Treating metastatic sarcomas locally: A paradoxe, a rationale, an evidence?

• Median survival of metastatic sarcomas has improved, and range from 12 to 18 months.
• The mainstay of first line treatment is chemotherapy.
• Metastatic patients also receive metastatic ablative treatment in a significant number of cases.
• Despite its routine use, the exact role of local treatment remains controversial.
• Practical trial design is needed with quality of life analysis and impact of technological advances.

PurposeThe mainstay of first line treatment in metastatic sarcomas is chemotherapy with response rates of ≈25% but the optimal management of further events is debated. We assessed the benefit of local metastatic treatment in metastatic sarcomas.ResultsLocal control of local treatment strategies (≈85%) is excellent but highly institution-dependent and subject to selection biases. Formal evidence of an improvement of survival with local ablative treatments has been limited to retrospective studies. On the other hand, some chemotherapy trials are inconclusive because about 20% of patients receive local metastatic ablation as it is considered unethical to omit local treatment in these patients. Further, technology has made surgery, stereotactic irradiation and radiofrequency ablation highly effective on local control with limited morbidity.ConclusionThe benefit on survival of metastatic ablation deserves prospective studies integrating quality of life, cost effectiveness and patient-reported outcomes assessment.