The Influence of Age on Morbidity in Primary High Grade Sarcoma of the Extremity

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

Introduction: STS & Age

Wibmer C et al. Ann Oncol 2009

Local Recurrence & Age

Cahlon O et al. ASTRO 2008

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

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

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)

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

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

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

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

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

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

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

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

Joint Stiffness

n (%)

Grade 0 382 88

Grade 1 26 6

Grade 2 20 5

Grade 3 5 1

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%)

Edema

n (%)

Grade 0 387 89

Grade 1 17 4

Grade 2 24 6

Grade 3 5 1

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%)

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

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

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

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

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

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

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

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%)