A 25-year-old female with high-grade spindle cell sarcoma of the thyroid persistent after thyroidectomy performed at another hospital was referred to our institute. Chemotherapy followed by surgery ...with intraoperative radiotherapy and postoperative intensity-modulated radiotherapy were planned within the sarcoma board. Chemotherapy was discontinued after two cycles because of local disease progression and surgery with intraoperative radiotherapy, was anticipated. The treatment was completed with postoperative radiotherapy. After 36 months off-therapy, the patient was free of disease without significant late effects. Thyroid sarcomas are very rare and there is no consensus on their clinical management. Hence, case reports are useful to share treatment options. In this patient case, the histotype and the high-grade disease required a combined therapy program, managed in a multidisciplinary setting.
Une femme de 25 ans atteinte d’un sarcome de haut grade à cellules fusiformes de la thyroïde persistant après une thyroïdectomie effectuée dans un autre hôpital a été référée à notre institut. Une chimiothérapie suivie d’une intervention chirurgicale et d’une radiothérapie peropératoire et une radiothérapie conformationnelle avec modulation d’intensité ont été planifiées par le club des sarcomes. La chimiothérapie a été arrêtée après deux cycles en raison de l’extension locale de la maladie, puis la chirurgie et la radiothérapie peropératoire ont été anticipées. Le traitement a été complété par la radiothérapie postopératoire. Après 36 mois sans traitement la patiente était guérie sans séquelle tardive significative. Les sarcomes thyroïdiens sont très rares et il n’y a pas de consensus sur leur prise en charge clinique. Par conséquent, les études de cas sont utiles pour partager les options de traitement. Dans ce cas clinique, le type histologique et le haut grade ont nécessité un programme thérapeutique multidisciplinaire.
Abstract
Background
Brain metastases (BMs) occur in 20%-40% of adult cancer patients, and their incidence has increased from 2 to 5 times over the past 40 years. Treatment options include surgery, ...whole-brain radiation therapy (WBRT), and stereotactic radiosurgery (SRS). As a single modality, none of these are able to obtain an adequate local control (LC) of large BMs (≥2.1 cm), and therefore a combined approach, is recommended. We designed a prospective phase II study aimed to assess the benefit of surgical resection followed by fractionated radiosurgery (FSRS) on the tumor bed, instead of postoperative WBRT, for patient with single large brain metastases from solid tumor. The potential advantage of this treatment is to improve local control and to reduce toxicity compared with WBRT after surgical resection. Primary endpoint was local control rate; secondary endpoints incidence of new brain metastases, and patients overall survival.
Material and Methods
Patients with age >18 years, KPS ≥70, oligometastatic disease, controlled primary tumor and extracranial metastases, single BM ≥ 2.1 cm, and estimated survival ≥3 months were enrolled. Patients underwent previous WBRT were excluded. Surgical resection was performed with the aim to maximally (>95%) remove the tumor. Within 1 month from surgery, a fractionated SRS was performed on the tumor bed for a total dose of 30 Gy in 3 daily fractions. Outcome was evaluated by neurological examination and MRI performed 2 months after treatment and every 3 months thereafter. Response in site of treatments was assessed according to RANO criteria.
Results
Between 2014 and May 2018, 122 patients were enrolled, 56 female and 66 male with a median age of 49 years. The most common primary tumor was Non-Small Cell Lung Cancer (47%), followed by breast cancer (27%) and melanoma (10%). The median follow-up was 22 months (range 7–48 months). The 1,2-year LC rate were 98%, and 98%. Forty-two (34%) patients had new BDP at a median time of 19 months. The median 1,2-year overall survival were 24 months, 91.3% and 73%. At the last observation time, 27 patients (22%) were dead and 95 patients (78 %) were alive. No detrimental effect on neurocognitive functions was recorded.
Conclusion
Fractionated SRS after surgical resection is a safe and feasible option in patients with large brain metastases and oligometastatic disease.
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