Localized operable soft tissue sarcoma of the upper extremity. Presentation, management, and factors affecting local recurrence in 108 patients

Factors influencing local recurrence and survival in patients with soft tissue sarcoma of the upper limb

Fifty-one patients with soft tissue sarcoma of the upper limb were studied to identify risk factors for local recurrence and survival. More than half (53 per cent) of the patients referred had locally recurrent disease. The flexor aspect of the forearm was the most common site of origin. The majority of patients were managed by a combination of conservative surgery and radical radiotherapy. Wide or radical excision was achieved in 49 per cent of cases. One-third of patients required partial resection of bone or neurovascular structures; 75 per cent of them had presented with local recurrence after treatment elsewhere. Skin grafts and flap repairs were used more often in patients with local recurrence (P = 0.013) and 20 (74 per cent) of those referred with locally recurrent disease have had no further local relapse. The overall 5-year survival rate of 80 per cent (95 per cent confidence interval 61-90 per cent) supports a policy of conservative surgery. Factors associated with a lower survival rate were deep fixation, origin in the flexor aspect of the forearm, and previous local recurrence. Deep fixation was also associated with an increased risk of local recurrence. Referral to a specialist unit at the time of initial presentation may result in lower rates of local recurrence and may improve the survival rate.

The role of multimodality therapy in soft-tissue sarcoma

Soft-tissue sarcomas are uncommon malignancies. The development during a period of 8 years, in one institution, of a prospective data base incorporating more than 1600 patients with these tumors is described. The most common sites for occurrence are the extremities, but they can occur in any of the soft tissues of the body. Liposarcoma and leiomyosarcoma are the most common histopathologic conditions identified. Prognostic factors for both recurrence and survival include site, histopathology, size, grade, and adequacy of resection. A prospective randomized trial of the use of adjuvant radiation by the brachytherapy technique in extremity lesions has shown a decrease in local recurrence, but no impact on survival. Eligible patients not randomized to the trial show no difference in local recurrence or survival, regardless of whether they received adjuvant radiation.

The influence of local recurrence of extremity soft tissue sarcoma on metastasis and survival

One hundred seventy-five consecutive patients with soft tissue sarcoma of the limb and limb girdle were studied using univariate and multivariate analysis. The most important factor determining risk of local recurrence was the quality of treatment of the primary tumor, with wide or radical surgery plus radical radiotherapy obtaining the best local control. Tumor size, site, and histologic grade were not predictive of local recurrence. The important tumor variables predicting survival were tumor size at first presentation and histologic grade. Tumors with greater than 10 cm greatest diameter and high-grade tumors carried a poor prognosis. Local recurrence was significantly associated with reduced survival, but only when (correctly) considered as a time-dependent variable in multivariate analysis. Irradiation was also significantly associated with poor survival. Review of the literature indicates that local recurrence is believed to have little influence on survival. Since the relevant randomized controlled trials have been small, the evidence is inconclusive.

Role of compartmental resection for soft tissue sarcoma of the limb and limb girdle

A total of 143 consecutive operations for soft tissue sarcoma of the extremity, performed by one surgeon over a 5-year period, was studied to determine the place of compartmental excision. The surgical aim was to achieve the nearest to radical surgery compatible with preservation of a functional limb. Of the operations, 73 were for previously untreated primary tumour and 70 for local recurrence. Two tumours arose in areas previously irradiated for other malignancies and 35 recurrences had occurred despite prior radiotherapy; of the 106 remaining cases, adjuvant radiotherapy was used for 79. Adjuvant chemotherapy was used only occasionally and was more often regional than systemic. For the majority of tumours, compartmentectomy was inappropriate or inadequate: 49 were extracompartmental in origin and 48 extended beyond their compartment of origin at the time of surgery. The remaining 46 were confined to one compartment; in only 21 of these 46 operations was a radical compartmental excision performed. Compartmental excision was more likely to be performed when the tumour was centrally located within a compartment, was so large that it replaced most of the muscle group, or was high grade or recurrent (particularly when adjuvant radiotherapy had already been used). The general preference was to combine less-than-radical surgery with adjuvant radiotherapy rather than sacrifice entire muscle groups or adjacent, functionally important, structures such as artery or nerve. This reflects the proven efficacy of radiotherapy in controlling microscopic disease. Overall, compartmental excision was considered appropriate in only 15 per cent of operations.

Soft tissue sarcomas

Soft tissue sarcomas in infants and children differ from those in adults in clinical presentation, histology, and response to therapy. For rhabdomyosarcoma, the most common sarcoma in children, each primary site has special characteristics that affect both treatment programs and survival rates. Some results are so good, from the standpoint of survival data, that studies are now in progress to evaluate means of reducing treatment morbidity. Other ongoing studies focus on improved protocols for metastatic or recurrent rhabdomyosarcoma. Results thus far in the IRS trials have proven the value of cooperative clinical trials in the management of patients with this disease.

The prognostic value of histologic subtypes in primary extremity liposarcoma

Patients with a localized primary liposarcoma of the extremity who were treated in Memorial Sloan-Kettering Cancer Center between 1968 and 1978 were studied. The prognosis of patients with extremity liposarcoma was analyzed according to histopathologic subtypes. A system of five subtypes was used; well-differentiated, myxoid, fibroblastic, lipoblastic, and pleomorphic liposarcomas. The 5-year treatment failure rates and survival rates were, respectively, 30% and 100% for well-differentiated, 25% and 88% for myxoid, 60% and 58% for fibroblastic, 100% and 40% for lipoblastic, and 64% and 56% for pleomorphic liposarcomas. Although local recurrence was present in all five subtypes, a significant increment in local failure was seen in patients with high-grade liposarcomas. Distant metastasis after the initial operation was not found in patients with well-differentiated liposarcoma and rare in the patients with myxoid liposarcoma. In contrast, 50% of the patients with fibroblastic, lipoblastic, and pleomorphic liposarcoma had a distant relapse within 5 years.

Extremity soft tissue sarcomas: analysis of prognostic variables in 300 cases and evaluation of tumor necrosis as a factor in stratifying higher-grade sarcomas

From July 1975 to February 1985, 300 patients with extremity soft tissue sarcomas (STS) were entered into treatment protocols at the National Cancer Institute. Using the Cox proportional hazards model, the STS were analyzed for independent prognostic variables that had significant association with disease-free and overall survival. The effects of adjuvant treatment were also included in the analysis. Percent tumor necrosis was the basis for separating intermediate and high-grade STS (less than 15% necrosis = grade 2; greater than 15% necrosis = grade 3). The most important prognostic variable was histologic grade, which was highly associated with relative risk of metastasis and fatal outcome (P less than .0001). Histologic type of STS was not a significant prognostic variable in predicting metastases. Patients with tumors located on the proximal or middle part of the extremity had a fivefold increased risk of death (P = .02) compared with patients who had STS located more distally. Mitotic activity (P = .0005) and vascular invasion (P = .0034) were also associated with malignant behavior, but histologic grade was the most significant predictor of outcome. Histologic grade of malignancy was based upon a combination of tumor typing and visual estimation of extent of tumor necrosis; using these two features, one can reliably separate low-grade (i.e., grade 1) from high-grade STS and also stratify the more aggressive (i.e., grade 2 and 3) tumors. Over the 9.5-year period of study, the tumor-related mortality was as follows: grade 1 (1/38), 3%; grade 2 (19/142), 13%; and grade 3 (45/120), 38%.

Management of extremity soft-tissue sarcoma

Soft-tissue sarcomas remain relatively uncommon neoplasms, but they present major problems for both the patient and clinician. The identification of prognostic variables based on both clinical and histologic factors has allowed comparisons to be made between various therapeutic regimens. In extremity sarcoma, a more conservative operation utilizing adjuvant radiotherapy has decreased the need for radical surgery and maximized function without loss of survival benefit. The identification of high-risk groups, that is, patients with high-grade, large lesions, has highlighted the inadequacies of treatment in some areas. Similarly, this has led to more aggressive and innovative developmental programs. The progress, understanding, and therapeutic management of extremity lesions have not been matched in visceral and retroperitoneal tumors. Current efforts are directed at more appropriate use of radical surgery, maximizing conservative function-sparing operations with the use of adjuvant local therapy, and development of new regimens directed at prevention and treatment of metastatic disease.

Management of extremity sarcomas

Soft tissue sarcomas remain an uncommon neoplasm. They do, however, provide a significant model for the examination of genetic predisposition, natural history, and therapeutic strategies for localized, regional and disseminated disease. Approaches developed in these solid tumours may well provide a rational basis for the management of other malignancies.

Low-grade soft tissue sarcomas of the extremities. Analysis of risk factors for metastasis

Of 130 patients with low-grade localized soft tissue sarcomas of the extremities treated at Memorial Hospital between 1968 and 1978, 18 (14%) developed metastases. The risk of metastasis could not be predicted by the clinical or pathologic size, tumor depth, proximal location, recurrence before presentation or subsequent to treatment at our institution, the type of surgical and adjuvant therapies, and the adequacy of surgical margins. The median age of patients with metastases was 10 years older than the other patients (57.5 years and 47.5 years, respectively). Of the more common sarcomas in this study, malignant peripheral nerve tumors and malignant fibrous histiocytomas had the highest prevalence of metastasis (27% (three of 11) and 17% (three of 18), respectively). Although patients with low-grade extremity sarcomas treated during the first 5 years of this review had an increased rate of metastasis, no other patient, tumor, or treatment variable examined significantly differed between the two time periods. Although grade alone is a good predictor of the risk of metastasis from soft tissue sarcomas of the extremity, 14% of patients in this series with low-grade histology developed metastases. Further review of larger numbers of these tumors should be undertaken in an effort to more definitively identify risk factors predictive of metastatic potential in low-grade sarcomas.