Scandinavian Sarcoma Group. Ass. Prof. Otte Brosjö,, Karolinska Hospital, Stockholm

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1 Scandinavian Sarcoma Group Ass. Prof. Otte Brosjö,, Karolinska Hospital, Stockholm

2 The Scandinavian Sarcoma Group Organisation of Care and Research

3 Quality management - the SSG experience Multidisciplinary approach = quality in care Communication Protocols and guidelines The Registry Population based studies - RESEARCH

4 Comprehensive Sarcoma Center (CSC) A multidisciplinary approach to the patient Orthopaedic / Abdominal surgeon Cytologist Pathologist Cytogenetics Imaging Patient Oncologist (Pediatric/Adult) Treatment plan Surgeon: Plastic Head & Neck Neuro Thorax Surgery Radiotherapy: Preoperative Chemotherapy: Neoadjuvant Intraoperative Adjuvant Postoperative Intra-arterial Sequential ILP Brachytherapy Hyperthermia Follow-up Centralized registration

5 Quality management the SSG experience Multidisciplinary approach = quality in care Communication = meetings Protocols and guidelines The Registry Population based studies - RESEARCH

6 SSG meetings Plenary meeting every other year Working group meetings every year Surgery Oncology Pathology Radiology Tumor biology Patient care

7 SSG-plenary meetings Oslo Copenhagen Malmö/Lund Helsinki Gothenburg , 2nd ISG/SSG Stockholm Uppsala 1984 Reykjavik Århus 1991 Bergen Trondheim 1997 Snekkersten 1998 Åbo 2000 Capri St. Petersburg 2004 Cetraro, Italy 2000, 1st ISG/SSG 2006, 3rd ISG/SSG

8 SSG meetings Plenary meeting every other year Working group meetings every year Surgery Oncology Pathology Radiology Tumor biology Patient care

9 Orthopedic sarcoma network All sarcoma surgeons in Scandinavia Internet connection Difficult cases presented Free discussion and solutions If needed, surgeon travel to other sarcoma center

10 International network EORTC EMSOS ISOLS ISG SSG ESMO CTOS SIOP

11 Quality management the SSG experience Multidisciplinary approach = quality in care Communication Protocols and guidelines The Registry Population based studies - RESEARCH

12 Osteosarcoma SSG II Combination therapy in OS SSG VIII Therapy of OS ISG/SSG I An Italian-Scandinavian treatment and research protocol for high-grade osteosarcoma of the extremities ISG/SSG II Treatment of metastatic and pelvic osteosarcoma SSG XIV A Scandinavian treatment research protocol for extemity localized highgrade osteosarcoma Euroboss I A European treatment protocol for bone sarcoma in patients older than 40 years 2003 Euramos I An American/European treatment protocol 2004 for OS in patients <40 years EURELOS European relapsed osteosarcoma registry 2005

13 Ewing s sarcoma SSG IV Combined modality therapy in EWS SSG IX Therapy of EWS ISG/SSG III ISG/SSG treatment protocol for non-metastatic EWS Since 2008 standard therapy in EWS ISG/SSG IV ISG/SSG treatment protocol for high-risk EWS

14 Soft Tissue Sarcoma SSG I Adjuvant chemotherapy in STS SSG V Treatment program for STS 1986 SSG X Treatment of metastatic STS (VIG) SSG XII Metastasecetomy and CHT for lungmet from STS. An EORTC/SSG randomized phase III study SSG XIII Treatment protocol for adults with high-risk STS in extremities and trunk wall SSG XVIII/AIO Adjuvant study for high risk GIST SSG XX Modified treatment protocol for adults 2007 with high-risk STS in extremities and trunk wall

15 Guidelines for treatment of metastatic STS in adult patients With a curative intent With a palliative intent Chemotherapy-Surgery-Radiotherapy

16 Guidelines for treatment of abdominal sarcomas Preoperative diagnosis and planning Surgery Chemotherapy, radiotherapy Follow-up Centralized management!

17 Quality management the SSG experience Multidisciplinary approach = quality in care Communication Protocols and guidelines The Registry Population based studies - RESEARCH

18 SSG Registry All sarcoma centers in Sweden (5) and Norway (3) register patients, Finland (1) Almost population based for Norway and Sweden. Referral pattern, treatment, prognosis etc.

19 SSG Central Registry patients May Soft tissue sarcomas in extremity and trunk wall 2870 Bone sarcomas + Giant cell tumors 2277 Abdominal/Head-Neck/Gynecology sarcomas

20 SSG Registry Important to assess sarcoma treatment in a whole population Conclusions from trials need to be validated in non-selected settings

21 SSG Registry in Lund Improving data quality by registry inquiry when data are missing or incongruent. Control runs

22 Must be recorded Hospital Age at Diagnosis Sex Date of Diagnosis Referral pattern Metastasis at Diagnosis Site Location Number of operation for primary. Opdate Other treatment or protocol number Histology = Sarcoma/GCT Malignancy grade/mgna Size Follow-up date. State at follow-up Death date. Reason for death

23 Example of quality control SSG registry patients with STS Follow-up reported in 90% of patients. Median follow-up 5 years.

24 Referral before surgery of STS Subcutanoues Deep

25 Surgical treatment 2702 patients without metastases were operated for primary tumor at a sarcoma center 6 % primary amputations. But, no improvement in reported surgical margins only 55 % wide ???

26 More radiotherapy? before 1990: 16 % : 38 % And chemotherapy increased from 3 % to 14%

27 Improved local control? : Local control rate : : years postoperatively

28 Do local recurrences make a difference? Local recurrence leads to increased morbidity and a high risk of amputation (Trovik et. al). Local recurrence was the most important risk factor for metastases 2 years after surgery (Engellau et. al).

29 Improved survival? Overall 5 years metastases-free Metastasis free survival survival: 0, years

30 Local recurrenc after treatment of osteosarcoma SSG II 6% SSG VIII 7% SSG XIV 4% Bologna 6% Münster 8% COSS 5% Vienna 2,3%

31 Quality management the SSG experience Multidisciplinary approach = quality in care Communication Protocols and guidelines The Registry Population based studies - RESEARCH

32 Quality control in registry research Register data has to be checked Missing data has to be completed Diagnosis has to be reviewed by the Pathology Board

33 SSG theses

34

35 Chest wall sarcomas SSG Registry Sarcoma Centers Swedish Cancer Register Non-speciality hospital All diagnoses was reviewed by the SSG Pathology Board

36 Surgical margins chest wall CS wide marginal intralesional Sarcoma center Non-specialty hospital

37 Local recurrence chest wall CS Sarcoma center 16 % (9/55) Non-specialty hospital 57 % (24/42)

38 Surgical margins and survival - chest wall CS

39 Better outcome at sarcoma centers - chest wall CS

40 Identification of a high-risk subset of patients with STS of extremity or trunk wall Population based study from Southern health region of Sweden (Pelle Gustafson) : 508 pts with STS of extremity or trunk wall (non-metastatic at presentation) Independent variables for development of metastases Presence of vascular invasion Size > 10 cm Presence of Necrosis (not depth and grade)

41 Outcome according to SIN factor metastasis-free survival Probability of survival 1,0,8,6,4,2 No Yes Months from diagnosis 400 1,0,8,6,4,2 No Yes Months from diagnosis 1,0,8,6,4,2 No Yes Months from diagnosis Vascular invasion Necrosis Size (> 10 cm) 23% 52% 23%

42 S I N system Size, Invasion, Necrosis Probability of survival 1,0,9,8,7,6,5,4,3,2,1 Metastasis-free survival 0/1 factor 10y-MFS: 77% 2/3 factors 10y MFS: 32% Months from diagnosis High-risk

43 Peripheral tumor growth pattern Pushing growth 1/3 Infiltrative growth 2/3 Local recurrence in 124 adequately treated STS of extremity or trunk wall (J. Engellau) Pushing 0/32 Infiltrative 19/92 Conclusion (Cox regression analysis): Tumors with an infiltrating growth pattern have a high risk of local recurrence independently of margins and depth.

44 Theses in the future Leiomyosarcoma C. Svarvar, Helsinki Osteosarcoma C. Müller, Oslo Skeletal metastases B. H. Hansen, Århus Radiation therapy and local recurrence in STS N. L. Jebsen, Bergen

45 Thank you!

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