠:Those with nerve resection were excluded
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Influence of Age on EBRT Morbidity
< 70 ≥ 70 p
Wound re-operation 3% 13% 0.03
Fracture 8% 5% 0.8
Stiffness 22% 28% 0.6
Edema 14% 28% 0.09
Nerve Damage♠ 10% 6% 0.7
♠:Those with nerve resection were excluded
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Morbidity & Type of RT in < 70
BRT EBRT p
Wound re-operation 9% 3% 0.05
Fracture 2% 8% 0.03
Stiffness 5% 22% 0.005
Edema 6% 14% 0.009
Nerve Damage♠ 8% 10% 0.7
♠:Those with nerve resection were excluded
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Morbidity & Type of RT in ≥ 70
BRT EBRT p
Wound re-operation 11% 13% 0.9
Fracture 2% 5% 0.7
Stiffness 6% 28% 0.006
Edema 11% 28% 0.07
Nerve Damage♠ 1% 6% 0.7
♠:Those with nerve resection were excluded
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RT Type & Age Groups
< 70 (n = 339) ≥ 70 (n = 94) p
BRT 188 (56%) 51 (54%)
EBRT 119 (35%) 40 (43%) 0.18
BRT + BRT 32 (9%) 3 (3%)
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