84inis There a Role for Neo-adjuvant Systemic Treatment in Sts?

I will try to answer this question after first replying this one: Is there any room for complementary systemic treatment in STS and if so, then are there more reasons for neo-adjuvant than for adjuvant systemic treatment? Most of second adjuvant generation trials in STS entered, in addition to old studies, into the meta-analyses published in 2008. All the efficacy items were in favor of chemotherapy. Remarkably, schemes of anthracyclines plus ifosfamide were clearly superior compared to doxorubicin in monotherapy. Interestingly, the latest studies included a higher dose-intensity for the two most active drugs in STS and more restrictive inclusion criteria, since high risk patients were enrolled. In this second meta-analyses, adjuvant chemotherapy significantly decreased the risk of metastases appearance and improved overall survival. Regardless of that, controversies still remain, mainly due to the fact that the last largest adjuvant trial conducted by EORTC was a negative study and it was published after the most recent meta-analyses. However, it is noteworthy to consider that those patients with tumors of grade 3, located in limbs and with largest diameter were clearly benefited in the chemotherapy arm. Thus, the most recent trial conducted by ISG with GEIS collaboration, administering full-dose of epirubicin and ifosfamide consistently reproduces the previous outcome with the same scheme in the same high risk population, obtaining 5-year overall survival of 70%. Taken together, these data suggest a positive role for adequate adjuvant chemotherapy in appropriate scenario: limbs/trunk wall, grade 3,≥ 5 cm and deep STS. If the latter statement is assumed then, does neo-adjuvant add value to adjuvant chemotherapy?. In a similar way to osteosarcoma or Ewing’s sarcoma, recent studies suggest that relevant prognostic information could also stem from neo-adjuvant chemotherapy in STS. Response rate according to Choi or baseline prognostic biomarkers could add value to neo-adjuvant setting. Additionally, some recent data also suggest that pre-surgical combination of chemo-radiotherapy could be beneficial when close margins are anticipated in localized, high risk STS.There is room for neo-adjuvant treatment with full-doses of anthraciclines plus ifosfamide in localized high risk STS.