Factors predicting local recurrence, metastasis, and survival in pediatric soft tissue sarcoma in extremities

Optimizing Morbidity in Unplanned Soft Tissue Sarcoma Excisions: Should We Skip the Reconstructive Ladder?

INTRODUCTION

Soft tissue sarcomas (STSs) are rare and diverse primary malignant tumors that comprise approximately 1% of all malignancies. Misdiagnoses and unplanned excisions of STSs are common due to the tumor's rarity, leading to secondary tumor bed excisions (TBEs). Reconstructive outcomes for TBEs remain poorly understood, prompting this study to address the knowledge gap and inform preoperative discussions.

METHODS

This was a retrospective cohort study of patients who underwent STS excisions at a quaternary cancer center. Patients were categorized into mass excision (ME) and TBE groups. Reconstructive approaches were divided into simple (primary closure, complex repair, skin grafts, local flaps) and advanced (pedicled or free flaps). The groups were compared for postoperative outcomes, including complications, recurrence, and death.

RESULTS

When simple reconstructive techniques were used, TBEs exhibited higher rates of overall and major complications, whereas MEs had higher rates of overall and minor complications. Intergroup analysis revealed that with simple reconstruction, rates of overall and major complications were higher in TBEs than in MEs, and rates of minor complications were higher in MEs than in TBEs. Regression analyses revealed that simple reconstruction of TBEs had 90% and 180% higher odds of major complications and reoperation compared to simple reconstruction of MEs (P < 0.05).

CONCLUSION

TBEs, despite their smaller size, exhibited a heightened susceptibility to overall and major complications, challenging the notion that simpler techniques suffice in these cases. Our findings encourage the consideration of advanced reconstructive techniques for TBEs that may seem amenable to simple reconstructive techniques.

Intraoperative radiation therapy for pediatric sarcomas and other solid tumors

PURPOSE

To evaluate local failure (LF) and toxicity after intraoperative radiation therapy (IORT) in pediatric solid tumors (ST).

METHODS

A single-institution retrospective study of 96 pediatric patients (108 applications) with ST treated from 1995 to 2022 with IORT. LF was calculated via cumulative incidence function and overall survival (OS) by Kaplan-Meier method, both from the day of surgery.

RESULTS

Median age at time of IORT was 8 years (range: 0.8-20.9 years). Median follow-up for all patients and surviving patients was 16 months and 3 years, respectively. The most common histologies included rhabdomyosarcoma (n = 42), Ewing sarcoma (n = 10), and Wilms tumor (n = 9). Most (95%) received chemotherapy, 37% had prior external beam radiation therapy to the site of IORT, and 46% had a prior surgery for tumor resection. About half (54%) were treated with upfront IORT to the primary tumor due to difficult circumstances such as very young age or challenging anatomy. The median IORT dose was 12 Gy (range: 4-18 Gy), and median area treated was 24 cm2 (range: 2-198 cm2). The cumulative incidence of LF was 17% at 2 years and 23% at 5 years. Toxicity from IORT was reasonable, with postoperative complications likely related to IORT seen in 15 (16%) patients.

CONCLUSION

Our study represents the largest and most recent analysis of efficacy and safety of IORT in pediatric patients with ST. Less than one quarter of all patients failed locally with acceptable toxicities. Overall, IORT is an effective and safe technique to achieve local control in patients with challenging circumstances.

Effect of radiotherapy on local recurrence, distant metastasis and overall survival in 1200 extremity soft tissue sarcoma patients. Retrospective analysis using IPTW-adjusted models

BACKGROUND AND PURPOSE

Neoadjuvant (NRTX) and adjuvant radiotherapy (ARTX) reduce local recurrence (LR) risk in extremity soft tissue sarcoma (eSTS), yet their impact on distant metastasis (DM) and overall survival (OS) is less well defined. This study aimed at analysing the influence of NRTX/ARTX on all three endpoints using a retrospective, multicentre eSTS cohort.

MATERIALS AND METHODS

1200 patients (mean age: 60.7 ± 16.8 years; 44.4 % females) were retrospectively included, treated with limb sparing surgery and curative intent for localised, high grade (G2/3) eSTS. 194 (16.2 %), 790 (65.8 %), and 216 (18.0 %) patients had received NRTX, ARTX and no RTX, respectively. For the resulting three groups (no RTX vs. NRTX, no RTX vs. ARTX, NRTX vs. ARTX) Fine&Gray models for LR and DM, and Cox-regression models for OS were calculated, with IPTW-modelling adjusting for imbalances between groups.

RESULTS

In the IPTW-adjusted analysis, NRTX was associated with lower LR-risk in comparison to no RTX (SHR [subhazard ratio]: 0.236; p = 0.003), whilst no impact on DM-risk (p = 0.576) or OS (p = 1.000) was found. IPTW-weighted analysis for no RTX vs. ARTX revealed a significant positive association between ARTX and lower LR-risk (SHR: 0.479, p = 0.003), but again no impact on DM-risk (p = 0.363) or OS (p = 0.534). IPTW-weighted model for NRTX vs. ARTX showed significantly lower LR-risk for NRTX (SHR for ARTX: 3.433; p = 0.003) but no difference regarding DM-risk (p = 1.000) or OS (p = 0.639).

CONCLUSION

NRTX and ARTX are associated with lower LR-risk, but do not seem to affect DM-risk or OS. NRTX may be favoured over ARTX as our results indicate better local control rates.

Evaluation of the Effect of Photodynamic Therapy on CAM-Grown Sarcomas

Resection margin adequacy plays a critical role in the local control of sarcomas. Fluorescence-guided surgery has increased complete resection rates and local recurrence-free survival in several oncological disciplines. The purpose of this study was to determine whether sarcomas exhibit sufficient tumor fluorescence (photodynamic diagnosis (PDD)) after administration of 5-aminolevulinic acid (5-ALA) and whether photodynamic therapy (PDT) has an impact on tumor vitality in vivo. Sixteen primary cell cultures were derived from patient samples of 12 different sarcoma subtypes and transplanted onto the chorio-allantoic membrane (CAM) of chick embryos to generate 3-dimensional cell-derived xenografts (CDXs). After treatment with 5-ALA, the CDXs were incubated for another 4 h. Subsequently accumulated protoporphyrin IX (PPIX) was excited by blue light and the intensity of tumor fluorescence was analyzed. A subset of CDXs was exposed to red light and morphological changes of both CAMs and tumors were documented. Twenty-four hours after PDT, the tumors were excised and examined histologically. High rates of cell-derived engraftments on the CAM were achieved in all sarcoma subtypes and an intense PPIX fluorescence was observed. PDT of CDXs resulted in a disruption of tumor-feeding vessels and 52.4% of CDXs presented as regressive after PDT treatment, whereas control CDXs remained vital in all cases. Therefore, 5-ALA mediated PDD and PDT appear to be promising tools in defining sarcoma resection margins (PDD) and adjuvant treatment of the tumor bed (PDT).

Proton Therapy for Primary Bone Malignancy of the Pelvic and Lumbar Region - Data From the Prospective Registries ProReg and KiProReg

Purpose/Objective(s)

Multimodality treatments together with local proton therapy (PT) are commonly used in unresectable primary bone malignancies in order to provide better tumor control rate while maintaining good feasibility. The aim of this study is to provide data on outcome of PT for the challenging cohort of pelvic and lumbar bone tumors.

Methods and Materials

This retrospective study includes all patients with primary bone malignancy of the pelvis and lumbar spine receiving PT in our institution between May 2013 and December 2019 enrolled in the prospective registries KiProReg and ProReg collecting information on demographics, treatment, tumor characteristics, toxicities, and outcome.

Results

Eighty-one patients were enrolled with a median age of 19.7 years (1.3–85.8). The median follow-up time was 27.5 months (1.2–83.2). The majority of patients was male (64.2%), ECOG status of 0–1 (75.2%), underwent only biopsy (50.6%), received chemotherapy (69.1%) and was assigned for definite PT (70.4%). The predominant tumor characteristics were as follows: Ewing’s sarcoma histology (58%), negative nodal involvement (97.5%) and no metastasis at diagnosis (81.5%). Median maximal diameter of tumor was 8 cm (1.4–20). LC, EFS and OS rate were 76.5, 60, and 88.1% at two years and 72.9, 45.7, and 68.9% at three years, respectively. Age over 20 years was a significant negative factor for LC, EFS, and OS. Metastatic disease at initial diagnosis affected OS and ECOG status of 2–4 affected EFS only. Regarding 17 relapsed cases (21%), isolated distant relapse was the most common failure (46.9%) followed by local failure (40.6%). Eleven out of 14 evaluable patients relapsed within high-dose region of radiotherapy. Acute grade 3–4 toxicity was found in 41 patients (50.6%) and all toxicities were manageable. Late grade 3 toxicity was reported in 7 patients (10.4%) without any of grade 4. Most common higher grade acute and late side effects concerned hematologic and musculoskeletal toxicity.

Conclusion

Proton therapy resulted in good oncological outcomes when being part of the multimodality treatment for pelvic and lumbar primary bone malignancies. However, distant metastases and local failures within the high-dose region of radiotherapy are still a common issue. Acute and late toxicities of combined therapy were acceptable.

Score for the Risk and Overall Survival of Lung Metastasis in Patients First Diagnosed With Soft Tissue Sarcoma: A Novel Nomogram-Based Risk Assessment System

Background: Metastatic soft tissue sarcoma (STS) patients have a poor prognosis with a 3-year survival rate of 25%. About 30% of them present lung metastases (LM). This study aimed to construct 2 nomograms to predict the risk of LM and overall survival of STS patients with LM. Materials and Methods: The data of patients were derived from the Surveillance, Epidemiology, and End Results database during the period of 2010 to 2015. Logistic and Cox analysis was performed to determine the independent risk factors and prognostic factors of STS patients with LM, respectively. Afterward, 2 nomograms were, respectively, established based on these factors. The performance of the developed nomogram was evaluated with receiver operating characteristic curves, area under the curve (AUC) calibration curves, and decision curve analysis (DCA). Results: A total of 7643 patients with STS were included in this study. The independent predictors of LM in first-diagnosed STS patients were N stage, grade, histologic type, and tumor size. The independent prognostic factors for STS patients with LM were age, N stage, surgery, and chemotherapy. The AUCs of the diagnostic nomogram were 0.806 in the training set and 0.799 in the testing set. For the prognostic nomogram, the time-dependent AUC values of the training and testing set suggested a favorable performance and discrimination of the nomogram. The 1-, 2-, and 3-year AUC values were 0.698, 0.718, and 0.715 in the training set, and 0.669, 0.612, and 0717 in the testing set, respectively. Furthermore, for the 2 nomograms, calibration curves indicated satisfactory agreement between prediction and actual survival, and DCA indicated its clinical usefulness. Conclusion: In this study, grade, histology, N stage, and tumor size were identified as independent risk factors of LM in STS patients, age, chemotherapy surgery, and N stage were identified as independent prognostic factors of STS patients with LM, these developed nomograms may be an effective tool for accurately predicting the risk and prognosis of newly diagnosed patients with LM.

Impact of surgical margin on survival in extremity soft tissue sarcoma: A systematic review and meta-analysis

BACKGROUND

The impact of surgical margin status on the survival of patients with extremity soft tissue sarcoma (STS) remains to be clearly defined. The evidence regarding the impact of surgical margins on survival is limited by retrospective single-institution cohort studies. We conducted a systematic review and meta-analysis to examine the impact of surgical margin status on patient survival in extremity STS.

METHODS

A literature search in the PubMed, EMBASE, and Cochrane Controlled Trials Register electronic databases, and a manual search of reference lists of original studies was performed. The following text words and/or Medical Subject Heading terms were searched: (neoplasm) or/and (sarcoma) and/or (connective tissue) and/or (soft tissue) and/or (extremity) and/or (extremity) and/or (surgical margin).

RESULTS

Six selected studies that reported a total of 2917 cases of extremity STS were published between 1994 and 2013. All the eligible studies were observational cohort studies, and the sample size ranged from 95 to 1261 patients. A meta-analysis of 6 studies showed that a positive surgical margin predicted poor 5-year OS in a random-effects model (summary hazard ratio, 1.56; 95% confidence interval, 1.12-2.17). Moderate heterogeneity was observed among the studies (P < .075; heterogeneity, 45.6%).

CONCLUSIONS

This meta-analysis supports the hypothesis that adequate surgical margins are associated with improved survival in extremity STS.

A multi-institutional phase 2 trial of stereotactic body radiotherapy in the treatment of bone metastases in pediatric and young adult patients with sarcoma

BACKGROUND

Metastasectomy is standard of care for pediatric patients with metastatic sarcoma with limited disease. For patients with unresectable disease, stereotactic body radiotherapy (SBRT) may serve as an alternative. Herein, the authors report the results of a prospective, multi-institutional phase 2 trial of SBRT in children and young adults with metastatic sarcoma.

METHODS

Patients aged >3 years and ≤40 years with unresected, osseous metastatic nonrhabdomyosarcoma sarcomas of soft tissue and bone were eligible. Patients received SBRT to a dose of 40 Gray (Gy) in 5 fractions. Local control (LC), progression-free survival (PFS), and overall survival (OS) were calculated using the Kaplan-Meier method.

RESULTS

Fourteen patients with a median age of 17 years (range, 4-25 years) were treated to 37 distinct metastatic lesions. With a median follow-up of 6.8 months (30.5 months in surviving patients), the Kaplan-Meier patient-specific and lesion-specific LC rates at 6 months were 89% and 95%, respectively. The median PFS was 6 months and the median OS was 24 months. In a post hoc analysis, PFS (median, 9.3 months vs 3.7 months; log-rank P = .03) and OS (median not reached vs 12.7 months; log-rank P = .02) were improved when all known sites of metastatic disease were consolidated with SBRT compared with partial consolidation. SBRT was well tolerated, with 2 patients experiencing grade 3 toxicities.

CONCLUSIONS

SBRT achieved high rates of LC in pediatric patients with inoperable metastatic nonrhabdomyosarcoma sarcomas of soft tissue and bone. These results suggest that the ability to achieve total consolidation of metastatic disease with SBRT is associated with improved PFS and OS.

PROGNOSTIC FACTORS IN PATIENTS WITH APPENDICULAR MYXOFIBROSARCOMA

Objective

Myxofibrosarcoma (MFS) is a common soft tissue sarcoma (STS) that affects the extremities in elderly patients. The objective was to analyze the prognostic factors and outcomes of patients with MFS treated at a single institution.

Methods

We retrospectively reviewed the records of 75 patients with MFS. We compared age, sex, tumor size and location, grade and stage of the disease. Median age was 49.7 years (range, 1 to 88 y).

Location

upper extremity (25.4%), lower extremity (66.6%) and pelvis (8%). Patients had high-grade tumors in 46.7% of the reports. Margins were negative in 76% of the cases. Bivariate Cox regression analysis was used to determine associations between clinical and treatment factors with local recurrence (LR).

Results

Median follow-up time was 30.7 months (range, 1.8 to 383.8 m). We found 26.7% of LR. Distant metastasis (DM) was reported in 27 (36%) patients. Lung was the most common site of DM, reported in 92.6% of patients. Overall survival (OS) with metastasis was 21.2 months (range, 4.8 to 114.8 m). Predictors of OS were grade, LR (hazard ratio [HR] 5.13, 95% confidence interval, 2.15-12.24, P <0.001), and DM (HR 540.97, 95% confidence interval, 5.04-58112.03, P< 0.001).

Conclusions

Tumor grade, LR, positive margins and DM were significant predictors of poor OS prognosis. Level of Evidence IV, Case Series.

Interstitial brachytherapy for pediatric soft tissue sarcoma: Evolving practice over three decades and long-term outcomes

PURPOSE

Evaluate long-term clinical outcomes, adverse effects, and evolving practice of interstitial brachytherapy (BT) for pediatric soft tissue sarcomas (STS).

METHODS

From September 1984 to December 2014, 105 children (median age 10 years) were included. There were 60 males and 45 females. The majority (74%) had primary lesions. Synovial sarcoma (22%) was the most frequent histology. Treatment included wide local excision and BT with or without external beam radiotherapy (EBRT). Eighty-five (81%) received BT alone.

RESULTS

After a median follow-up of 65 months, local control (LC), disease-free survival (DFS), and overall survival (OS) at 10 years were 83, 66, and 73%, respectively. On univariate analysis, LC was superior with tumors <5 cm versus >5 cm (93% vs. 75%, P = 0.10), Grade I/II versus Grade III tumors (97% vs. 73%, P = 0.01), nonround cell versus round cell histology (89% vs. 72%, P = 0.03), and trunk/extremity versus head and neck/genitourinary sites (87% vs. 57%, P = 0.0001). On multivariate analysis tumor size (P = 0.03) and location (P = 0.002) retained significance. Children receiving BT alone had comparable LC to those receiving BT and EBRT (84% vs. 80%, P = 0.43). There was no difference in LC between LDR versus HDR BT (86% vs. 83%, P = 0.30). Wound complications were seen in 6%. Subcutaneous fibrosis (25%), limb edema (6%), skeletal abnormalities (3%), and neuropathy (1%) were the late complications. One child (0.9%) developed a second malignancy after 7 years.

CONCLUSION

Interstitial BT with or without EBRT results in excellent outcomes. Radical BT alone, when used judiciously, results in excellent local control and function with minimal treatment-related morbidity.

Conditional survival of pediatric, adolescent, and young adult soft tissue sarcoma and bone tumor patients

BACKGROUND

Survival estimates for soft tissue sarcomas (STS) and malignant bone tumors (BT) diagnosed in pediatric, adolescent, and young adult patients are not easily available. We present survival estimates based on a patient having survived a defined period of time (conditional survival). Conditional survival estimates for the short-term were calculated for patients from diagnosis to the first five years after diagnosis and for patients surviving in the long-term (up to 20 years after diagnosis).

METHODS

We identified 703 patients who were diagnosed with a STS or BT at age ≤25 years from January 1, 1986 to December 31, 2012 at a large pediatric oncology center in Salt Lake City, Utah, United States. We obtained cancer type, age at diagnosis, primary site, and demographic data from medical records, and vital status through the National Death Index. Cancer stage was available for a subset of the cohort through the Utah Cancer Registry. Cox proportional hazards models, adjusted for age and sex, calculated survival estimates for all analyses.

RESULTS

Short-term survival improves over time for both sarcomas. Short-term survival for STS from diagnosis (Year 0) did not differ by sex, but short-term survival starting from 1-year post diagnosis was significantly worse for male patients (Survival probability 1-year post-diagnosis [SP1]:77% [95% CI:71-83]) than female patients (SP1:86% [81-92]). Survival for patients who were diagnosed at age ≤10 years (Survival probability at diagnosis [SP0]:85% [79-91]) compared to diagnosis at ages 16-25 years (SP0:67% [59-75]) was significantly better at all time-points from diagnosis to 5-years post-diagnosis. Survival for axial sites (SP0:69% [63-75]) compared to extremities (SP0:84% [79-90]) was significantly worse from diagnosis to 1-year post-diagnosis. Survival for axial BT (SP0: 64% [54-74] was significantly worse than BT in the extremities (SP0:73% [68-79]) from diagnosis to 3-years post diagnosis. Relapsed patients of both sarcoma types had significantly worse short-term survival than non-relapsed patients. Long-term survival for STS in this cohort is 65% at diagnosis, and improves to 86% 5-years post-diagnosis. BT survival improves from 51% at diagnosis to 78% at 5-years post-diagnosis.

CONCLUSION

Conditional survival for short- and long-term STS and BT improve as time from diagnosis increases. Short-term survival was significantly affected by patients' sex, age at diagnosis, cancer site, and relapse status.

Unplanned Resection of Sarcoma

Unplanned resection is a common problem in the management of sarcoma. Because sarcomas are so rare, they may be misdiagnosed initially as more common benign lesions. When the treating surgeon is unaware of or does not adhere to proper surgical principles of orthopaedic oncology, an intralesional procedure may be performed without the requisite preoperative imaging, staging, or wide resection margins for optimal management of sarcoma. Studies show that oncologic outcomes after unplanned resections are mixed; however, surgical outcomes drastically deteriorate. Failure to adhere to oncologic principles accounts for increased morbidity and amputation rates with re-resection. No diagnostic modality has been proven to accurately predict residual disease in the resection bed following unplanned resection. Thus, repeat surgery with or without adjuvant treatment is usually offered to these patients, thereby adding considerable cost and morbidity. Medical malpractice litigation associated with unplanned sarcoma resection is common, with delayed diagnosis and unnecessary amputation most often cited in cases decided in favor of the plaintiff.

Soft tissue masses for the general orthopedic surgeon

Soft tissue sarcomas are a rare, heterogeneous group of malignancies that should be included in the differential diagnosis for any patient presenting with a soft tissue mass. This article reviews strategies for differentiating between benign and malignant soft tissue masses. Epidemiology, appropriate workup, and treatment of soft tissue sarcomas are reviewed.

Primary flap reconstruction of tissue defects after sarcoma surgery enables curative treatment with acceptable functional results: a 7-year review

Background

Sarcomas, a heterogeneous group of tumors, are challenging to treat and require multidisciplinary cooperation and planning. We analyzed the efficacy of flap reconstruction in patients with bone and soft tissue sarcoma.

Methods

Patient charts and operative records were retrospectively reviewed from January 2006 through October 2013 to identify sarcoma patient characteristics, postoperative complications, revisions, recurrences, and survival. Pedicled and/or free flap reconstruction was performed in 109 patients. Flap selection was based on defect size, and exposure of anatomically critical structures or major orthopedic implants.

Results

Of 109 patients, 71 (65.1 %) were men, and mean age was 56.4 years. Tumors most frequently located in a lower extremity (38.7 %). Primary sarcomas comprised 79.2 % and recurrences occurred in 18.9 %. Wide resection was performed for 65.7 %, and there were 10 planned amputations combined with flap reconstruction. A total of 111 tumors received 128 flaps: 76 pedicled flaps, 42 free flaps, and 5 combined (10 total) pedicled + free-flaps. The success rate was 94 % for the pedicled flap group, 97 % for the free-flap group, and 100 % for the pedicle + free-flap group. Of 35 patients, 5 developed deep prosthetic infections. Only one amputation due to disease progression was performed. Satisfactory functional outcome was achieved in 69 %. Survival rate during a mean (standard deviation) 3(2) year follow-up was 83.5 %.

Conclusions

Primary flap reconstruction after sarcoma surgery satisfies oncologic goals. Large tumors in difficult areas can be removed and complete tumor resection achieved. Our findings indicate a high survival rate after sarcoma surgery utilizing flap reconstruction and a low recurrence rate.

The effect of the setting of a positive surgical margin in soft tissue sarcoma

BACKGROUND

The objectives of this study were to evaluate the risk of local recurrence and survival after soft tissue sarcoma (STS) resection with positive margins and to evaluate the safety of sparing adjacent critical structures.

METHODS

One hundred sixty-nine patients with localized STS who had positive resection margins were identified from a prospective database. Patients who had positive margins were stratified into 3 groups, each representing a specific clinical scenario: critical structure positive margin (eg major nerve, vessel, or bone), tumor bed resection positive margin, and unexpected positive margin. The rates of local recurrence-free survival (LRFS) and cause-specific survival (CSS) were calculated and compared with relevant control patients who had negative margins after STS resection.

RESULTS

After planned close dissection to preserve critical structures, the 5-year LRFS and CSS rates both depended on the quality of the surgical margins (97% and 80.3%, respectively, for those with negative margins vs 85.4% and 59.4%, respectively, for those with positive margins; P = .015 and P = .05, respectively). Negative margins achieved through resection of critical structures because of tumor invasion or encasement only slightly improved the 5-year rates of LRFS (91.2%) and CSS (63.6%; P = .8 and P = .9, respectively). The lowest 5-year LRFS and CSS rates were 63.4% and 59.2%, respectively, after an unexpected positive margin during primary surgery.

CONCLUSIONS

After patients undergo resection of STS with positive margins, oncologic outcomes can be predicted based on the clinical context. Sparing adjacent critical structures in this setting is safe and contributes to improved functional outcomes.

Endoprosthetic reconstruction for large extremity soft-tissue sarcoma with juxta-articular bone involvement: functional and survival outcome

BACKGROUND

Large extracompartmental limb soft-tissue sarcoma with juxta-articular bone involvement poses major challenges in disease management. Radical resection of sarcoma frequently requires concomitant bone resection and reconstruction. We describe the clinical outcomes of endoprosthetic reconstruction and the complications associated with this procedure.

METHODS

Thirty patients with soft-tissue sarcomas with local juxta-articular bone involvement in an extremity underwent surgery at our center between May 2004 and October 2011, 20 for primary sarcomas and 10 for local recurrences. Clinical data from those patients were analyzed retrospectively. The bone affected included the proximal femur (10 cases), the distal femur (nine cases), the proximal humerus (eight cases), the proximal tibia (two cases), or the total femur (one case). Wide excision of the tumor and the bone tissue involved was performed on every patient, followed by reconstruction of the subsequent defect using tumor endoprosthesis. All patients underwent regular follow-up for an average of 25 (range, 3-84) mo.

RESULTS

Three patients had poor wound healing. Implant fractures leading to additional revisions occurred in two cases. Local tumor recurrence developed in four patients. There were 15 patients with lung metastases, and 11 patients died of disseminated metastases. In the latest follow-up, 14 patients survived free of disease and five were alive with tumors. The mean Musculoskeletal Tumor Society functional analysis for proximal femur, distal femur, proximal tibia, proximal humerus, and total femur were 90%, 82%, 73%, 71%, and 60%, respectively. The 2- and 5- y survival rates were 61.6% and 30.0%, respectively.

CONCLUSIONS

Endoprosthetic reconstruction could yield satisfactory results as a wide excision and limb salvage therapeutic strategy for patients with large extracompartmental soft-tissue sarcomas with juxta-articular bone involvement. Acceptable complications occurred in the present report.

What are risk factors for local recurrence of deep high-grade soft-tissue sarcomas?

BACKGROUND

Patients with local recurrence of soft-tissue sarcomas have a poor overall survival. High-grade, soft-tissue sarcomas in deep locations may have a poorer prognosis regarding local recurrence than low-grade sarcomas or those located superficially. Although previous reports evaluated tumors at various depths, it is unclear what factors influence recurrence of deep, high-grade sarcomas.

QUESTIONS/PURPOSES

We therefore determined whether possible risk factors (tumor size, location, histologic subtype, unplanned excision, local recurrence at presentation, metastasis at diagnosis, surgical procedure, surgical margin, and adjuvant treatments) influenced local recurrence of deep, high-grade, soft-tissue sarcomas.

PATIENTS AND METHODS

We retrospectively reviewed 433 patients with deep, high-grade, soft-tissue sarcomas surgically treated between 1985 and 2005. For each patient, we reviewed tumor size, location, histologic subtype, unplanned excision, local recurrence at presentation, metastasis at diagnosis, surgical procedure, surgical margin, and adjuvant treatments and determined the effect of each prognostic variable on local recurrence. The minimum followup was 1 month (median, 51 months; range, 1-305 months).

RESULTS

Forty-seven patients had local recurrence at a median of 10.7 months. Local recurrence at presentation, metastasis at diagnosis, and positive margins independently predicted local recurrence. No other factors independently predicted local recurrence.

CONCLUSIONS

Unplanned excisions did not increase the rate of local recurrence of deep, high-grade, soft-tissue sarcomas if treated appropriately. Aggressiveness of tumor represented by metastasis or local recurrence at presentation may be a risk for local recurrence.

LEVEL OF EVIDENCE

Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.