Objectives The role of primary tumor surgery in patients with de novo metastatic soft tissue sarcoma (STS) is controversial, with a lack of objective selection criteria. This study aimed to identify patients who may benefit from surgery and to evaluate the prognostic value of integrated 18F-FDG PET/CT metabolic parameters and clinicopathological factors. Materials and methods Forty patients with de novo metastatic STS undergoing pretreatment ¹⁸F-FDG PET/CT were analyzed. Clinical data and metabolic parameters (maximum standardized uptake value [SUVmax], total metabolic tumor volume, and total lesion glycolysis [TLG]) were collected. Prognostic factors for overall survival (OS) were assessed using Cox regression. Heterogeneity was examined through pre-specified subgroup analyses and formal interaction tests. Results Multivariate analysis identified age > 50 years, lactate dehydrogenase (LDH) > 200 U/L, and SUVmax > 10.0 as independently associated with worse OS (all p < 0.05). Significant interactions were observed between surgical treatment and both the Ki67 index and TLG (P for interaction = 0.006 and 0.042, respectively). Surgery was associated with significantly improved OS in patients with low Ki67 (HR = 0.24, 95% CI: 0.06–0.89; p = 0.032) or low TLG (HR = 0.21, 95% CI: 0.04–0.97; p = 0.046), with no significant benefit observed in corresponding high-expression subgroups (all p > 0.05). Conclusion The survival benefit of primary tumor surgery in de novo metastatic STS is restricted to patients with less aggressive tumor dbiology, characterized by low proliferative activity (Ki67 ≤ 35%) or low TLG. Integrated assessment of Ki67 and PET/CT parameters, particularly TLG, provides a practical framework for personalized surgical decision-making. Key Points <Emphasis Type="BoldItalic">Question</Emphasis> Does primary tumor surgery provide a survival benefit for patients with de novo metastatic STS based on PET/CT and clinicopathological markers? <Emphasis Type="BoldItalic">Findings</Emphasis> Surgery was associated with improved survival only in patients with low Ki67 or low TLG, with significant interaction effects (p = 0.006 and 0.042, respectively). <Emphasis Type="BoldItalic">Clinical relevance</Emphasis> Surgical selection in metastatic STS should be guided by tumor biology. Integrating Ki67 and TLG provides a practical framework to identify patients most likely to derive a survival benefit from primary tumor resection. Graphical Abstract

Surgery confers survival benefit in De Novo metastatic soft tissue sarcoma patients with low Ki67 or low total lesion glycolysis: a combined PET/CT and clinicopathological analysis

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2026年7月10日

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Shaoli Li,
Xin Zheng,
Menglei Jin,
Hui Wang,
Rui Bai,
Ying Dong

摘要

Objectives

The role of primary tumor surgery in patients with de novo metastatic soft tissue sarcoma (STS) is controversial, with a lack of objective selection criteria. This study aimed to identify patients who may benefit from surgery and to evaluate the prognostic value of integrated ¹⁸F-FDG PET/CT metabolic parameters and clinicopathological factors.

Materials and methods

Forty patients with de novo metastatic STS undergoing pretreatment ¹⁸F-FDG PET/CT were analyzed. Clinical data and metabolic parameters (maximum standardized uptake value [SUVmax], total metabolic tumor volume, and total lesion glycolysis [TLG]) were collected. Prognostic factors for overall survival (OS) were assessed using Cox regression. Heterogeneity was examined through pre-specified subgroup analyses and formal interaction tests.

Results

Multivariate analysis identified age > 50 years, lactate dehydrogenase (LDH) > 200 U/L, and SUVmax > 10.0 as independently associated with worse OS (all p < 0.05). Significant interactions were observed between surgical treatment and both the Ki67 index and TLG (P for interaction = 0.006 and 0.042, respectively). Surgery was associated with significantly improved OS in patients with low Ki67 (HR = 0.24, 95% CI: 0.06–0.89; p = 0.032) or low TLG (HR = 0.21, 95% CI: 0.04–0.97; p = 0.046), with no significant benefit observed in corresponding high-expression subgroups (all p > 0.05).

Conclusion

The survival benefit of primary tumor surgery in de novo metastatic STS is restricted to patients with less aggressive tumor dbiology, characterized by low proliferative activity (Ki67 ≤ 35%) or low TLG. Integrated assessment of Ki67 and PET/CT parameters, particularly TLG, provides a practical framework for personalized surgical decision-making.

Key Points

Question Does primary tumor surgery provide a survival benefit for patients with de novo metastatic STS based on PET/CT and clinicopathological markers?

Findings Surgery was associated with improved survival only in patients with low Ki67 or low TLG, with significant interaction effects (p = 0.006 and 0.042, respectively).

Clinical relevance Surgical selection in metastatic STS should be guided by tumor biology. Integrating Ki67 and TLG provides a practical framework to identify patients most likely to derive a survival benefit from primary tumor resection.

Graphical Abstract