Selective combination of modalities in soft tissue sarcomas: limb salvage and survival

Quality of life following amputation or limb preservation in patients with lower extremity bone sarcoma

Purpose: Although functional differences have been described between patients with lower extremity bone sarcoma with amputation and limb-preservation surgery, differences have not clearly been shown between the two groups related to quality of life. The purpose of the study was to determine if there is a difference in overall quality of life in lower extremity bone sarcoma survivors related to whether they had an amputation or a limb-preservation procedure while identifying psychological differences for further evaluation. The main hypothesis was that sparing a person’s limb, as opposed to amputating it, would result in a better quality of life.

Patients and Methods: Eighty-two long-term survivors of lower extremity bone sarcoma were studied to make a comparison of the overall quality of life, pain assessment, and psychological evaluations in limb preservation and amputation patients. Forty-eight patients with limb preservation and thirty-four patients with amputations were enrolled in the study. Validated psychometric measures including the Quality of Life Questionnaire (QLQ), the Minnesota Multiphasic Personality Inventory, and visual analog scales were utilized.

Results: The overall quality of life of patients with limb preservation was significantly higher than patients with amputation (p-value < 0.01). Significant differences were noted in the categories of material well-being, job satisfiers, and occupational relations.

Conclusion: The overall quality of life of patients with limb-preservation appears to be better than for those patients with amputation based on the QLQ in patients surviving lower extremity bone sarcoma. Further analysis needs to verify the results and focus on the categories that significantly affect the overall quality of life.

[Vascular reconstruction for limb preservation during sarcoma surgery: a case series and a management algorithm]

OBJECTIVE

To evaluate the results of vascular reconstruction in soft tissue sarcoma surgery and establish an algorithm based on current evidence.

MATERIAL AND METHODS

We studied patients undergoing soft-tissue sarcoma in a tertiary hospital. A retrospective review of 8 cases was carried out, analysing the demographics, surgical planning, complications, disease-free survival and bypass patency.

RESULTS

Successful limb preservation was observed in all patients, and the bypass remained patent in all cases. The mean follow-up was 38.4 months average, with 87.5% survival and no recurrences.

CONCLUSIONS

The involvement of major vascular structures in soft tissue sarcomas of the limbs does not necessarily exclude resectability. In selected cases, resection is possible with vascular reconstruction and limb preservation. However, multidisciplinary planning is needed.

Disease incidence and results of extremity lesion treatment: mersey region soft tissue sarcomas (1975-1985)

Purpose. The incidence and treatment results of extremity soft tissue sarcoma (STS) in the Mersey Region, in the absence of a Multi-Disciplinary Unit, for the period 1975–1985, have been analysed.

Subjects and methods. Data from cases presenting with STS within the Mersey region, from 1 January 1975 until 31 December 1985, were reviewed. Only patients with sarcoma of head and neck, thoracic wall, abdominal wall, retroperitoneum, limb girdle or extremity were included. Extremity lesions were staged according to the MTS system. Pathological data also were assigned a grade according to tumour differentiation, mitosis count and tumour necrosis. Data from patients with a minimum follow-up of 5 years were collated, and patterns of treatment failure were investigated. Finally, time to first occurrence was analysed.

Results and Discussion. The incidence of STS in this study was identical to that reported by the US Department of Health in 1976. Five year survival rate for Stage I tumours was only 51.7% which compares very unfavourably with contemporary series from Multi-Disciplinary Units. Five year survival rate following wide local excision ± adjuvant therapy is 52.4%, while that following amputation ± adjuvant therapy is 45.5%. While not attaining the results reported by other centres, limb-sparing surgery does not appear to appreciably prejudice long-term survival.

Conclusions. STS are rare in the UK, leading to poor classification and suboptimal treatment of lesions. It is important to establish multidisciplinary teams of surgeons, radiologists, radiotherapists and oncologists to plan and organise multimodality therapy for STS.

Results of limb-salvage surgery with vascular reconstruction for soft tissue sarcoma in the lower extremity: comparison between only arterial and arterovenous reconstruction

BACKGROUND

Reports on vascular reconstruction in conjunction with limb salvage techniques for soft tissue sarcomas in the lower extremity have been published. The aim of this study was to investigate the necessity for venous reconstruction by comparing the results of arterial reconstruction alone and those of arteriovenous reconstruction.

METHODS

Twenty-five (6.7%) of 373 patients underwent vascular resections for lower limb soft tissue sarcomas. Only arterial reconstruction was performed for 12 patients. Arteriovenous reconstruction was performed for 13 patients. The clinical results, complications, and postoperative function were compared between only arterial reconstruction group and arteriovenous reconstruction group.

RESULTS

Limb salvage was achieved in 92% of all cases. No local recurrence has been observed. Nineteen patients (76%) are continuously free of disease. Histopathologic examination of the specimens showed that blood vessels had been infiltrated in 24%. The mean Musculoskeletal Tumor Society score was 70%. There were no significant differences in complication rate and postoperative function between two groups.

CONCLUSIONS

Wide resection with vascular reconstruction for patients of soft tissue sarcomas involving major vessels in the lower limb provide long term local control and limb salvage. This study could not indicate the usefulness of additional venous reconstruction after vascular resection in the lower extremity.

The surgical and functional outcome of limb-salvage surgery with vascular reconstruction for soft tissue sarcoma of the extremity

BACKGROUND

This study compared the surgical, oncological, and functional outcomes of patients undergoing limb-salvage surgery for extremity soft tissue sarcoma with vascular resection and reconstruction with the outcomes of those undergoing limb-salvage without vascular reconstruction.

METHODS

Nineteen patients were identified from a prospective soft-tissue sarcoma database who underwent vascular resection and reconstruction as part of their limb-salvage surgery and who were followed up for at least 1 year or until death. Each of these 19 patients was case-matched to 2 additional patients on the basis of tumor location, size, and depth; patient age; and timing of radiation. To compare functional outcome, a subset of patients was case-matched with additional criteria including wound-complication status, motor nerve sacrifice, similar preoperative function as determined by the Toronto Extremity Salvage Score, and no metastases at diagnosis or the 1-year follow-up.

RESULTS

Patients in the vascular reconstruction group were more likely to require a muscle transfer (53% vs. 18%; P = .008), experience a wound complication (68% vs. 32%; P = .03), experience deep venous thrombosis (26% vs. 0; P = .003), experience significant limb edema (87% vs. 20%; P = .001), and ultimately require an amputation (16% vs. 3%; P = .07). Patients who underwent vascular reconstruction had only slightly lower Toronto Extremity Salvage Score scores 1 year after surgery (78.5 vs. 84.2; P = .35). There were no significant differences in local or systemic tumor relapse between the two groups.

CONCLUSIONS

Vascular reconstruction is a feasible option in limb-salvage surgery for soft tissue sarcoma but is associated with an increased risk for postoperative complications, including amputation. Although function is not significantly worse after vascular reconstruction, the results are less predictable.

Local recurrence and survival in soft-tissue sarcomas

BACKGROUND

There is a continuous interest in the literature concerning the management and survival after treatment of local recurrence in sarcomas because it is one of the most common types of recurrence.

DESIGN

We retrospectively reviewed 93 patients treated for local recurrence from soft-tissue sarcoma.

METHODS

We evaluated prognostic parameters (grade, tumor size, location) and the effect of treatment on survival.

RESULTS

Resection of all the gross tumor at first visit to our Institute for local recurrence was accomplished in 88 patients (95%). Of the 59 patients with extremity tumors, six (10%) required an amputation. At a mean follow-up of 66 months, further local recurrence was noted in 27%. The estimated 5-year survival rate was 100% for patients with grade I tumors (n = 16), 77% for grade II (n = 31), and 45% for grade III tumors (n = 46) (p = 0.0002). This value was 78% for tumors < or = 5 cm and 57% for those > 5 cm (p = 0.03).

CONCLUSIONS

Local recurrence is resectable and limb preservation is possible in the majority of patients. The overall 5-year survival rate was 65%. Survival after treatment of local recurrence is determined mainly by the grade and secondarily by the size of the tumor as for primary sarcomas.

Resectability and survival in retroperitoneal sarcomas

BACKGROUND

Retroperitoneal sarcomas historically have presented difficulties in their management due to a high rate of unresectability, which affects the survival of these patients.

METHODS

We retrospectively reviewed the charts of 87 consecutive patients with retroperitoneal sarcomas treated in the period 1977-1994.

RESULTS

The resectability rate was 100% for the primary tumors (n = 55) and 87% for the locally recurrent tumors (n = 32). The 5-year survival rate was 63% (66% for the primary tumors and 57% for those with local recurrence). The 10-year survival rate was 46% (57% for primary tumors and 26% for those referred with locally recurrent tumor). The overall local recurrence rate was 31% (25% for the primary tumors and 41% for those referred with local recurrence); it was 56% after local excision and 15% after wide resection (p = 0.0003). The 10-year disease-free survival of patients with local excision (n = 25) was 7%, and that of patients with wide resection (n = 54) 59% (p = 0.0001).

CONCLUSIONS

The overall resectability rate of retroperitoneal sarcomas was 95%. Wide resection produced a significantly higher survival rate compared with that of local excision. The survival rate for the primary tumors, varying significantly with the histologic grade, approached the rate reported for primary soft-tissue sarcomas of the extremity.

Soft tissue sarcomas: preoperative versus postoperative radiotherapy

External beam radiation may be given either before or after excision of a primary soft tissue sarcoma. This study was undertaken to determine whether or not the timing of radiotherapy was associated with any difference in either local control, survival, or incidence of complications. The files of 112 patients with a primary, nonmetastatic, extremity soft tissue sarcoma, treated with limb salvage surgery and irradiation were evaluated. Data regarding tumor stage, grade, site, surgical margin, dosage and timing of radiotherapy, treatment complications, disease relapse, and relapse-free survival (RFS) were analyzed. Kaplan-Meier lifetable analysis was used to determine survival estimates. There was no significant difference in the 5-year RFS between patients receiving radiotherapy (RT) preoperatively versus postoperatively; 56 +/- 15% and 67 +/- 12% (P = 0.12, Mantel-Cox), respectively. There was no significant difference in the overall survival between patients receiving RT preoperatively versus postoperatively; 75 +/- 15% and 79 +/- 11% (P = 0.94), respectively. Actuarial local control at 5 years for preoperative versus postoperative RT patients was not statistically different; 83 +/- 12% versus 91 +/- 8% (P = 0.41), respectively. Wound complications were more frequent in preoperative RT patients (31%) compared to postoperative RT patients (8%) (P = 0.0014, chi-square). Preoperative irradiation was not associated with any benefit in terms of relapse-free survival, overall survival or actuarial local control in this series. A higher incidence of major wound complications was found among patients treated with preoperative irradiation. We recommend that patients with a resectable extremity soft tissue sarcoma be treated with postoperative irradiation, reserving preoperative irradiation for those situations in which either the tumor is initially thought to be unresectable or the original tumor boundaries are obscured.

Resectability of retroperitoneal sarcomas: a matter of surgical technique?

The management of retroperitoneal sarcomas has been hampered by the difficulty in complete resection, the resectability rate in the literature being about 53%. In a review of the last 88 consecutive patients with retroperitoneal sarcomas the resectability rate was 95%. At a mean follow-up of 48 months, the local recurrence rate was 17% following wide resection and 59% following local excision (P = 0.0002). For patients with minimum follow-up of 5 years, the local recurrence rate was 39% for those with primary tumours and 57% for those referred with local recurrence. Local recurrence diminished the rate of long-term survival. The 5- and 10-year survival rates for the primary retroperitoneal sarcomas (n = 55) were 66% and 57% and for those referred with locally recurrent sarcoma (n = 33) 57% and 26%, respectively. The 5-year survival rate varied significantly with the grade of the tumour, from 88% for Grade I to 44% for Grade III tumours (P = 0.006). In conclusion, with modern surgical techniques the resectability rate of retroperitoneal sarcomas is about 95%, and the survival rate of the primary tumours approximates that of the primary soft tissue sarcomas of the extremities.

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.

Primary soft tissue sarcoma of the extremities in adults

The modern literature on adult extremity sarcoma implies that adjuvant therapy (usually irradiation) is mandatory for adequate local control, at least in patients with high-grade tumours undergoing limb-sparing procedures. In 152 primary extremity soft tissue sarcomas, wide or radical resection was employed (116 patients) including amputation in nine patients (6 per cent), or local excision followed by adjuvant postoperative radiation therapy (36). Local recurrence alone occurred in 5 per cent of patients, and in combination with distant metastases in 9 per cent. The total rate of local recurrence was 10 per cent after wide resection (with or without chemotherapy) and 25 per cent after conservative resection and radiotherapy (with or without chemotherapy). Limb sparing was possible in 94 per cent of patients. The majority (76 per cent) had surgical resection alone as local treatment with satisfactory results. Wide resection, when feasible, provides acceptable local control and may be preferable to local excision plus radiation therapy.

Various types of hemipelvectomy for soft tissue sarcomas: complications, survival and prognostic factors

Fifty-three hemipelvectomies were performed for primary or recurrent soft tissue sarcomas with fixation to the pelvis or peripelvic tissues. Resection was carried out in the absence of distant metastases in 70% of the cases. The hemipelvectomy was posterior in 66%, anterior in 6% and internal in 28%. Post-operative complications included wound edge necrosis in 19% and infection in 43% of cases. The mortality rate was 5.7%. Margins were macroscopically clear in 76% and marginal in 24% of cases. Tumours were high grade in 92%; their mean diameter was 16.5 cm. Local recurrence occurred in 19% and distant recurrence in 66% of patients. Overall survival was 39% at 2 years and 10% at 5 years. Pelvic soft tissue sarcomas have a poor prognosis. However, in the absence of other effective therapy, hemipelvectomy provides local control with acceptable morbidity in the majority of patients, with a small percentage (10%) surviving 5 years or longer.

Preoperative radiation therapy and iododeoxyuridine for large retroperitoneal sarcomas

PURPOSE

Local failure is frequent after conventional therapy for patients with retroperitoneal sarcomas. A Phase I/II multimodality approach was used, combining iododeoxyuridine (IdUrd) and radiation therapy, followed by attempted surgical resection, with the goal of improving local control.

METHODS AND MATERIALS

Patients with retroperitoneal sarcomas were treated with three to five consecutive cycles of treatment. Each 14-day cycle consisted of a continuous intravenous infusion of IdUrd on days 1-5, twice a day radiation therapy (1.25 Gy/fraction) on days 8-12, and a break on day 13 and 14. Surgical resection was attempted after three or five cycles. Patients resected after three cycles received an additional two cycles of treatment with radiation directed to the tumor bed. IdUrd dose was escalated in Phase I fashion (1000 mg/m2/day, 1333 mg/m2/day, and 1600 mg/m2/day). The median potential follow-up was 31 months.

RESULTS

Sixteen patients (13 with high grade tumors) were treated. The median maximum tumor size was 17 cm. Resection margins were negative in four patients, microscopically positive in four patients, and grossly positive in three patients. Five patients were not resected. The only grade 4 acute toxicity observed was vomiting which occurred in three patients receiving upper abdominal radiation. Postsurgical and long-term complications were rare. Median survival overall and for resected patients were 18 and 32 months, respectively. Local control was observed in three out of four patients with negative margins (9, 40+, and 51+ months), two out of four patients with microscopically positive margins (4 and 22 months), and one out of three patients with grossly positive margins (46+ months). The overall freedom from local progression was 45% at 24 months.

CONCLUSION

Retroperitoneal sarcomas can be resected after preoperative radiation therapy and IdUrd, with encouraging local control in patients resected with negative or microscopically positive margins. The recommended dose using this drug and radiation schedule appears to be 1600 mg/m2/day, which will form the basis for a Phase II trial.

Clinical outcome after neoadjuvant thermoradiotherapy in high grade soft tissue sarcomas

In the treatment of soft tissue sarcomas, hyperthermia has been demonstrated to enhance tumor necrosis from radiation therapy. The current study reports the clinical course of patients treated with this neoadjuvant therapy regimen. Forty-four patients with deep, undisturbed, nonmetastatic, high grade soft tissue sarcomas completed a neoadjuvant treatment protocol with combined hyperthermia and radiation therapy followed by wide surgical resection. Negative surgical margins were obtained in 40 patients. There was one local recurrence, thus yielding a local control rate of 97.5%. All other failures were either through regional lymphatic spread or pulmonary metastasis. As a group, the patients at 36 months had a 72% overall and a 58% disease-free survival. The most common pathologic diagnosis was malignant fibrous histiocytoma (MFH), which demonstrated a 36-month survival of 52% vs. 82% for others (P = 0.02). Tumor size was not prognostically significant for disease free or overall survival (P = 0.13). Those patients with surgical margins < 1 cm had a significantly lower disease-free survival and overall survival in a multivariate analysis (P = 0.02 and P = 0.006, respectively). Overall survival did not correlate with either the number of hyperthermia treatments received or the amount of tumor necrosis. Although this neoadjuvant protocol results in excellent local control rates, overall survival rates are comparable to adjuvant therapy employing radiation alone.

Soft-Tissue Tumors: Diagnosis, Evaluation, and Management

Benign soft-tissue neoplasms and tumorlike conditions of the musculoskeletal system are common. Sarcomas are less frequent, with only 5,000 new cases diagnosed each year in the United States. After plain radiographs of the affected area have been obtained, magnetic resonance (MR) imaging (both T1- and T2-weighted sequences) is the best imaging modality for detecting and characterizing the lesion. Although MR imaging is not specific in determining whether lesions are benign or malignant, it can be useful in evaluating other characteristics, such as size, pattern of growth, integrity of natural boundaries, and homogeneity. Biopsy must be done carefully, so as not to adversely affect the outcome. Technical considerations include proper location and orientation of the biopsy incision, meticulous hemostasis, and frozen-section analysis to ensure that diagnostic material has been obtained. Effective treatment requires close coordination between the surgeon, the radiation oncologist, the pathologist, the plastic surgeon, and the diagnostic radiologist. Limb-salvage surgery has resulted in a local control rate greater than 90%. High-grade tumors that are larger than 5 cm in diameter have the worst prognosis. The role of chemotherapy remains controversial and unresolved.

Desmoid tumors of the trunk and extremity

BACKGROUND

Twenty-six patients with desmoid tumors of the extremities (n = 20) or trunk (n = 6) have been treated since 1977. Nine of these were referred with primary tumors and 17 with recurrent tumors.

METHODS

The tumor was removed in all patients, and 10 received adjuvant radiation. Five patients (19%) developed local recurrence; one of them was lost to follow-up, and the remaining four patients had the recurrence controlled with surgical resection or resection plus adjuvant radiation.

RESULTS

All 25 patients who have been followed are alive and disease-free at a mean follow-up of 84 months (median, 81 months). None with extremity tumors (n = 20) required an amputation. The estimated survival rate for the entire group is 95% at 42 months.

CONCLUSIONS

Desmoid tumor of the trunk or extremities treated with surgical resection, supplemented selectively by adjuvant radiation, can be controlled locally in the majority (96%) of patients.

Vascularized tissue transfer for closure of irradiated wounds after soft tissue sarcoma resection

During the years 1985 to 1989, 82 patients were included in the soft tissue sarcoma protocol. Preoperative irradiation (50-54 Gy) was performed in all patients before tumor extirpation. Microwave hyperthermia was performed in conjunction with radiation in patients who had gross tumor remaining after initial biopsy. Primary closure with vascularized tissue (flaps) in lieu of conventional wound closure by skin approximation led to less complications (19% versus 51%), fewer secondary procedures for wound closure (10% versus 35%), shorter average hospitalization (15 versus 48 days) and greater limb salvage rate (97% versus 91%). The authors conclude that vascularized tissue (flaps) for primary wound closure in irradiated tissue leads to improved wound healing, and should be considered the procedure of choice for heavily irradiated soft tissue sarcoma defects.

Comparison of amputation with limb-sparing operations for adult soft tissue sarcoma of the extremity

The use of amputation in extremity soft tissue sarcoma has been decreasing at Memorial Sloan-Kettering Cancer Center (MSKCC) over the last 15 years. In an attempt to define the efficacy and future role of amputation in extremity soft tissue sarcoma, a prospective sarcoma database compiled at MSKCC from July 1982 to January 1990, consisting of 649 patients, was analyzed in a retrospective fashion. Ninety-two patients underwent amputation, and 557 had a limb-sparing procedure. Patients selected for amputation were those who had large (T greater than or equal to 5 cm) high-grade tumors that invaded major vascular or nervous structures. The amputation group achieved significantly better local control than the limb-sparing group (p = 0.007). No survival benefit could be demonstrated, however, in the groups selected for amputation (i.e., large, high-grade tumors) when compared with patients undergoing a limb-sparing procedure with similar tumors. Prevention of local recurrence by amputation also did not improve survival in this group compared with similar patients undergoing limb-sparing surgery who did develop a local recurrence. The group of patients with high-grade tumors 10 cm or larger who received chemotherapy did have a significant improvement in survival (p = 0.01) compared with a similar group of patients who did not receive chemotherapy, regardless of the type of operation. The prognosis of patients most likely to undergo an amputation for extremity soft tissue sarcoma (those with high-grade, large tumors) is not related to their local disease, but rather to the risk of distant metastases. Therefore, amputation in this cohort of patients can be recommended only when a limb-sparing procedure cannot achieve gross resection of tumor while still preserving a useful extremity, because amputation improves only local control and does not address distant disease. Further improvement in survival in this group of patients will be dependent on better systemic treatment for extremity soft tissue sarcoma, and not on more radical surgery.