15th Congress of the European Society of Surgical Oncology (ESSO), 15–17 September 2010, Bordeaux

Dr Tim Pencavel and Dr Dirk Strauss – Royal Marsden Hospital, London, UK

Breast sarcoma: a large single-centre experience

Interviewed by Peter Goodwin

PG: A fascinating session on sarcoma; I’ve just been listening to a story from Tim Pencavel and Dirk Strauss from the Royal Marsden. Dirk, first of all, you’ve been looking at breast sarcoma, can you explain to me why you decided to look at this disease?

DS: Sarcoma is, as a whole disease, such a very rare condition, it’s one of the rare cancers and specifically the sarcomas that occur in the breast are very rare and we don’t have very good data on how these patients are treated, what the outcomes and what the best management options for these patients are. That’s why we thought we have a collection of a reasonable sized group of patients, let’s analyse them and see how we manage them and what made a difference in the outcome.

PG: Now Tim, you’ve just presented the work here and you have got some quite optimistic news. That’s not to say that this is an easy challenge for clinicians but could you tell us about the study that you’ve published and you’ve now been talking about?

TP: Yes, we evaluated 63 patients who had all had breast sarcoma, of which about half had had radiation before and the other half hadn’t. Particularly we looked at a group of sarcomas called the angiosarcomas which are more common after previous breast irradiation; they happen in about one in a thousand cases after irradiation for other diseases. What we found, really, was that we can gain local control which is important in these cases by doing reasonably good operations and that when we looked at all the breast sarcomas as a whole, we actually got fairly good survival outcomes at both two and five years.

PG: Dirk, doctors have been a bit scared of this disease, haven’t they? It has been regarded as having a dismal prognosis.

DS: It is definitely a difficult disease to manage. It’s a disease that has aggressive biology and very frequently after an operation can come back in the same site that you’ve done your operation, or they also have the potential to spread to the lungs and cause distant metastases. So it is a difficult disease to manage.

PG: But Tim, can you tell us what were some of the good things that emerged from your study?

TP: It’s extremely reassuring that when we look at all breast sarcomas we can achieve two and five year survival rates of between 80% and 90% and that’s reassuring that we can get such good survival data. One of the other things to say is that although this is a relatively, for the size of the literature, large series of angiosarcomas, what we’re definitely not saying is that this is such a big worry that people shouldn’t have irradiation after primary breast cancer. One of the other things that we’d say after this study is that radiation, yes, in some cases causes this problem but probably saves more lives than it costs.

PG: Local recurrence was an issue and, in fact, the radiation naïve patients were different from those who had their sarcoma caused by radiation, weren’t they?

TP: They were and this probably is because of what we call the field change effect, which means that obviously there is a margin of safety built in to radiation treatment which includes treating some normal tissue that wasn’t involved in the cancer and that normal tissue will still sustain the effects of the radiotherapy without the effect of treating the primary cancer. That really is why they’re more difficult to get local control over, because you have to make sure you excise all the tissue that was irradiated. So, by definition, they need bigger surgery. What we’re saying is that the bigger surgery actually can produce some good outcomes.

PG: Now, at the Royal Marsden your unit is a specialist unit and you did get good survival data. Is it possible to reproduce those survival results elsewhere? What do you have to do to get that expertise?

TP: There’s extensive data across a whole range of cancer primary types that actually centralising services treating in high volume units, particularly in the rare cancers like this, will improve outcome. Really, the finding that we did very well comparatively at the Marsden is good, it shows that, again, centralisation is going to help treatment of these cancers and yes, it is possible to get these results elsewhere but in the context of a centralised service that treats a lot of sarcoma patients.

DS: That’s definitely true what Tim says and the importance of grouping these patients in centralised centres of excellence are that everyone involved in the team looking after them are specialists in their field. So not only the surgeons, the oncologists, the plastic surgeons, the ITU personnel, the theatre, everyone is a specialist looking at specific conditions and then create the expertise and the centre of excellence that you need to manage these conditions.

PG: Could you explain some of the tricks of the trade to actually get the kind of management results? What do you specifically need to do?

DS: It starts off with not only having the surgeons that treat the patients, that are exposed to large numbers of those rare conditions but also having the pathologists to analyse the pathology, to have the radiologists that look at the scans and can help you with the planning and the plastic surgeons that will help you to reconstruct the defects caused by surgeons. And support with the nursing staff, the psychological support and the whole multi-disciplinary team that is involved in looking after these complex patients.

PG: But mainly it’s surgery?

DS: It’s mainly surgery but definitely about managing a big team and you need the help of the radiologists to look at the scans for you, the help of the pathologist to analyse the specimens, the oncologist to decide which patients need adjuvant treatment, the plastic surgeons to help the sarcoma surgeons to manage the wounds and to close the defects that we create. So it’s definitely a multi-disciplinary team effort.

PG: Is there any evidence that the quality of the end result when you’ve resected influences the ultimate outcome, survival and so on?

DS: That is most directly linked to the local recurrence. If one can gain wide clear margins of the tumour, we will hopefully establish local control so the patient will not have a problem with a tumour fungating from her breast. However, it’s more difficult to directly relate the tumour to the potential it has to spread to the lungs and how that relates to your surgery. That’s probably more dictated by the tumour biology rather than the surgery that we can do.

PG: What about adjuvant systemic therapy?

DS: That’s very difficult in sarcoma because for the majority of the sarcomas, we don’t have chemotherapy that is effective and especially for the breast sarcoma patient group, they are not chemosensitive or they’re not sensitive to the treatments we have at the moment so we don’t use them. In the majority of sarcoma surgery we compliment the operation with radiotherapy but especially in the patient group that already had radiotherapy, we can’t compliment it with the radiotherapy and we just have to rely on surgery as sole treatment.

PG: So, could I ask you both to say what are the clinical implications of this report that you’ve delivered here in this beautiful part of France?

TC: The take-home message, if you like, from what we’ve said is it’s vitally important you do a good operation and that good operations probably happen best in high volume units but that good results are achievable within that setting.

DS: I agree completely with Tim. These patients are definitely best managed by a group of people that is experienced in managing this difficult patient group.