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Local Treatment Choices by Site: Introduction
written and compiled by doctordee
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How To Use This Section

Metastatic Disease

How to Use This Section of the Website

This section describes options for LOCAL control of tumors [as opposed to SYSTEMIC control], and is organized by the site of the tumor.

The medical journal articles state that surgery is the gold standard, and resection with wide margins should be done wherever possible.
Surgery is the Gold Standard. Reference.
Surgery is the Gold Standard. Another Reference.
Surgery is the Gold Standard. A Third Reference, of Many.


For situations where surgery is not possible, here are other options for local control: local ablative methods like cryosurgery and radio frequency ablation, different kinds of embolization, isolated perfusions, hyperthermia, and others. Each site is dealt with separately, as different techniques apply.

The first subject below, Metastatic patterns of Sarcomas, gives some indication of where metastases are most commonly found. With leiomyosarcoma, the site of the metastasis can be almost anywhere. But there are more frequent and less frequent sites of metastatic occurrence. Sites given special attention here are: Liver, Lung, Liver&Lung, Limb, Brain, and Bone.

The index gives the sites of the metastases chosen for consideration. The techniques of treatment that can be used with each metastatic site are discussed under each site, often with a short explanation.
For each technique, there is a collection of medical journal article references relating to that technique, its success with LMS or sarcomas, if such is available, and further information about its use and complications. Note that some of these articles refer to treatment of other types of cancer, or are not recent. The articles on other cancers are included for their description of complications, or to show that this is a respected technique, which has some reasonable results... HOWEVER, the response rates for other cancers, even sarcomas, do not necessarily mirror or predict LMS response.

Some of the articles might be 10 or 20 years old, they are usually the clinical trials for the technique, or clearly explain the risks and complications of the technique, something a more recent paper might take for granted.
Generally, the best way to deal with LMS metastases is by surgical resection, if it is at all possible. If it is not, and should you be interested in a specific technique, the medical journal citations, or their abstracts on PubMed, can be highlighted and copied, and then printed out and taken with you to your doctor for further discussion. Some techniques are discussed in much greater detail in the Techniques section of this website.

[ ] will indicate editorial comment by the compiler. Some sentences are highlighted in bold, again choice of the compiler.

Metastatic Patterns in Sarcoma

Cancer 1989 Mar 1;63(5):935-8
Patterns of metastasis in uterine sarcoma. An autopsy study.
Rose PG, Piver MS, Tsukada Y, Lau T. Department of Gynecologic Oncology, Roswell Park Memorial Institute, Buffalo, NY 14263.

The autopsy findings of 73 patients with uterine sarcoma were studied to determine the sites and possible modes of metastasis. Homologous mixed mesodermal tumors were the most frequent (41%) followed by leiomyosarcoma (26%),.... The peritoneal cavity and omentum were the most frequently involved sites (59%), followed by the lung (52%), pelvic lymph nodes (41%), paraaortic lymph nodes (38%), and liver parenchyma (34%). The presence of lung metastasis was not associated with pelvic or paraaortic node metastasis or intraperitoneal disease. Metastasis to other distant sites including the brain, heart, kidney, and bone were independent of pelvic and paraaortic nodal metastasis or intraperitoneal disease. Metastatic sites were not different among various histologic types. Distant metastatic sites were statistically associated with lung metastasis. Hematogenous metastasis best explains this metastatic pattern and adjuvant systemic therapy seems indicated.
Fetch PMID: 2914299


J Clin Oncol 1985 Mar;3(3):353-66
Patterns of recurrence in patients with high-grade soft-tissue sarcomas.
Potter DA, Glenn J, Kinsella T, Glatstein E, Lack EE, Restrepo C, White DE, Seipp CA, Wesley R, Rosenberg SA.

From July 1975 to December 1982, 563 patients were referred to the Surgery Branch of the National Cancer Institute with the diagnosis of soft-tissue sarcoma. Three hundred and seven of these patients had fully resectable, localized high-grade soft-tissue sarcomas and were treated at the National Cancer Institute using standard protocols with surgery alone, or in combination with chemotherapy and/or radiotherapy. An aggressive surgical approach was undertaken in the management of patients who subsequently developed recurrent disease. These 307 cases have been reviewed, with a median duration of follow-up of 30 months, to determine the frequency of recurrent disease, the patterns of recurrence, and the impact of surgery on the survival of patients who developed recurrent disease. Disease recurred in one hundred seven patients (107/307, 35%), with a median disease-free interval of 18 months (range, 0.5 to 72.0 months). The frequency of recurrence by site of primary sarcoma was extremity, 31% (65/211); head and neck, 33% (4/12); trunk, 40% (17/42); retroperitoneum, 47% (17/36); and breast, 67% (4/6). Isolated pulmonary metastatic disease was the most common pattern of initial recurrence (56/107, 52%) followed by isolated local recurrence (21/107, 20%). ... The relative frequency of each of these four patterns of recurrence varied with the site of the primary sarcoma. The outcome for patients with recurrent disease depended on the site of recurrence, rather than on the site of the primary sarcoma. Sixty-six patients (66/107, 62%) with recurrent disease were rendered surgically disease-free with the first recurrence, including 40 (40/56, 72%) patients with isolated pulmonary metastases, 20 patients (20/21, 96%) with isolated local recurrences, five patients (5/15, 33%), with isolated other sites of recurrence and one patient (1/15, 7%) with multiple sites of initial recurrence. Following surgical resection, the actuarial three-year survival for the 66 patients rendered disease-free was 51%. The median survival for the 41 patients not rendered surgically disease-free with the first recurrence was only 7.4 months. Thirty of the sixty-six patients (30/66, 45%) rendered disease-free with the first recurrence remained disease-free at follow-up, with a median follow-up of 28 months from the time of resection of the first recurrence. The remaining 36 patients (36/66, 55%) subsequently recurred, with a median disease-free interval of 7.3 months...
Fetch PMID: 3973646


Arch Surg 1983 Aug;118(8):915-8
Metastatic patterns in soft-tissue sarcomas.
Vezeridis MP, Moore R, Karakousis CP.

In 242 patients with recurrent soft-tissue sarcomas, the most common sites of initial recurrence were the primary site in 47.5% of patients and the lungs in 38% of patients. Further recurrences in the course of the disease concerned the lungs, bones, liver, and brain. Total survival and survival after recurrence were influenced by the histologic type, which also affected the site of recurrence. In the management of local recurrence, a five-year disease-free survival rate of 38% was achieved with surgical treatment, while radiation or chemotherapy alone was ineffective. Local recurrences resulted in significantly higher survival rates than those involving other organs. The disease-free interval was a significant prognostic indicator of subsequent survival in the whole group of patients and among those with local recurrence.
Fetch PMID: 6307217


Surg Clin North Am 2000 Apr;80(2):603-32
Hepatic malignancies.
Tsao JI, DeSanctis J, Rossi RL, Oberfield RA. Department of Surgery, Tufts University School of Medicine, Burlington, Massachusetts, USA.

... tremendous strides have been made in the past decade, such as improved diagnostic capabilities, safe surgical resection, availability of safe nonsurgical ablative modalities, multimodality therapy, and aggressive approach to recurrent disease. ...recurrence of primary and secondary malignancies of the liver continues to be the cause of demise for more than 70% of treated patients. ... investigations are focused on delineating the pathophysiology of cancer on the molecular and genetic levels and mapping the patterns of cancer emergence and spread. The new millennium holds promise for formulating therapies that may improve disease-free survival for patients with malignancies of the liver.
Fetch PMID: 10836009


Cancer J Sci Am 2000 Apr;6 Suppl 2:S159-68
The role of laparoscopy in the treatment of intra-abdominal malignancies.
Lefor AT. Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California 90048, USA.

"The role of laparoscopy in the care of patients with cancer is currently evolving. Numerous experimental and clinical studies have attempted to elucidate the nature and cause of port-site metastases--particularly to discern whether they simply are a marker of advanced disease, or if they are a result of the laparoscopic intervention."
Laparoscopy has a role in establishing the diagnosis of cancer in some situations:
... allowing biopsy of intraperitoneal and retroperitoneal masses, lymph nodes, and visceral lesions,
... examination of abdominal contents under direct vision or with ultrasound probes
... staging of established malignancies such as pancreatic cancer, hepatic lesions, lymphoma, and esophageal cancer. ... surgical treatment of a variety of malignancies, including gastric, pancreatic, splenic and adrenal cancers, [safety of laparoscopy for resection of colon cancer has not yet been proven]
... palliative care of the cancer patient -- feeding-tube placement or intestinal stoma creation.

"It is imperative that using laparoscopy in the care of patients with malignancies be carefully and thoroughly evaluated since this technique can either benefit or adversely affect survival or quality of life."
Fetch PMID: 10803831

Choose Your Surgeons Carefully

A general surgeon will NOT do well when faced with LMS work, it is more complicated and margins have to be wider than the surgeon is used to dealing with. Have skilled oncological surgeons do the work, and the best that you can find. Often the prognosis is decided by who does the first operation. See below.

Ann Surg 1999 Dec;230(6):759-65; discussion 765-6
Does the subspecialty of the surgeon performing primary colonic resection influence the outcome of patients with hepatic metastases referred for resection?
Wigmore SJ, Madhavan K, Currie EJ, Bartolo DC, Garden OJ.
University Department of Surgery, Royal Infirmary of Edinburgh, United Kingdom.

To compare resection rates and outcome of patients subsequently referred with hepatic metastases whose initial colon cancers were resected by surgeons with different specialty interests.... Variation in practice among noncolorectal specialist surgeons has led to recommendations that colorectal cancers should be treated by surgeons trained in colorectal surgery or surgical oncology. ...The resectability of metastases, the frequency and pattern of recurrence after resection, and the length of survival were compared in patients referred to a single center for resection of colorectal hepatic metastases. The patients were divided into those whose colorectal resection had been performed by general surgeons (GS) with other subspecialty interests (n = 108) or by colorectal specialists (CS; n = 122). RESULTS No differences were observed with respect to age, sex, tumor stage, site of primary tumor, or frequency of synchronous metastases. Comparing the GS group with the CS group, resectable disease was identified in 26% versus 66%, with tumor recurrence after a median follow-up of 19 months in 75% versus 44%, respectively. Recurrences involving bowel or lymph nodes accounted for 55% versus 24% of all recurrences, with respective median survivals of 14 months versus 26 months. CONCLUSION: Fewer patients referred by general surgeons had resectable liver disease. After surgery, recurrent tumor was more likely to develop in the GS[General Surgeons] group; their overall outcome was worse than that of the CS [Colorectal Specialists] group. This observation is partly explained by a lower local recurrence rate in the CS group.
Fetch PMID: 10615930

Written and compiled by doctordee May 2001
updated November 2003


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