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

Low local recurrence rates following marginal surgical resection of non-coelomic Atypical Lipomatous Tumours/Well-differentiated Liposarcomas

INTRODUCTION

High rates of local recurrence (LR) have been reported following resection of extremity Atypical lipomatous tumours/Well-differentiated liposarcomas (ALTs). This retrospective study of patients who underwent resection of primary deep extremity and trunk ALTs at a specialist sarcoma centre aims to assess morbidity and factors associated with low local recurrence rates (LRR).

METHODS

To review a homogeneous cohort of patients with low-grade disease, tumours with known high-risk histological features were excluded. Prognostic variables potentially influencing local recurrence (LR) (age, size, site, margin status, and histological findings) were analysed. Endpoints were LR, distant recurrence (DR) and local disease-free survival (LDFS).

RESULTS

127 patients were identified, with median follow-up of 54 months (0-235). Median tumour size was 17.5 cm (5-36). 85 % occurred in the lower limb. 93.7 % underwent marginal resection. No patients received radiotherapy. Median hospital stay was 3 days (0-16). 7.9 % returned to theatre for evacuation of haematoma or infected seroma and 18.1 % had outpatient seroma aspiration. Surgical margins were R0/R1 in 93.7 % of patients and R2 in 6.3 % with a LR rate of 8.4 % and 75 % respectively at median time of 54 months. One- and 5-year LDFS was 100 % and 88.4 %, respectively. DR rate was 0.8 % (1/127) this patient had pleomorphic liposarcomatous transformation on recurrence and subsequently developed distant metastases. No patients died of disease.

CONCLUSION

Function-preserving marginal resection of non-coelomic ALTs has low morbidity, low LR and extremely low rates of distant relapse. Patients with lower limb ALT were found to have significantly lower LR, which may impact follow-up protocols.

Enbloc resection of primary oral cancer involving infratemporal fossa: A systematic "out to in and top to bottom" surgical approach and outcomes

AIM AND INTRODUCTION

The oral cavity Squamous Cell Carcinoma (OCSCC) involving infratemporal fossa (ITF) is considered as cT4b stage per AJCC 8th classification. The treatment of these group of patients is challenging due to the difficulty in achieving negative resection margin status. In this study we have highlighted our surgical technique with oncological outcome of enbloc resection of primary oral cancer involving ITF.

METHODOLOGY

- This was a single center retrospective study which included only patients with OCSCC extending into ITF. Our surgical technique of systematic "out to in and top to bottom" approach was detailed. The perioperative outcomes, histopathological details, survival outcomes were measured.

RESULTS

- Over the period of 1 year a total of 340 patients with OCSCC reported to our outpatient department, out of which 120 patients belonged to cT4 category and 32 patients were cT4b stage with involvement of ITF. Amongst 32 patients, 2 patients had distant metastasis and were excluded from the study. The 5 patients received neoadjuvant chemotherapy followed by surgery and rest all patients were taken up for upfront curative surgery. There were no significant intraoperative and postoperative complications. None of the margins were found to be involved or close in the final histopathology report. The median DFS and OS were 31 months and 27 months respectively at a median follow up of 29 months.

CONCLUSION

- Our systematic approach of enbloc resection of primary oral cancer involving ITF is safe and easily reproducible with high rate of negative resection margin status.

Surgical Excision of Intramuscular Sarcomas: Description of Three Cases in Dogs

Compartmental excision consists of the complete resection of an anatomic district in which specific structures act as a barrier to local tumour invasion. It is a well-established procedure in human medicine, while only a few reports are available in veterinary medicine. The aim of this study was to describe complete muscle resection in 3 dogs affected by different intramuscular sarcomas. The clinical outcome was also reported. Medical records were searched, including preoperative diagnostic findings, compartmental excision, histologic diagnosis, and outcome. Three dogs fit the inclusion criteria, which had a sarcoma confined to a single muscular belly (semitendinosus, biceps, and splenius capitis muscles). Complete excision of the affected muscle was performed in all cases. One dog showed moderate lameness in the immediate postoperative period, resulting from the dorsal lifting of the scapula due to serratus ventralis tenotomy performed to remove the caudal insertion of the splenius capitis muscle. All the dogs recovered fully within one month, experiencing good clinical function. Histopathology showed complete tumour removal with no neoplastic fascial disruption in all cases. Compartmental excision provides effective local tumour control, representing an alternative to limb amputation or more radical excision if adjuvant radiotherapy is not an option for owners.

Popliteal sarcomas: presentation, prognosis, and limb salvage

Soft tissue sarcomas of the popliteal fossa are rare diseases. Resection is challenging because of their extracompartmental location and proximity to neurovascular structures. Their prognosis is inferior to intracompartmental extremity soft tissue sarcomas. We ascertained the mode of initial presentation, the rates of local recurrence and distant metastasis, and the morbidity and complications of limb salvage procedures. We retrospectively analyzed the data of 29 consecutive patients operated on between 1989 and 2003. The median followup was 79 months. Sixteen, five, and eight patients were diagnosed with high-, intermediate-, and low-grade tumors, respectively. High-grade tumors were smaller than low- and intermediate-grade tumors. Thirty-one percent of patients presented with localized pain. Of the 26 patients who had primary limb salvage resections, 14 had negative surgical margins, six had close margins, and six had positive margins. Seventeen patients were treated with radiotherapy and 10 patients received chemotherapy. The local recurrence rate was 10.3%, four patients with high-grade tumors had distant metastasis, and the limb-salvage rate was 86.2%. Postoperatively, six patients experienced wound dehiscence and four had mild flexion contractures. Soft tissue sarcomas of the popliteal fossa have an atypical presentation. Limb salvage can be accomplished in most patients with low morbidity and good systemic and local control.

Chirurgie des sarcomes des tissus mous des membres et de la paroi du tronc

For this review of surgery in soft tissue sarcoma, we reviewed literature and added our personal experience. In front of a soft tissue tumour, the major objective is to think it could be a sarcoma. Diagnosis actually is made by core needle biopsies, but sometimes a surgical biopsy is needed. Surgical resection is better defined since ten years and distinguishes resection R0 (in sano), R1 (microscopic residual disease) and R2 (macroscopic residual disease). Quality of resection is determined collegially by confrontation of surgical and pathological reports according recommendations of the French Sarcoma Group (FSG). The risk of local recurrence depends on resection-type and tumour grade. With the help of the surgical classification from FSG, local prognosis is better understood and treatment can be adapted to individual tumours. In experienced hands, local recurrence can be pushed down to near 10 against 20% formerly. Severe complications after sarcoma surgery occur in 14% of cases. Functional outcome studies have benefited from new scoring systems, which complete each other. Isolated limb perfusion is a method that could save limbs in some desperate situations.

CONCLUSION

Due to rarity and treatment specifications, soft tissue sarcoma should be treated in specialised centres.

[Definitions of target volumes in soft tissue sarcomas of the extremities]

Soft tissue sarcomas of the extremities are currently treated with more conservative and functional approaches, combining surgery, radiotherapy and chemotherapy. The role of external beam radiotherapy and brachytherapy has been defined through randomised studies performed in the 80's and 90's. However, the ubiquity of tumour location for these tumours makes difficult a systematic definition of local treatments. Tumour volume definition is based on pre and post surgical imaging (MRI) and on described pathological report. The clinical target volume will take into account quality of the resection and anatomical barriers and will be based on an anatomy and not only on safety margins around the tumour bed. General rules for this irradiation (doses, volumes) and principal results will be presented.

Soft-tissue sarcomas

Sarcomas of the soft tissues are challenging lesions for the surgical oncologist. Careful planning must be done at all stages of diagnosis and treatment, because every sarcoma is unique with respect to histologic type, size, and location. Pretreatment discussions in a multidisciplinary format are useful to ensure appropriate and effective management of these tumors.

The local management of soft tissue sarcoma

Soft tissue sarcomas (STS) are rare tumors arising from the connective tissues. STS can arise at any anatomic site, can demonstrate varied behavior and prognosis, and therefore present a formidable challenge in management. The local treatment of STS demands technical complexity in the application of diagnostic tools, including pathology and imaging, as well as treatment approaches, including surgical ablation and reconstruction, radiotherapy, and, in defined cases, chemotherapy. The understanding of the management of these lesions is profoundly dependent on the multidisciplinary setting, where experience has been gained and skills are available to increase the likelihood of a successful result. Several proven options are available for optimal local management, and the choice of approach depends on the prevailing practice and resource profile of the treating center. With modern approaches, the local control rate can be expected to be at least 90% for extremity lesions, which constitute the most common STS. The experience in other anatomic sites is less favorable as a result of a combination of late diagnosis, technically difficult access sites, and possibly less familiarity with these less common presentations. The disappointing results make it all the more important for patients to be referred to a multidisciplinary setting with experience in sarcoma management to maximize the chance of successful local outcome.

Extremity soft tissue sarcoma: factors predictive of local recurrence and survival

BACKGROUND

To identify risk factors for local recurrence and overall survival in patients with extremity soft tissue sarcoma.

METHODS

A retrospective study was performed of all patients with extremity soft tissue sarcoma treated at the Combined Surgical Oncology Clinic in the Institute of Oncology at Prince of Wales Hospital between 1972 and 1992. Variables analysed included clinical presentation, patient characteristics, tumour characteristics, treatment factors and outcome.

RESULTS

One hundred and nineteen patients were eligible for the study. The most common type of presentation was with a painless mass, usually in the thigh. Local control rates at 5 and 10 years were 75% and 73%. Local control was higher in patients who had more radical surgery and in those who received adjuvant radiotherapy. Tumour size and high grade were independent risk factors for poorer survival. Patients over 50 had poorer survival than younger patients and those who presented with recurrent tumours also tended to have poor survival compared to patients presenting de novo. The respective 5- and 10-year survival rates were 65% and 62%.

CONCLUSION

This study suggests that local control of extremity soft tissue sarcoma is improved by radical surgery and by the addition of radiotherapy when more conservative procedures are used. Overall survival appeared to be largely determined by patient (age, recurrent presentation) and tumour characteristics (grade, size).

High grade soft tissue sarcoma of the flexor fossae. Size rather than compartmental status determine prognosis

BACKGROUND

High grade soft tissue sarcoma arising in the popliteal space, axilla, and antecubital fossae (flexor fossae tumors) have by convention been classified as extracompartmental tumors by the accepted staging and grading criteria of the Musculoskeletal Tumor Society (MSTS). Advances in neoadjuvant chemotherapy and radiation therapy have made surgical resection more feasible. The hypothesis to be tested is that compartmental status may not be of prognostic significance if the tumor is adjusted for size, histologic grade, and distant metastasis after undergoing adjuvant chemotherapy and radiation.

METHODS

From June 1976 to December 1992, 22 patients with high grade soft tissue sarcomas of the flexor fossae (Group A) were treated at UCLA Medical Center. The histologic subtypes were liposarcoma (five), synovial cell sarcoma (eight), malignant fibrous histiocytoma (four), leiomyosarcoma (two), angiosarcoma (two), and rhabdomyosarcoma (one). The popliteal fossa was the location in 11, the axilla in 10, and the antecubital fossa in 1. Wide resection was attempted in all patients after preoperative chemotherapy and radiation therapy. Amputation was performed in 5 patients because of repeated or extensive recurrent tumor. A group of 77 patients (Group B) with high grade soft tissue sarcoma located within an extremity compartment were chosen to test the hypothesis that survival of patients with tumors in the flexor fossae is equal to that of patients with intracompartmental tumors of similar size and grade if both are given adjuvant therapy. This group was chosen so that histologic subtype, size, sex, and location would be similar in the two groups. The authors selected thigh and calf tumors for comparison with popliteal fossa tumors and periscapular, deltoid, and arm tumors for comparison with axilla and antecubital fossae tumors. All of these patients had similar treatment and follow-up protocols. The median follow-up of survivors in Group A was 104 months and for patients in Group B was 79 months.

RESULTS

The 5-year cumulative survival rate (Kaplan-Meier method) of patients in Group A was 76%, and 67% for those in Group B. The difference was not significant. Three patients in Group A (14%) and 17 (22%) in Group B had local tumor recurrence. Eight patients in Group A (36%) and 27 (35%) in Group B had lung metastases. Age, sex, histologic subtype, and surgical margins did not affect survival outcomes, lung metastasis, and local recurrence. However, patients with larger tumors (maximum dimension > or = 8 cm or cross-sectional area > or = 40 cm2) had significantly poorer survival, more metastases, and local recurrences.

CONCLUSION

Flexor fossae sarcomas do not have a poorer prognosis than extremity intracompartmental tumors when adjusted for size, distant metastasis, and histologic grade when they are treated with adjuvant radiation therapy, chemotherapy, and surgery.

Surgery in soft tissue sarcomas

The surgical treatment of soft tissue sarcomas improved in the last decade, with better regional control and an increased number of limb sparing operations, but procedures and criteria of indication are not unified. Moreover, a great discrepancy exists in the incidence rate of local recurrence reported in literature, and also major centres denounce a high rate of local failures. The major predictive parameters of adequate regional control are the size and location of primary lesion, the pathological grading, previous treatments and the quality of surgical margins. Results in terms of regional control of 417 cases treated at our institute in the period 1974-1984 are analysed and discussed. Local failure occurred in 113 cases (27% crude, 31% actuarial risk at 5 years) and has been analysed according to factors which had impact on local failures: pathological grading (low grade 24% local recurrence vs. high grade 35% recurrence, P = 0.05), site (extremity and girdle 26% vs. trunk and head and neck 47%, P = 0.001), previous surgical treatment (32% for lesions recurrent at entry vs. 43% for virgin tumours, P = 0.05), quality of margins (adequate surgery 24% vs. marginal surgery 47%, P < 0.001); intralesional operations are excluded from this series. Histopathology is stratified in four categories that can actually influence the treatment schedule: low grade, spindle cell type high grade, small blue cell, miscellaneous sarcomas of different or unclear histogenesis. The size is detailed in different definitions of small or large, in a site-size relationship which may be useful in surgical practice, with no prognostic purposes. Finally, the adequacy of a surgical treatment is evaluated and discussed by the quality of surgical margins, defined according to the concept of compartment. A surgical indication rationale is, therefore, proposed taking into account the above-mentioned parameters and conclusive points of discussion.

Preoperative radiotherapy for initially inoperable extremity soft tissue sarcomas

The results and complications of a combination of preoperative radiotherapy and surgery in the treatment of 70 patients with large or fixed extremity soft tissue sarcomas are reported. Sixty-one patients were referred with a primary tumour and 9 had recurrences. Thirty-three patients had tumours in the thigh and 38 tumours were fixed to neighbouring structures. The mean preoperative dose was 53 Gy (range 21-75). Eleven patients received a postoperative boost to tumour site. Four patients received preoperative intra-arterial Adriamycin. Overall, 42 patients (60%) responded to the radiotherapy, 4 with complete tumour resolution. Eighty per cent of those receiving greater than or equal to 60 Gy responded and a significant correlation between 2 Gy equivalent dose and response was demonstrated (P less than 0.005). The degree of tumour necrosis was increased in 23 of 52 evaluable patients following radiotherapy, although there was no correlation with dose or clinical response. There have been eight local recurrences and 17 deaths after a median follow-up of 2 years. Tumour size less than 10 cm was the only significant factor in the development of local recurrence (P = 0.04). Thirty-six patients developed immediate postoperative complications: 9 major (13%), 13 moderate (19%) and 14 minor (20%). Increasing patient age was the only significant independent factor for the development of complications (P = 0.015). Preoperative radiotherapy will usually permit limb conservation of extremity sarcomas which otherwise would be inoperable or require amputation. However, the increased incidence of wound complications in older patients demands meticulous technique.

Limb function following conservation treatment of adult soft tissue sarcoma

Quality of life and limb function were studied in 54 patients who were disease-free 2 or more years after limb-conserving treatment for soft tissue sarcoma of the leg or pelvic girdle. Tumours of the thigh predominated (25 patients) and the mean tumour size was 9.9 cm. 41 patients had been treated with a combination of surgery and radiotherapy (29 with conventional and 12 with high dose), 12 with surgery alone and one with irradiation and intra-arterial doxorubicin. Only 15 patients had a normal range of movement in all lower limb joints and only 12 had normal power in all muscle groups; tumours of the lower leg were particularly unfavourable in this respect. Gait was normal in 42 patients but 8 required a walking aid and 4 a joint support. 16 had detectable lymphoedema but only 2 needed to wear compression hosiery. 35 patients still experienced pain at some time but only 6 required analgesia. However, when assessed by questionnaire for locomotion, grooming and home/leisure/vocational activities, 37 patients (68%) reported excellent function, and only 2 had moderate impairment. Function loss was most marked in leisure (25 patients) and vocational (8) activities, but was mild in 66% of cases. Multivariate analysis was carried out to determine the prognostic factors for poor limb function. The results suggested that overall functional score was predominantly determined by gait (P less than 0.001), muscle power or range of movement (P less than 0.001), with increasing age, female sex and the use of radiotherapy poor prognostic factors. Reduced muscle power or range of movement were the major factors determining gait (P less than 0.02) with the use of radiotherapy the significant prognostic factor for both in the conventionally treated group. Doses in excess of 60 Gy resulted in increased fibrosis and a worse functional outcome. Extent of surgery was not an independent prognostic factor for limb function, although univariate analysis suggested an association with range of movement in the conventionally treated group (P less than 0.025). Despite significant objective loss of range of movement and muscle power patients retain excellent limb function and quality of life following limb conserving treatment. For optimal function, radiotherapy should be given with small fractions to a dose not exceeding 60 Gy.

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.

High dose hyperfractionated radiotherapy in the treatment of extremity soft tissue sarcomas

A hyperfractionated radiotherapy schedule has been evaluated in the treatment of 29 adults with limb or limb girdle soft tissue sarcomas. The objective was to increase the total administered dose and possibly improve local control, without increasing late normal tissue damage. Twice daily 1.25 Gy fractions (with a minimum interval of 6 h) have been given over 5 to 6 weeks to 12 patients pre-operatively, 10 post-operatively and 7 palliatively. Five patients received 62.5 Gy in 5 weeks pre-operatively and 3 palliatively. Nineteen of the remaining 21 patients received 75 Gy in 6 weeks with a field size reduction after 5 weeks. Sixteen of 29 tumours were situated in the thigh and only 2 were in the upper limb. Twenty were of high grade. The mean tumour size of those treated radically was 13.1 cm (range 5 to 40 cm). Sixteen patients (76%) given 75 Gy developed moderate or severe skin erythema maximal at 5 weeks. Despite the large field sizes used (mean phase one of 34.5 cm, and phase two of 22.8 cm) only 2 patients failed to complete the planned treatment because of the severity of these reactions. Two other patients developed partial wound breakdowns after the end of treatment--both healing spontaneously. Fourteen patients developed an area of moist desquamation--11 mild, 2 moderate and one severe. There have been four late wound breakdowns requiring surgical intervention; all have since healed well. The median follow up is short at 556 days. Ten of 19 evaluable patients have developed moderate/severe induration, 5/19 mild and 4/19 none.(ABSTRACT TRUNCATED AT 250 WORDS)

Management of soft tissue sarcomas in Portsmouth 1965-1985

This paper describes the results of combined surgical and radiotherapy management of 118 patients with soft tissue sarcoma referred to the Department of Radiotherapy and Oncology at Portsmouth between 1965 and 1985. After exclusion of paediatric rhabdomysarcomas, tumours of the gastrointestinal tract and patients who were referred for follow-up only, 109 patients were left for retrospective analysis: 23 patients had surgery only, 11 received a course of preoperative radiotherapy, 52 were irradiated postoperatively and 14 had only radiotherapy. A range of doses and fractionations was used. The total 5-year actuarial survival was 39.7%, the disease-free survival was 35.6%. After excluding Kaposi sarcomas, retroperitoneal tumours, patients with distant metastases or those too ill for radical therapy, the respective figures were 55.5% and 49.7%. If we also excluded patients, treated by radiotherapy only, or irradiated with gross postoperative disease, the figures were 62.7% and 57.3% respectively. Five-year actuarial local control in 68 patients irradiated either without surgery, or postoperatively, was 57.2%. In tumours smaller than 5 cm in diameter, 5-year survival was 86.7%, and local control was 93.3%. For large tumours over 10 cm in diameter, the respective values were 22.2% and 50%. The dose of 60 Gy was satisfactory, if the surgical procedure removed all macroscopical disease, but higher doses are recommended when there is clinically apparent residual disease.