Cure Alveolar Soft Part Sarcoma International (iCureASPS)

Summary

While histologic grade as presently defined is useful and
meaningful when soft tissue sarcomas are viewed as a whole
group, no current system is perfect. Moreover, when
applying grading systems on an individual case basis, there
are frequent failures in prediction of outcome. Accurate
histologic typing remains absolutely central to reliable prognostication.
Although in practice it is difficult to apply
widely, there is as yet no better predictor of outcome than
experienced specialist histologic examination. In the understandable
and frequent absence of such specialization, the
updated FNCLCC system for histologic grading seems to be
the most effective17 and has mounting appeal in the United
States and internationally. Ultimately, however, the true
biologic grade of a sarcoma is multifactorial and depends on
the complex interplay of histologic type, tumor size, tumor
depth (in relation to fascia), tumor location, histologic grade,
and clinical stage. Understanding the relative importance of
each of these factors in a given tumor sufficiently well to
allow reliable prognostication in all soft tissue sarcomas at
present remains a somewhat forlorn hope. Therefore,
perhaps most important, pathologists must take responsibility
for informing and educating clinicians about the problems
and present subjectivity of grading. Otherwise, the
increasing obsession with selecting treatment based on histologic
grade (type often being regarded clinically as irrelevant)
can lead only to less sophisticated and less scientific
treatment of patients with a soft tissue sarcoma. As Wolter
Mooi, MD, in the Netherlands has stated, lack of precision in
tumor typing cannot be compensated for by apparent precision
in tumor grading, no matter how much apparently
detailed and precise information on tumor grade might instill
trust and confidence.20 Personal experience suggests that
modern sarcoma management strategies are quite often
leading to treatment of tumors of unproven histotype, graded
on smaller and smaller biopsy specimens before the use of
neoadjuvant (ie, preoperative) therapies. This cannot
possibly represent good medicine!