Management of extremity soft-tissue sarcoma

Willingness of patients with sarcoma to participate in cancer surveillance research: a cross-sectional patient survey

OBJECTIVES

To determine the proportion of patients with extremity sarcoma who would be willing to participate in a clinical trial in which they would be randomised to one of four different postoperative sarcoma surveillance regimens. Additionally, we assessed patients' perspectives on the burden of cancer care, factors that influence comfort with randomisation and the importance of cancer research.

DESIGN

Prospective, cross-sectional patient survey.

SETTING

Outpatient sarcoma clinics in Canada, the USA and Spain between May 2017 and April 2020. Survey data were entered into a study-specific database.

PARTICIPANTS

Patients with extremity sarcoma who had completed definitive treatment from seven clinics across Canada, the USA and Spain.

MAIN OUTCOME MEASURES

The proportion of patients with extremity sarcoma who would be willing to participate in a randomised controlled trial (RCT) that evaluates varying postoperative cancer surveillance regimens.

RESULTS

One hundred thirty complete surveys were obtained. Respondents reported a wide range of burdens related to clinical care and surveillance. The majority of patients (85.5%) responded that they would agree to participate in a cancer surveillance RCT if eligible. The most common reason to participate was that they wanted to help future patients. Those that would decline to participate most commonly reported that participating in research would be too much of a burden for them at a time when they are already feeling overwhelmed. However, most patients agreed that cancer research will help doctors better understand and treat cancer.

CONCLUSIONS

These results demonstrate that most participants would be willing to participate in an RCT that evaluates varying postoperative cancer surveillance regimens. Participants' motivation for trial participation included altruistic reasons to help future patients and deterrents to trial participation included the overwhelming burden of a cancer diagnosis. These results will help inform the development of patient-centred RCT protocols in sarcoma surveillance research.

LEVEL OF EVIDENCE

V.

Malignant bone tumours of the foot

Introduction Malignant osseous foot tumours are uncommon. Their oncological outcomes have been poorly documented in the literature so far. The aim of this study was to establish the incidence and to evaluate the oncological outcomes of such patients. Methods Our large orthopaedic oncology database was used to review 70 malignant osseous foot tumour patients. Results The age at diagnosis of malignant osseous foot tumours demonstrated a bimodal distribution peaking in the second and eighth decades of life. Overall, 55 primary malignant bone tumours of the foot (79%) were identified. The median duration from onset of symptoms to diagnosis was 52 weeks (interquartile range [IQR]: 17-104). Eight primary tumours (15%) underwent an accidental excision (ie intralesional excision of a malignant bone tumour where some of the tumour has been left behind, also known as a 'whoops procedure') prior to referral to our unit. Forty-six patients (84%) underwent surgery overall and thirteen of these developed recurrence or metastases. Seven of eight patients with a previous accidental excision underwent amputation. Fifteen osseous metastatic foot lesions were identified. The median length of foot symptoms to diagnosis was 24 weeks (IQR: 20-36 weeks). The median time to death following diagnosis of osseous foot metastases was 20.1 months (IQR: 11.3-27.8 months). Conclusions A high index of suspicion and awareness of clinical features of malignant osseous foot tumours are both essential to avoid diagnostic delays. Amputation is associated with a respectable outcome for patients who have undergone previous accidental excisions.

Incidence and Treatment Pattern of Extremity Soft Tissue Sarcoma in Korea, 2009-2011: A Nationwide Study Based on the Health Insurance Review and Assessment Service Database

Purpose

We conducted a nationwide study to assess the incidence and treatment patterns of extremity soft tissue sarcoma (STS) in South Korea.

Materials and Methods

The nationwide incidence and treatment patterns of extremity STS were assessed using two nationwide databases, the Korea National Cancer Incidence (KNCI) database and the Health Insurance Review and Assessment Service (HIRA) database.

Results

A total of 1,236 patients were newly diagnosed with extremity STS during the 3-year study period, from 2009 to 2011. The annual incidence of extremity STS in the Korean population was approximately 0.9 per 100,000 people with a male bias that increased with age and was especially pronounced amongst individuals aged > 80 years. Approximately 7% of patients did not receive any treatment, and surgical excision was performed for 85% of those who were treated.

Conclusion

This is the first nationwide study of the incidence and treatment patterns of extremity STS in Korea using two national databases (KNCI and HIRA), which include the entire Korean population. The results of this study may be useful for future planning and management of STS, at the national level.

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.

The influence of pulmonary metastasectomy on survival in osteosarcoma and soft-tissue sarcomas: a retrospective analysis of survival outcomes, hospitalizations and requirements of home oxygen therapy

OBJECTIVES

Pulmonary metastasectomy for sarcoma is a widely accepted practice. Nevertheless, no previous studies has been reported the outcomes following metastasectomy compared with chemotherapy for patients with resectable and isolated pulmonary metastases. Our aim is to compare these modalities for the subset of patients with resectable metastases. Furthermore, the outcomes for patients with unresectable lung metastases are reported.

METHODS

Sarcoma patients with isolated lung metastases were identified and their computed axial tomography scans were reviewed by a thoracic surgeons' committee. Patients were divided into three groups: A: patients with resectable metastases treated with metastasectomy (n=29), B: patients with resectable metastases who received systemic therapy (n=17) and C: patients with unresectable metastases (n=25). Survival outcomes were plotted and compared through log-rank test for osteosarcoma and non-osteosarcoma patients.

RESULTS

Seventy-one patients (32 with osteosarcoma and 39 with non-osteosarcoma) were eligible. Progression-free survival (PFS) was superior in patients who belonged to Group A compared with Groups B and C (8.0, 4.3 and 2.2 months, respectively, P=0.0002). Furthermore, overall survival (OS) was superior in patients who belonged to Group A compared with Groups B and C (39.6, 20.0 and 7.8 months, respectively, P<0.0001). A subanalysis for osteosarcoma patients showed superior PFS and OS for Group A vs B (median PFS 21.6 and 3.65 months, respectively, P=0.011 and median OS 34.0 and 12.4 months, respectively, P=0.0044). For non-osteosarcoma patients, there were no such significant survival differences between Groups A and B. Overall, patients who belonged to Group A had significantly lower mean percentage of their follow-up time spent admitted at hospital, and a trend towards lower requirements for home oxygen therapy.

CONCLUSIONS

Pulmonary metastasectomy is associated with improved survival of osteosarcoma patients with resectable lung metastases. For non-osteosarcoma patients, the survival benefit of metastasectomy over chemotherapy is uncertain and warrants further evaluation. Patients with unresectable metastases have poor prognosis.

Repeated and aggressive pulmonary resections for leiomyosarcoma metastases extends survival

BACKGROUND

Sarcoma frequently metastasizes to the lungs, and pulmonary metastasectomy is the only treatment modality that can provide a cure for these patients. We attempted to determine the clinicopathologic features and survival determinants of a common subset of patients who undergo pulmonary metastasectomy for leiomyosarcoma.

METHODS

All patients undergoing pulmonary metastasectomy at The Brigham and Women's Hospital from 1989 to 2004 were reviewed retrospectively. Analyzed variables included number, size, pathology, and location of metastases, age, gender, location of primary tumor, disease-free interval (DFI), surgical approach, margin status, adjuvant therapy, recurrence, number of metastasectomies, and disease-free and overall survival.

RESULTS

Eighty-two patients underwent pulmonary metastasectomy for metastases from sarcoma. Leiomyosarcoma was the most common histologic finding (n = 31; 38%). Fifteen patients with leiomyosarcoma (48%) underwent repeated pulmonary metastasectomy. Patients with leiomyosarcoma were more commonly female (77% versus 43%; p = 0.031), less frequently received chemotherapy for their primary tumor (48% versus 71%, p = 0.041), and presented with fewer number of pulmonary metastases than did patients with nonleiomyosarcoma metastases (1.9 ± 1.5 standard deviation [SD] versus 3.6 ± 4.4; p = 0.033). Although there was no difference in disease-free survival, patients with leiomyosarcoma demonstrated improved overall survival compared with those with nonleiomyosarcoma metastases (70 versus 24 months; p = 0.049). In multivariate analyses, the DFI from primary tumor resection to pulmonary metastases and the DFI from pulmonary metastasectomy to second pulmonary recurrence were identified as independent predictors of survival.

CONCLUSIONS

Leiomyosarcoma is a common subset of sarcomatous pulmonary metastases that behave more indolently compared with other pulmonary metastases from sarcoma. Long-term survival is achievable with an aggressive approach toward pulmonary metastasectomy and repeated pulmonary metastasectomy.

Soft tissue sarcoma of the hand or foot: conservative surgery and radiotherapy

Purpose. Conservative treatment in the form of limited surgery and post-operative radiotherapy is controversial in hand and foot sarcomas, both due to poor radiation tolerance of the palm and sole, and due to technical difficulties in achieving adequate margins.This paper describes the local control and survival of 41 patients with soft tissue sarcoma of the hand or foot treated with conservative surgery and radiotherapy. The acute and late toxicity of megavoltage radiotherapy to the hand and foot are described. The technical issues and details of treatment delivery are discussed. The factors influencing local control after radiotherapy are analysed.

Subjects . Eighteen patients had sarcomas of the hand and 23 of the foot. All patients received post-operative radiotherapy, the majority receiving a dose of 60 Gy in 2-Gy daily fractions using a two-phase treatment.

Results . The acute and late toxicity of treatment were within acceptable limits. The actuarial 5-year overall survival of the whole patient group was 67.6% and the local relapse-free survival was 44%.The local control was similar in tumours of hand and foot, and in patients treated at first presentation or relapse.

Discussion. Post-operative radiotherapy to the hand or foot appears to be a well tolerated treatment resulting in long-term local control in a significant proportion of patients. The increased frequency of recurrence within the high-dose volume suggests the need for the use of higher total doses of radiotherapy.

Analysis of lung metastases in patients with primary extremity sarcoma

Purpose: To investigate the incidence, radiographic findings, and the time course for the appearence of lung metastases from primary extremity sarcoma.

Patients and methods: Four-hundred patients with extremity sarcoma were evaluated retrospectively for lung metastases. Multiple clinical factors were analyzed for possible influence on the metastases-free interval and subsequent metastases development. Radiographic findings of metastases were also reviewed.

Results: Ninety of 400 patients (23%) developed lung metastases. Median time from presentation to detection of metastasis was 8.0 ± 1.1 months (95% CI: 6.02–9.98). More than 75% of patients developed metastases within 1 year after presentation of the primary sarcoma. As disease grade increased, the metastases-free intervals shortened significantly. Histologically, synoviosarcoma and osteogenic sarcoma were more often associated with the development of lung metastases. In this subgroup, 54 patients (60%), the presence of solitary (11) or multiple (43) nodular metastases was the only radiological finding. In 36 of 90 patients (40%), parenchymal mass, pleural effusion, hilar lymphadenopathy and pneumothorax were found.

Conclusions: Twenty-three percent of patients in our study developed lung metastases. As the grade of the disease increased, metastases-free intervals are shortened. Although it has been reported that lung metastases in patients with extremity sarcomas may present as solitary or multiple nodules in earlier trials with radiographic screening methods, the current review of 400 patients found that a substantial number of patients may present radiological appearances other than nodular formations.

Surgical outcomes for liposarcoma of the lower limbs with synchronous pulmonary metastases

BACKGROUND AND OBJECTIVES

Surgical resection of pulmonary metastases from soft tissues sarcomas has typically yielded disparate results, owing to the histologic heterogeneity of various series and the presentation times relative to primary tumor discovery. It was our hypothesis that with expeditious, curative surgical resection of both, primary and metastatic disease, patients with liposarcoma of the lower limb and synchronous, resectable, pulmonary metastases might achieve satisfactory outcomes.

METHODS

A consecutive sample clinical study, with a mean follow-up duration of 30 months. Twenty-two patients (mean age, 50 years), each presenting with a liposarcoma of the lower limb and synchronous, resectable, pulmonary metastases, underwent curative resection of both the primary mass and all pulmonary metastases within a mean of 18 days from presentation (range 9-32 days).

RESULTS

Mean overall survival was 28 months, disease-related survival (SE) was 9% at 5 years (±9.7%), and disease-free survival was 9% at 5 years (±7.6%).

CONCLUSION

Expeditious, curative resection of both--primary and metastatic lesions--yields acceptable near-term results, with potential for long-term survival, in patients with liposarcoma of the lower limb and synchronous pulmonary metastases.

Pulmonary metastasectomy from soft tissue sarcomas

INTRODUCTION

Isolated pulmonary metastases from soft tissue sarcomas occur in 20-50% of these(the issue is about metastases, not lung cancer )patients, and 70% of these patients will present disease limited only to the lungs. Surgical resection is well accepted as a standard approach to treat metastases from soft tissue sarcomas isolated in the lungs, and many studies investigating this technique have reported an overall 5-year survival ranging from 30-40%. The most consistent predictor of survival in these patients is complete resection. The aim of the present study was to determine the demographics and clinical treatment-related variables associated with long-term (90-month) overall survival in patients with lung metastases undergoing pulmonary metastasectomy from soft tissue sarcomas.

METHODS

We performed a retrospective review of patients admitted in the Thoracic Surgery Department with lung metastases who underwent thoracotomy for resection following treatment of the primary tumor. Data regarding primary tumor features, demographics, treatment, and outcome were collected.

RESULTS

One hundred twenty-two thoracotomies and 273 nodules were resected from 77 patients with previously treated soft tissue sarcomas. The median follow-up time of all patients was 36.7 months (range: 10-138 months). The postoperative complication rate was 9.1%, and the 30-day mortality rate was 0%. The 90-month overall survival rate for all patients was 34.7%. Multivariate analysis identified the following independent prognostic factors for overall survival: the number of metastases resected, the disease-free interval, and the number of complete resections.

CONCLUSION

These results confirm that lung metastasectomy is a safe and potentially curative procedure for patients with treated primary tumors. A select group of patients can achieve long-term survival after lung resection.

Superficial soft tissue sarcomas of the extremities and trunk

BACKGROUND

Superficial soft tissue sarcomas (sSTS) are an important and frequent subtype of soft tissue sarcoma (STS). A wider knowledge of this tumor type may lead to better strategies in tumor therapy.

METHODS

An institutional review was performed on all patients with primary sSTS of the extremities and trunk operated on between 1990 and 2003.

RESULTS

The medical records of 108 patients with sSTS were analyzed. The local recurrence rate was 11% after a median of 25 (mean 42) months. Metastases occurred in 21 patients (19%), and 79 patients lived without evidence of disease after a mean follow-up of 112 +/- 42 months. Mean survival time was 89 months at a cumulative 5-year survival rate of 85%. R0 resection significantly enhanced cumulative survival (p = .001), as did patient age < 60 years (p = .002), tumor grading G1 and G2 compared to G3 (p = .004), absence of positive lymph nodes (p = .018), and no occurrence of metastases (p = .001). Tumor size < or = 5 cm reduced the local recurrence rate significantly (p = .044). Significant multivariate risk factors for metastases were age > or = 60 years (p = .016) and tumor grade G3 (p = .021).

CONCLUSIONS

Patients with sSTS who are > or = 60 years of age or who have G3 tumors have a high risk of distant metastases. Patients with T2 tumors have an elevated risk for local recurrence. Certainly all patients with sSTS should be in a tight after-care program to allow early diagnosis of local recurrence or distant metastases. Age < 60 years, tumor grade G1/2, no positive regional lymph nodes (N0), and a R0 resection are significant prognostic factors for survival.

Reconstructive treatment following resection of high-grade soft-tissue sarcomas of the lower limb

PURPOSE

To review the role of free tissue transfer in reconstructive surgery following resection of high-grade soft-tissue sarcomas of the lower limb.

METHODS

Medical records of all consecutive patients with high-grade soft-tissue sarcomas of the lower limbs between August 1997 and September 2003 were reviewed.

RESULTS

Of 8 patients (6 women and 2 men) aged between 19 and 65 years, 4 had malignant fibrous histiocytoma, one had malignant peripheral nerve sheath tumour, one had synovial sarcoma, one had recurrent liposarcoma, and one had epitheloid sarcoma. The tumour sizes ranged from 132 cm(2) to 483 cm(2). The soft-tissue defects following tumour extirpation ranged from 153 cm(2) to 896 cm(2). The flaps used were 3 free latissimus dorsi flaps, 2 free osteoseptocutaneous fibula flaps (one vascularised fibula flap and one 'double barrel' fibula flap), one free rectus abdominis flap, 2 free mini-transverse rectus abdominis flaps, and one pedicled rectus abdominis flap. Five patients did not have local recurrence and systemic metastases.

CONCLUSION

Tissue transfer allows early adjuvant therapy facilitating the multimodal approach for the high-grade soft-tissue sarcomas of the lower extremity.

The Indications for and the Prognostic Significance of Amputation as the Primary Surgical Procedure for Localized Soft Tissue Sarcoma of the Extremity

BACKGROUND

The indications for primary amputation of a localized soft tissue sarcoma (STS) of the extremity are not well defined in the literature. However, it has been suggested that patients who require an amputation to treat an STS are at increased risk for developing metastases. We categorized the main indications for primary amputation in our patient population and compared their oncological outcome with the outcome of patients who underwent limb-sparing surgery.

METHODS

413 consecutive patients treated surgically at a single center for primary, nonmetastatic, deep, intermediate-, or high-grade STS of the extremity were reviewed. Indications for primary amputation were identified. Demographics and outcomes were compared between the amputation and limb-salvage groups. Multivariate Cox model analysis was used to identify independent risk factors for systemic relapse.

RESULTS

Twenty-five (6%) of 413 patients with STS underwent primary amputation: they were older (P = .05), had larger tumors (P = .001), and had a significantly greater risk of developing metastatic disease than patients who underwent limb-sparing procedures (P = .008). However, multivariate analysis demonstrated that the only independent predictors of systemic relapse were tumor size (P = .0001) and tumor grade (P = .0001). Primary amputation was not an independent risk factor for metastatic disease.

CONCLUSIONS

The decision to perform a primary amputation for an STS of the extremity is based on the location and local extent of the tumor, and the expected function of the extremity after tumor resection. The higher risk of metastases for patients who require primary amputation is accounted for by independent risk factors associated with their tumors--predominantly large tumor size.

Sciatic nerve reconstruction: limb preservation after sarcoma resection

Limb salvage for extremity sarcoma has become the standard of care when possible. This review attempts to determine the outcome of sciatic nerve reconstruction after surgical tumor resection. The authors' objective was to determine the clinical value of extremity salvage with such a defect. Five patients (two male, three female) were selected from a department database at The University of Texas M.D. Anderson Cancer Center between 1995 and 1999 who met the following criteria: lower limb tumor resection involving a gap in the sciatic nerve with subsequent nerve autograft reconstruction. An additional patient who underwent primary sciatic nerve neurorrhaphy was also included. The average tumor size was 203 cm2. The most common tumor histology was spindle cell sarcoma. The average autograft length was 13 +/- 3.2 cm with one to four cables employed. Currently, 3 patients are still alive. Four of the 5 patients who received sciatic autonerve grafts reported partial distal sensory recovery subjectively. The patient who underwent primary neurorrhaphy has both motor and sensory innervation 42 months after surgery. Although not ideal for all patients, sciatic nerve reconstruction is a viable option for those willing to undergo limb preservation. Notable limitations to daily activity do not appear to be present, and patients are able to ambulate with or without assistive devices. With aggressive rehabilitation, some patients are able to function quite well with this bioprosthesis. Patients should consider, however, that their extremity is on loan. Substantial wound complications or infections may ultimately lead to amputation.

The treatment of high-grade soft tissue sarcomas with preoperative thermoradiotherapy

PURPOSE

To explore the use of a novel program of preoperative radiation and hyperthermia in the management of high-grade soft tissue sarcomas (STS).

METHODS AND MATERIALS

Eligible patients were adults over 18 with Grade 2 or 3 STS, surgically resectable without a local excision prior to referral to Duke University Medical Center and without distant metastases. Patients were staged generally with CT and/or MR imaging. The diagnosis was established with fine needle aspiration or incisional biopsy. Patients were then treated with 5000 to 5040 cGy, 180-200 cGy per fraction. Chemotherapy was usually not employed. Generally two hyperthermia treatments per week were given with a planned thermal dose of 10-100 CEM 43 degrees T90. Invasive thermometry and thermal mapping were done in all patients. Surgical resection was planned 4-6 weeks after the completion of radiation and hyperthermia.

RESULTS

Ninety-seven patients were treated on study between 1984 and 1996. Follow-up ranged from 12 to 155 months (median 32). All tumors were high-grade in nature, 44 greater than 10 cm in size (maximum tumor diameter), 43 5-10 cm in size, 10 less than 5 cm. Seventy-eight of the 97 tumors were located in an extremity. Of the 97 patients, 48 remain alive and continually free of disease following initial therapy. Of the remaining 49 patients, 44 have relapsed (34 dead, 10 living with disease), 3 have died secondary to complications of therapy, and 2 have died of unrelated causes. Ten-year actuarial overall survival, cause-specific survival, and relapse-free survival are 50, 47, and 47% respectively. The predominant pattern of failure has been distant metastases with only 2 patients developing local failure alone. Ten-year actuarial local control for extremity tumors is 94%, 63% for the 19 patients with tumors at sites other than the extremity. Of the 78 patients with extremity lesions, 63 have had limb preservation and remain locally controlled. Overall 38 patients experienced 57 major complications. There were 3 deaths, one due to adriamycin cardiomyopathy and two secondary to wound infections. Four patients required amputation secondary to postoperative wound healing problems. Complications directly attributable to hyperthermia occurred in 15 patients with 11 instances of second- or third-degree burns and two instances of subcutaneous fat necrosis. The hyperthermia complications were generally not severe and either healed readily or were excised at the time of surgical resection of the primary tumor.

CONCLUSIONS

For these aggressive high-grade soft tissue sarcomas, this treatment program of preoperative thermoradiotherapy provided excellent local regional control for extremity lesions (95%) and satisfactory local regional control (63%) of nonextremity sarcomas, but did not appear to influence the rate of distant metastases or survival. Complications were frequent but apart from the direct thermal burns, not too different from those reported for preoperative radiotherapy alone. More effective adjuvant systemic therapy is necessary to impact favorably on survival.

The effects of cisplatinum and vincristine on peripheral nerve regeneration

Current treatment modalities for extremity sarcoma often include tumor extirpation plus neoadjuvant therapy. Limb-sparing surgery may require reconstruction of critical nerve defects. Neurotoxic side effects from adjuvant chemotherapy have been reported and raise concerns regarding the effects of chemotherapy on nerve regeneration. In an attempt to define the effects of adjuvant chemotherapy on peripheral nerve regeneration, cisplatin and vincristine were administered to rats following isografting of the posterior tibial nerve. Parameters used to assess peripheral nerve regeneration included walking track analysis and histomorphology. Sixty 250-g Sprague-Dawley rats were randomly allocated into one of three treatment groups. Each animal underwent a 15-mm reversed interposition nerve isograft from 30 donor rats into the right posterior tibial nerve. Ten animals served as control. The remaining animals were divided into two groups of 25 animals each. One group received cisplatin (75 mg/m2) and the other group received vincristine (1 mg/m2). Chemotherapy was administered at 4-week cycles for a total of six cycles (24 weeks). Walking track analysis was performed monthly. Nerve specimens were harvested from the grafted segment and the distal posterior tibial nerve for histomorphology. Walking track analysis demonstrated no statistical difference in print length between the control and chemotherapeutic groups at the conclusion of the study. The number of axons per square millimeter and nerve fiber density were not statistically different between control and chemotherapeutic groups. In the rodent posterior tibial nerve model, postoperative adjuvant therapy does not significantly alter functional outcome in peripheral nerve regeneration. The practice of immediate nerve grafting after tumor extirpation, despite planned postoperative chemotherapy, is supported.

Adult soft tissue sarcoma

BACKGROUND

Soft tissue sarcomas (STS) are a group of anatomically and histologically diverse tumours. They account for about 1% of adult malignancies, and about 50% of patients diagnosed with sarcoma eventually die of the disease. These tumours are grouped together because of shared biological characteristics and treatment responses.

METHODS

A review of the key literature on STS was undertaken, complemented by data taken from the prospectively accumulated database of 3442 patients treated for STS at Memorial Sloan-Kettering Cancer Center (MSKCC) from July 1982 to December 1997.

RESULTS

Despite advances in knowledge of the molecular genetics of STS, the aetiology in most cases remains elusive. Management has been gradually refined over the last two decades. Core biopsy usually provides enough material for diagnosis. Computed tomography and magnetic resonance imaging provide a similar amount of information, which is usually adequate for surgical planning. Amputation as standard treatment for extremity lesions has been replaced by limb-sparing surgery in about 90% of patients. The role of adjuvant radiation has been further defined: it has been shown to be unnecessary for completely excised tumours less than 5 cm in diameter, but effective in decreasing local recurrence for others. Adjuvant chemotherapy has been controversial for many years. Recent meta-analysis of randomized trial results has found a small reduction in local and distant relapse, and a trend to better overall survival. Recurrent or metastatic disease should be completely excised if possible.

CONCLUSIONS

Soft tissue sarcoma requires multidisciplinary care tailored to the individual patient and tumour for optimal results.

Survival in primary soft tissue sarcoma of the extremities and trunk

BACKGROUND

Soft tissue sarcomas (STS) of the extremities are rare. The purpose of this study was to identify prognostic risk factors associated with survival in patients with primary extremity and truncal STS.

METHODS

Patient, tumor, and pathologic data from 149 consecutive patients with localized primary STS of the extremities and trunk were analyzed using Kaplan-Meier and Cox regression techniques to identify univariate and multivariate risk factors. A subgroup analysis was performed to compare factors predictive of survival in patients who received treatment before (n = 50) and after (n = 99) treatment was standardized in 1988.

RESULTS

The 5-year survival rate was 76.5% with an average follow-up of 6 years. Local recurrence occurred in 23% of all patients, 40% before 1988 and 15% after 1988 (P < 0.0001). Risk factors associated with survival included resection quality (R0 vs. R1; P < 0.0001), era of operation (P = 0.002), local recurrence (P < 0.001), UICC stage (P < 0.0001), tumor size (P < 0.001), tumor depth (P = 0.002), regional lymph nodes (P < 0.0001), and histology (P < 0.0001). Multivariate analysis revealed that tumor size, tumor depth, and resection quality were independent risk factors of survival.

CONCLUSIONS

These results indicate that management of STS in a specialized institution improves overall survival. Resection quality is the most important risk factor of survival. Therefore, effort should be made during primary treatment of STS to achieve wide, tumor-free resection margins.

Forequarter amputation with fasciocutaneous deltoid flap reconstruction for malignant tumors of the upper extremity

BACKGROUND

Malignant tumors of the upper extremity involving a considerable portion of the medial axillary wall may require forequarter amputation to achieve gross resection of tumor. These resections frequently leave a large defect, often requiring a split thickness skin graft or free flap to close the wound. To address this problem of wound closure, we have modified our technique and devised a reconstructive component as part of our forequarter amputation procedure.

METHODS

The medical records of seven patients who underwent forequarter amputation and fasciocutaneous deltoid flap reconstruction between 1982 and 1994 were reviewed.

RESULTS

All the amputation sites were completely closed with a fasciocutaneous deltoid flap without the use of additional skin grafts or free flaps. After a median follow-up of 12 months, there were no local recurrences. Three patients (43%) are alive and disease free 5, 12, and 19 months after their forequarter amputation. One patient is alive with disease after 14 months. The remaining three patients died of their disease.

CONCLUSION

The fasciocutaneous deltoid flap is technically easy to perform, provides wound coverage without the use of skin grafts, and is especially useful for tumors involving the media axillary wall and in patients with previous axillary radiation.

Elevation of glutathione and related enzyme activities in high-grade and metastatic extremity soft tissue sarcoma

BACKGROUND

Glutathione is a free radical scavenger implicated in the chemoresistance of certain tumors. As treatment with chemotherapy has added little to improved survival in adult soft tissue sarcoma and little is known concerning the mechanisms of chemoresistance in sarcoma, we studied concentrations of glutathione (nmol/mg protein) and activities of gamma-glutamylcysteine synthetase (GCS; nmol/mg protein/h) and gamma-glutamyl transpeptidase (GGTP; U/mg protein) in extremity soft tissue sarcoma.

METHODS AND RESULTS

Tumor specimens (n = 65) were frozen in liquid nitrogen at the time of resection. Fourteen low-grade tumors, 40 high-grade tumors, and 11 pulmonary metastases were analyzed. Glutathione concentrations and GGTP activity were significantly lower in low-grade (3.97 +/- 0.7 nmol/mg protein and 1.07 +/- 0.2 U/mg protein) than in high-grade (8.98 +/- 1.2 nmol/mg protein, p < 0.001; 2.10 +/- 0.4 U/mg protein, p < 0.002) tumors and pulmonary metastases (10.05 +/- 1.8 nmol/mg protein, p < 0.008; 3.14 +/- 2.8 U/mg protein, p < 0.04). While GCS activity was lower in low-grade (0.81 +/- 0.3 nmol/mg protein/h) than high-grade (1.49 +/- 0.5 nmol/mg protein/h) tumors and pulmonary metastases (1.03 +/- 0.2 nmol/mg protein/h), these differences were not significant. In those patients with a high-grade tumor presenting with a local recurrence, glutathione levels were higher in those patients who had received preoperative doxorubicin-based chemotherapy (9.25 +/- 1.7 nmol/mg protein; n = 7) than in those who had no preoperative chemotherapy (4.71 +/- 3.1 nmol/mg protein; n = 4, p = 0.08).

CONCLUSIONS

In extremity soft tissue sarcoma, glutathione concentration and GGTP activity are significantly elevated in patients with high-grade and metastatic sarcomas. In addition, there is a trend for increased glutathione levels in tumors previously exposed to doxorubicin-based chemotherapy. Glutathione may play a role in soft tissue sarcoma chemoresistance.

A psychosocial intervention for patients with soft tissue sarcoma

Support groups have increasingly been demonstrated to be an effective intervention in reducing psychological difficulties and emotional problems in patients with cancer. This report describes a pilot support group intervention based upon a modified version of Cain and colleagues' (1986) thematic counseling model for patients who have been treated for soft tissue sarcoma and are free of disease. The modified thematic counseling model consisted of eight group sessions that focused on providing information about soft tissue sarcoma, management of stress, relaxation techniques, and coping skills. In addition, time was set aside for general discussion of personal concerns. Common themes reported by patients were: communication with family, friends and physicians, anxiety about lack of information about soft tissue sarcoma, and major financial disruption because of their illness. At the conclusion of the eighth session, patients were given an informal survey and asked to rate the value of different aspects of the program for them. They reported that feelings of isolation, anger, depression, and anxiety significantly decreased; and their level of self-confidence increased dramatically. This pilot support group intervention is recommended as a model for enhancing the quality of life of patients with soft tissue sarcoma.

Management of soft tissue sarcomas of the extremity in adults

Concepts of the current management of soft tissue sarcomas (STS) of the extremities in adults are presented. The role of surgery, radiation, and chemotherapy as well as the combination of these modalities are reviewed. The addition of radiation therapy to less than radical surgery has resulted in higher rates of limb preservation and acceptable local control. A multidisciplinary approach will help achieve optimal functional results with less morbidity. Treatment of systemic disease is poor with current methods. Innovative uses of existing systemic modalities or new modalities will be important to improve results in the management of these difficult tumors.

Soft tissue sarcomas

Soft tissue sarcomas are relatively rare tumors with an annual incidence of 5000 to 6000 in the United States. The primary therapy is surgical resection with an adequate margin of normal tissue. For patients at high risk local control is improved with postoperative adjuvant radiation. Local recurrence rates vary depending on the anatomic site. In extremity lesions one third of patients will have locally recurrent disease with a median disease-free interval of 18 months. Treatment results for extremity local recurrence may approach those for primary disease. Isolated pulmonary metastases may be resected with 20% to 30% 3-year survival rates. Patients with sarcomas in other sites present similar but more difficult problems in terms of local control and management of disseminated disease. Patients with unresectable pulmonary metastases or extrapulmonary metastatic sarcoma have a uniformly poor prognosis and are best treated with systemic chemotherapy.

Limb-sparing treatment for soft tissue sarcomas: influence of prognostic factors

At present, limb-sparing surgery is the most appropriate and acceptable treatment available for sarcomas of the extremities, although the right balance between conservative therapy and maximum efficacy has yet to be found. A better knowledge of prognostic factors may help in planning the appropriate strategy for each case. Eighty patients underwent limb-sparing surgery for limb sarcomas (17 had surgery alone; 19 had neoadjuvant hyperthermic antiblastic perfusion combined or not with postoperative radiotherapy, and 44 had adjuvant radiotherapy). Univariate and multivariate analyses were made to detect statistically significant differences between subgroups and identify the more significant subset of prognostic factors. Only microscopically positive surgical margins were related to a greater risk of local recurrence, whereas overall survival was compromised by high grade and large tumor size.

Complications and outcome of external hemipelvectomy in the management of pelvic tumors

BACKGROUND

Although the technique of external hemipelvectomy has been adequately described, little is known about its complications and late results.

DESIGN

Retrospective review of 68 external hemipelvectomies performed at our Institute between 1973 and 1994.

MATERIALS AND METHODS

Eleven patients had bone tumor; 39 patients, soft-tissue sarcoma; seven patients, melanoma; 10 patients, squamous cell carcinoma; and one patient, giant neurofibroma. In 48 (71%) patients, the intent was curative. In 17 cases, the hemipelvectomy was extended.

RESULTS

Postoperative complications occurred in 36 (53%) patients, including flap necrosis in 11 (16%), wound infection in 24 (35%), and other complications in 12 (18%). Four (6%) patients died postoperatively. The average hospital stay after curative versus palliative resection was 39 versus 24 days. Only three (5%) patients were able to use a prosthesis, whereas 55 (81%) used crutches, six (9%) remained wheelchair bound, and four patients (6%) spent most of the time in bed. Local recurrence occurred in 35% of the patients. The estimated 5-year survival for curatively resected patients was 21%.

CONCLUSIONS

External hemipelvectomy is a procedure with considerable morbidity and is indicated for only a minority of far-advanced tumors. It offers a chance of palliation and possibly cure when lesser surgical options have been exhausted.

Early post-operative brachytherapy and free flap reconstruction in the management of sarcomas

Brachytherapy delivered within the early post-operative period has been associated with delayed healing and wound breakdown. The objective of this study was to determine whether reconstruction with a microvascular free flap reduced the incidence of wound breakdown after early post-operative brachytherapy and wide excision of soft tissue sarcomas. Four patients with sarcomas underwent excision and free flap reconstruction. Brachytherapy was administered in the early post-operative period using Iridium-192 wires via tubes inserted intraoperatively. In three of the four patients the wounds healed uneventfully, demonstrating that brachytherapy can be delivered in the early post-operative period following free flap reconstruction without an increase in the frequency of wound breakdown. There has been no local recurrence to date in this group of patients.

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.

Multimodality treatment of extra-visceral soft tissue sarcomas M0: state of the art and trends

We here outline principles and trends in the treatment of soft tissue sarcomas without distant metastases (M0). Over the last 15 years significant advances have been made in the diagnostic imaging and histological classification of these tumors as well as in their treatment. Magnetic resonance imaging (MRI) has essentially replaced computerized tomography (CT) for the evaluation of the local growth pattern, although the latter is still preferred for the detection of pulmonary metastases. Immunohistochemistry techniques and electron microscopy have improved the histological diagnosis, although the results obtained should always be interpreted in the context of routine light microscopy. Adequate surgical resection and radiotherapy can reduce the incidence of local recurrence, which is still high for head-neck and retroperitoneal sarcomas. Limb-sparing surgery in combination with irradiation and/or intra-arterial or perfusion chemotherapy is considered the treatment of choice in 90% of limb sarcomas, with a local recurrence rate of less than 20%. New radiotherapeutical techniques and anti-neoplastic agents are now under investigation in an attempt to improve local control. There is also a need for a more effective adjuvant chemotherapy. Randomized clinical trials using doxorubicin/ifosfamide and growth factors are now underway.

Immediate vs. salvage resection after local treatment for early rectal cancer

PURPOSE

There is an increasing awareness of local procedures to treat early stage rectal cancer. Abdominoperineal resection (APR) or low anterior resection (LAR) has been recommended if adverse pathologic findings are encountered in the local excision specimen. No data compare the impact on survival of "immediate" resection for adverse features vs. "salvage" resection for clinical recurrence.

METHODS

We reviewed retrospectively 155 patients who underwent initial curative treatment of invasive rectal cancer by excision (91), snare-cautery (44), and fulguration (20).

RESULTS

Twenty-one patients underwent APR/LAR immediately after initial local treatment, whereas another 21 patients underwent salvage APR/LAR for local recurrence. The disease-free survival after APR/LAR was 94.1 percent for the immediate group and 55.5 percent for the delayed group (P < 0.05).

CONCLUSION

This decreased survival observed after delayed resection supports the recommendation for immediate APR/LAR when adverse pathologic features are present in the excision specimen.

[Reconstruction with free vascularized or island flaps of soft tissue loss in the upper limb after tumor resection. 16 cases]

We have reviewed 16 cases of soft tissue sarcomas of the upper limb treated with wide excision of the tumour and immediate soft tissue reconstruction by means of a microvascular flap. 9 patients were males, 7 females; age ranged from 12 to 74 years. All the patients had been referred to us after previous failed or inadequate excisions. All the tumours were high-grade malignancies in an extracompartmental location (stade IIB according to Enneking). Histopathologic diagnosis was: synovial-sarcoma in 11 cases; fibrosarcoma in 2 cases; malignant fibrous histiocytoma in 1 case, soft tissue osteosarcoma in 1 case, epitheloid sarcoma in 1 case. The site of the tumour was the hand in 2 cases, the wrist in 6 cases, the forearm in 5 cases and the elbow in 3 cases. The free flaps used for soft tissue reconstructions were the latissimus dorsi in 6 cases, the dorsalis pedis in 2 cases, the lateral arm flap in 2 cases, the serratus in 1 case, the gracilis in 1 case. The island flaps were the radial forearm flap in 1 case, the posterior interosseous flap in 1 case, the cubital flap in 1 case. 14 cases required immediate associated reconstructive procedures such as tendon transfers or grafts (5 cases), vascularized or non vascularized bone grafts (4 cases), articular allografts (1 case), ligament reconstruction (1 case), nerve grafts (2 cases). Brachytherapy was associated to microsurgical reconstruction in the last 6 cases of this group. The catheters were charged with the radioisotope 5 days after surgery. No complications were observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Development and treatment of pulmonary metastases in adult patients with extremity soft tissue sarcoma

OBJECTIVE

The authors reviewed a series of adult patients with extremity soft tissue sarcoma to determine the incidence of pulmonary metastases and outcome after treatment.

METHODS

Of 716 patients admitted between January 1983 and December 1990, 135 (19%) had isolated pulmonary metastases as the initial site of distant recurrence. Fifty-eight percent (78 of 135) of the patients were treated surgically, and 83% of them had their tumors completely resected.

RESULTS

The median survival after complete resection was 19 months; incomplete resection, 10 months; and no operation, 8 months (p = 0.005). The 3-year survival rate after complete resection was 23%, compared with a 2% rate (1 of 57) in those treated nonsurgically (p < 0.001). Factors associated with an increased risk of pulmonary metastases included high tumor grade, tumor size greater than 5 cm, lower extremity site, and histologic type (spindle cell, tendosynovial, and extraskeletal osteosarcoma). Factors associated with complete resectability were the histologic types of spindle cell and extraskeletal osteosarcoma.

CONCLUSIONS

Complete surgical resection remains the only possibility for cure from pulmonary metastases in soft tissue sarcoma; however, only 11% of the 19% of patients with an extremity sarcoma whose first distant recurrence is in the lung will be alive at 3 years, despite therapy. Complete resection and the development of more effective adjuvant treatments are imperative to improve outcome for this group of patients.

Expression and modulation of class I and class II histocompatibility leukocyte antigens on human soft tissue sarcomas

BACKGROUND

Class I and Class II histocompatibility leukocyte antigens (HLA) play an important role in the antigenic recognition and target cell killing by T-lymphocytes. Their expression and modulation with gamma interferon on human soft tissue sarcomas were investigated.

METHODS

The phenotypic expressions of Class I and Class II HLA were determined by avidin-biotin immunoperoxidase staining using two monoclonal antibodies W6/32 and MEL3, respectively.

RESULTS

The present study showed that soft tissue sarcomas frequently had demonstrable Class I HLA and less-frequently expressed Class II HLA: The staining for Class I HLA was more diffuse, and the staining for Class II HLA was generally patchy in appearance. The expressions of two antigens on cultured sarcoma cells were found in accordance with the findings of sarcoma tumors. The expression of Class I antigen was enhanced, and Class II was induced in two cell lines by gamma interferon. The in vitro modulation of HLA with gamma interferon was reversible. Gamma interferon at the testing dose did not have cytotoxic or antiproliferative effects on either cell lines.

CONCLUSIONS

Through the modulation of HLA on soft tissue sarcomas, gamma interferon may play a role in the clinical management of sarcomas.

Early postoperative brachytherapy following free flap reconstruction

Brachytherapy delivered within the early postoperative period has been associated with delayed wound healing and wound breakdown. The objective of this study was to determine whether reconstruction with a microvascular free flap reduced the incidence of wound breakdown in the presence of early postoperative brachytherapy following wide excision of soft tissue sarcomas and head and neck carcinomas. Ten patients with malignant tumours underwent wide excision and free flap reconstruction. Brachytherapy was administered using Iridium-192 wires in the early postoperative period via tubes inserted intra-operatively. In 9 of the 10 patients the wounds healed uneventfully, demonstrating that brachytherapy can be delivered in the early postoperative period following free flap reconstruction without an increase in the frequency of wound breakdown.

Soft tissue sarcoma: the enigma of local recurrence

Local recurrence following the treatment of soft tissue sarcoma has been long recognized as a grave prognostic sign. Nevertheless, many investigators have recently suggested that local recurrence following limited surgery ("local persistence") may be a manifestation of a tumor's size and metastatic potential and not a cause of tumor cell dissemination. The author reviewed the experience of several investigators with local persistence. This event was not found to be a threat to survival. The author offers an explanation for this unexpected finding. Soft tissue tumors vary widely in their metastatic potential, and patients also may vary widely in their ability to resist the distant implantation of circulating tumor cells. Patients with a low level of host resistance may be more susceptible to both distant metastases and local persistence, and vice versa. Weaker patients succumb to their initial tumor. Patients who survive the circulating tumor cells from their primary tumor may be immunologically prepared to survive the local persistence of a similar volume of tumor without developing distant disease.

Intraarterial chemotherapy with limb-sparing resection of large soft-tissue sarcomas of the extremities

Fifteen patients with large (average, 15-cm), high-grade soft-tissue sarcomas of the extremities received prolonged selective intraarterial infusions of chemotherapeutic agents in an attempt to permit limb-sparing resection of these tumors, which would otherwise have required amputation. There were seven malignant fibrous histiocytomas, four liposarcomas, two fibrosarcomas, one leiomyosarcoma, and one rhabdomyosarcoma; 73% were grade III. Seven patients underwent two catheterizations, for a total of 22 infusions, which averaged 11.3 days each. There were four catheterization-related complications, including catheter occlusion or dislodgement in one patient each and two cases of arterial thromboembolism in patients in whom anticoagulant dose was not adequate. Both of the latter patients required thrombectomy; one developed gangrene, which precluded limb-sparing surgery. Thirteen of the 15 patients underwent limb-sparing resections, and two underwent amputations. No wound complications occurred. With a median follow-up of 36 months (mean, 34 months), life-table analysis indicates overall and disease-free survivals of 72% and 59%, respectively, at 2 years and 64% and 59% at 3 years. In comparison to other reported therapies, this technique permits limb salvage in most patients without the high wound complication rate associated with preoperative radiation therapy, with equivalent local disease control and survival.

Adult urological sarcoma

From July 1982 to December 1989, 43 of 1,583 adults (2.7%) with soft tissue sarcoma admitted to the Memorial Sloan-Kettering Cancer Center (MSKCC) had tumors arising from the urinary tract and male genital tract (urological sarcoma). The most common site of origin of the tumor was paratesticular (14 patients), followed by the prostate/seminal vesicle (12), bladder (10) and kidney (7). The most common histological type was leiomyosarcoma (19 patients), followed by rhabdomyosarcoma (14), liposarcoma (5) and 5 other histological sarcoma categories (angiosarcoma, malignant fibrous histiocytoma, mesenchymoma and 2 undifferentiated sarcomas). Most of the tumors were high grade (86%) and more than half (56%) were greater than 5 cm. in diameter. A total of 9 patients (21%) presented with metastatic disease, 8 of whom had rhabdomyosarcoma. Complete resection with negative microscopic margins was possible in 58% of the patients. Actuarial relapse-free survival for all patients at 3 and 5 years was 55% and 40%, respectively. There were no significant differences in survival based on patient age, sex or histological tumor type. Favorable prognostic variables by univariate analysis included tumor diameter less than 5 cm., low histological grade, paratesticular or bladder tumor site and complete surgical resection. Application of the MSKCC sarcoma staging system, which is based on grade, size, depth and presence or absence of metastasis, was useful to predict survival. In our experience patients with stage 3 (high grade, greater than 5 cm., 15 patients) or stage 4 (metastatic disease, 9 patients) had a combined 3-year relapse-free survival rate of only 26% and they should be considered candidates for adjuvant treatment protocols.

Postoperative radiation therapy for adult soft tissue sarcomas: a retrospective study

From 1977 to 1988, 81 adult patients with localized soft tissue sarcomas at different sites received postoperative external beam radiotherapy (55 Gy median dose) following primary conservative surgery. Sixty were new referrals after primary surgery and 21 were irradiated after excision of recurrent disease. With a median follow-up of 4 years (range: 2-13) the 5-year overall survival (Kaplan-Meier) and local control were 55.5% and 56% respectively, while 5-year disease-free survival is 49%. There were 26 (32%) local relapses and 22 (27%) distant failures. Local recurrence was the sole pattern of failure in 16 patients (20%). Functional and cosmetic results were good to excellent in most cases. In our series local control is the main prognostic variable influencing survival (P less than 0.0001), and its probability seems to show a link with the type of surgical procedure, with a trend (P less than 0.13) in favor of wide total excision. Postoperative radiation therapy represents an acceptable treatment strategy for ASTS, but further improvements are expected from future controlled clinical trials, aiming at the achievement of the definitive cure of these tumors.

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.

Brachytherapy and function-saving resection of soft tissue sarcoma arising in the limb

The treatment of soft tissue sarcoma of the limb by function-saving resection and brachytherapy (BRT) was systematically studied from 1975 to 1990 at the Memorial Sloan-Kettering Cancer Center, using iridium-192 temporary tumor-bed implants. Initial experiences showed an 88% local control rate in 33 patients who had locally advanced sarcomas, many of which would have required treatment by amputation. The technique also controlled 70% of tumors that abutted or invaded a major neurovascular bundle that was dissected out and preserved. A prospective randomized study (BRT vs no BRT) confirmed the highly significant efficacy of BRT in preventing local recurrence. This salutary effect is mainly seen in high-grade tumors. Major complications of wound healing occurred in the earlier years of this experience. Adoption of improved techniques of surgical wound repair, standardization of radiation dose planning, and in particular, postponing the loading of radiation sources until after the fifth postoperative day has reduced the rate of serious wound complications, to a level not significantly different from that seen after surgical resection alone. These results rival those currently achieved in centers experienced in external beam therapy of soft tissue sarcomas, and offer the advantage of completion of treatment in one relatively short hospital stay.