Surgery With or Without Radiation Therapy in Untreated Nonmetastatic Retroperitoneal Sarcoma

European Organisation for Research and Treatment of Cancer - EORTC266 enrolled

Overview

RATIONALE: Radiation therapy uses high-energy x-rays to kill tumor cells. Giving radiation therapy before surgery may make the tumor smaller and reduce the amount of normal tissue that needs to be removed. It is not yet known whether surgery is more effective with or without radiation therapy in treating nonmetastatic retroperitoneal soft tissue sarcoma. PURPOSE: This randomized phase III trial is studying radiation therapy followed by surgery to see how well it works compared with surgery alone in treating patients with previously untreated nonmetastatic retroperitoneal soft tissue sarcoma.

OBJECTIVES: Primary * To assess whether there is a difference in abdominal recurrence-free survival between retroperitoneal soft tissue sarcoma patients undergoing curative intent surgery alone and those undergoing preoperative radiotherapy followed by curative-intent surgery. Secondary * To assess whether there is a difference in metastasis-free survival, abdominal recurrence-free interval, and overall survival between these patients. * To assess tumor response in patients undergoing preoperative radiotherapy. * To assess toxicity of preoperative radiotherapy given prior to curative-intent surgery in these patients. OUTLINE: This is a multicenter study. Patients are stratified according to institution and WHO performance status (0-1 vs 2). Patients are randomized to 1 of 2 treatment arms. * Arm I: Patients undergo surgical resection of the tumor mass within 4 weeks following randomization. * Arm II: Patients undergo 3-dimensional conformal radiation therapy (RT) or intensity-modulated RT within 8 weeks after randomization. RT continues 5 days a week for approximately 5.5 weeks. Patients undergo surgical resection of the tumor mass within 4-8 weeks after the completion of RT. Tumor tissue, normal abdominal wall fat, and peripheral blood may be collected during surgery to identify new prognostic factors for translational research. After completion of study therapy, patients are followed at day 60 post-surgery and every 6 months thereafter.

Study Type

INTERVENTIONAL

Allocation

RANDOMIZED

Purpose

TREATMENT

Masking

Eligibility

Sex: ALLMin age: 18 YearsMax age: 120 Years

Medical Language ↔ Plain English

DISEASE CHARACTERISTICS: * Histologically confirmed retroperitoneal sarcoma (RPS) by local pathologist, imaging-guided or surgical biopsy, including the following: * Primary soft tissue sarcoma of retroperitoneal space or infra-peritoneal spaces of pelvis * Sarcoma not originated from bone structure, abdominal, or gynecological viscera * Unifocal tumor (not multifocal disease) * Absence of extension through the sciatic notch or across the diaphragm * The following histological sub-types are not allowed: * Gastrointestinal stromal tumor (GIST) * Rhabdomyosarcomas * Primitive neuroectodermal tumor (PNET) or other small round blue cells sarcoma * Osteosarcoma or chondrosarcoma * Aggressive fibromatosis * Sarcomatoid or metastatic carcinoma * No metastatic disease * Untreated disease * Tumor must be operable and suitable for radiotherapy, based on the following criteria: * Pre-treatment CT scan/MRI and multidisciplinary consultation with surgeon, radiation oncologist, and radiologist (anticipated macroscopically complete resection, R0/R1 resection) * No surgery anticipated to be R2 on the CT scan before randomization * Must have American Society of Anesthesiologist (ASA) score ≤ 2 * None of the following unresectable criteria: * Involvement of superior mesenteric artery * Involvement of aorta * Involvement of bone * Must have radiologically measurable disease (RECIST 1.1), as confirmed by abdomino-pelvic CT (with IV and PO contrast) or MRI (with IV contrast) PATIENT CHARACTERISTICS: * WHO performance status 0-2 * WBC ≥ 2,500/mm\^3 * Platelet count ≥ 80,000/mm\^3 * Total bilirubin \< 1.5 times the upper limit normal * Calculated creatinine clearance normal * Functional contra-lateral kidney to the side involved by the RPS as assessed by intravenous pyelogram * Adequate cardiac function (NYHA class I-II) * ECG normal (without clinically significant abnormalities) * No history of any of the following disorders: * Bowel obstruction * Mesenteric ischemia * Severe chronic inflammatory bowel disease * Negative pregnancy test * Not pregnant or nursing concurrently and for at least 1 month after the surgery * Fertile patients must use effective contraception during the study treatment period and for at least 1 month after the surgery * No co-existing malignancy within the past 5 years, except for adequately treated basal cell carcinoma of the skin or carcinoma in situ of the cervix * No psychological, familial, sociological, or geographical condition potentially hampering compliance with the study protocol and follow-up schedule PRIOR CONCURRENT THERAPY: * No prior surgery (excluding diagnosis biopsy), radiotherapy, or systemic therapy * No prior abdominal or pelvic irradiation for another prior malignancy or other disease * No concurrent systemic anticancer treatment (chemotherapy, molecular-targeted therapy) * No postoperative radiotherapy planned

Locations (37)

Dana-Farber Cancer Institute & Harvard Medical School

Boston, Massachusetts, United States

Hopitaux Universitaires Bordet-Erasme - Institut Jules Bordet (101)

Brussels, Belgium

U.Z. Gasthuisberg

Leuven, Belgium

Mount Sinai Hospital

Toronto, Ontario, Canada

CHUM - Centre Hospitalier de l'Université de Montreal - Hopital Notre-Dame

Montreal Quebec, Quebec, Canada

Outcomes

Primary Outcomes

Number of Patients With Abdominal Recurrence or Death

Abdominal recurrence was defined by one of the following events: local/abdominal or distant progressive disease during preoperative radiotherapy (as per RECIST 1.1), tumor or patient becoming inoperable (ASA score of 3 or involvement of superior mesenteric artery, aorta, or bone), peritoneal metastasis found at surgery, macroscopic residual disease left in at surgery (R2 resection), or local relapse (after macroscopically complete resection). Liver metastases were regarded as distant metastatic events. Patients with distant metastases were followed until local failure was detected. Patients without one of these events were censored at the date of last follow-up.

Time frame: ARFS was measured from date of randomization to date of abdominal relapse or death, whichever occurred first, up to a maximum of 7 years.

Secondary Outcomes

Acute Toxicity Profile of Preoperative Radiotherapy.

The acute toxicity was assessed in randomized patients who received at least one dose of preoperative radiotherapy (RT). It follows Common Terminology Criteria for Adverse Events (CTCAE) version 4.0 in the RT safety population, assuming the following classification: * Grade 0 No event reported * Grade 1 Mild; asymptomatic or mild symptoms; clinical or diagnostic observations only; intervention not indicated. * Grade 2 Moderate; minimal, local or noninvasive intervention indicated; limiting age-appropriate instrumental ADL. * Grade 3 Severe or medically significant but not immediately life-threatening; hospitalization or prolongation of hospitalization indicated; disabling; limiting self care ADL. * Grade 4 Life-threatening consequences; urgent intervention indicated. * Grade 5 Death related to AE. For each item of the CTCAE, the worst grade of acute toxicity from the data of randomization prior to surgery was taken

Time frame: From date of randomization to the date of surgical procedure, prior to surgery

Perioperative Complications

Adverse events and side effects possibly related to surgery were assessed according to the Dindo's classification. This scales the observed side effects as Grade 0 No event Grade I Any deviation from the normal postoperative course without the need for pharmacological treatment or surgical, endoscopic and radiological interventions Grade II Requiring pharmacological treatment with drugs other than such allowed for grade I complications. Grade III Requiring surgical, endoscopic or radiological intervention Grade IV Life-threatening complication (including CNS complications) requiring IC/ICU-management Grade V Death of a patient For each item, the frequency of the worst grade of the observed toxicity was tabulated by treatment group. The perioperative period commence at the time of surgery (at the time of the induction anaesthesia) to the complete closure of the wound.

Time frame: From the date of surgery, up to 60 days following surgery

Late Complications

The late toxicities occurring more than 60 days after surgery. These were reported using Common Terminology Criteria for Adverse Events (CTCAE) v4.0. This scales the observed toxicity from Grade 1 to 5, assuming the following classification: * Grade 0 no event * Grade 1 Mild; asymptomatic or mild symptoms; clinical or diagnostic observations only; intervention not indicated. * Grade 2 Moderate; minimal, local or noninvasive intervention indicated; limiting age-appropriate instrumental ADL. * Grade 3 Severe or medically significant but not immediately life-threatening; hospitalization or prolongation of hospitalization indicated; disabling; limiting self care ADL. * Grade 4 Life-threatening consequences; urgent intervention indicated. * Grade 5 Death related to AE. Full AE reporting can be found in the Adverse Event Section.

Time frame: From day 60 after surgery till end of follow-up, up to 7 years

Tumor Response to Preoperative Radiotherapy

For patients that received preoperative radiotherapy, the tumor response was assessed using RECIST 1.1. Response criteria were essentially based on a set of measurable lesions identified at baseline as target lesions, and followed at the end of the radiotherapy. Response was not the primary endpoint, so a confirmatory CT-scan was not mandatory.

Time frame: Two weeks after completion of Pre-operative Radiotherapy, before Surgery

Number of Patients With an Abdominal Recurrence

Abdominal recurrence was defined in the ARFS section. The following are considered competing events: * death in the absence of abdominal failure * distant metastases diagnosed before abdominal failure Patients without one of these events were censored at the date of last follow-up.

Time frame: ARFI was measured from the date of randomization to the date of abdominal relapse, up to a maximum of 7 years

Number of Patients With Metastases or Death

Alive and metastases free patients will be censored at the date of last follow-up.

Time frame: Metastases free survival was measured from the date of randomization to the date of occurrence of distant metastases or death, whichever occurred first, up to a maximum of 7 years.

Number of Patients Alive

Alive patients were censored at the date of last follow-up. Causes of death were recorded and reported as a table.

Time frame: Overall survival was measured from the date of randomization to the date of death, whatever the cause, up to a maximum of 7 years