Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Local Excision Without Radiation for High-Grade Soft-Tissue Sarcoma of the Extremity and Superficial Trunk

Local Excision Without Radiation for High-Grade Soft-Tissue Sarcoma of the Extremity and... Purpose. Limb-sparing surgery c ombined w ith ra diation t reatment has become the ac cepted tre atment for patients wi th high-grade soft -tissue sarcoma. Adjuvant radiation w as not rout inely u sed a t this institution f or patients w ith c lear marg ins after surgery. This retrospective re view analyse s the ou tcome of this group of patients. Patients and meth ods . Patients st udied w ere refer red from 1984 t o 1 995, were ov er 16 y ears of age, w ere d iagnosed wit h primary high-grade soft -tissue sarcoma of the e xtremity or super® cial tr unk, had clear marg ins after excision a nd di d not receive radiati on as a part of their init ial t reatment. A total of 46 patie nts w ere ide nti® e d. Results. At 5 y ears, the loc al c ontrol rate w as 87%, di sease-speci® c s urvival was 75% a nd ov erall survival was 68%. Of the 6 lo cal re currences, 3 were l ocated in t he but tock (from a total of 7 pa tients wit h pr imary tumours of the butt ock), 3 had a primary size of ‡ 10 cm (from a total of 8 pr imary tumours of that s ize) and all were de ep tum ours. Discussion. Our data, and tho se f rom other repo rts, suggest that in c arefully selected patie nts appro priate surgery alone results in a cceptable loc al c ontrol a nd sur vival, and t hat the m orbidity of radiation c an be av oided. Key words: soft tis sue sa rcoma, local excision reported. Because of the morbidity as sociated wi th Introduction adjuvant radiation, it has not b een u sed r outinely at Soft tissue s arcomas ( STSs) ar e r are n eoplasms, our i nstitution in t he management of primary STS. accounting fo r appr oximately 1% of cancer cas es 1 Our pr actice has been to employ l imb-sparing WL E diagnosed an nually in the USA. The tr eatment o f without radiation the rapy for patien ts with negative the primary s ite co ntinues to be re ® n ed w ith the margins fol lowing su rgery. The p urpose o f this study develop ment of ne wer s urg i cal a nd r adiation is to review the outcome o f 46 patients with high- techniques.With sur gical tre atment alon e, lo cal rec ur- grade S TS of the extremity or su per® cia l tr unk t reated rence (LR ) rates ar e c learly re lated to the extent of in thi s fashion. surgery. After am putation or ` radical’ local e xcision, LR r ates o f 2± 13% are re ported, c ompared w ith Methods substan tially high er L R r ates w ith less r adical 2,3 surgery. There a re now many r eports d emonstrating All patie nts aged 16 or m ore t hat presented t o the acceptable LR r ates a fter limb-sparing wide local exc i- British C olumbia Can cer A gency (BC CA) b etween 1 sion (WLE ) combined with pre- or pos t-operative January 1984 and 31 December 1995 with high- 3± 8 radiation tr eatment. Currently, m ost can cer t reat- grade ST S o f the extremity an d s uper® ci al tr unk ment ce ntres h ave adopted l imb-sparing su rgery a nd were r etrospectively reviewed. A ll p atients had a adjuvant radiation a s the treatment o f choice for ST S, pathological d iagnosis o f high-grade S TS c on® r med and am putation fo r p rimary tr eatment i s r ecom- by central p athology review at the BCCA. T he 9,10 mended for v ery few patients. tumours w ere g raded accord ing to the system of Costa The u se o f adjuvant radiation, how ever, is ass oci- et al. Patients wer e e xcluded fr om th e analysis if ated with added m orbidity that is n ot in signi® can t. they had m etastases o r re current di sease a t presenta- Comp lications i nc ludi ng f ra cture , o ed ema , tion, if they received ad juvant radiation tre atment for contractur e an d p oor wo und h ealing h ave been the primary d isease or if the de® n itive s urgical Correspondence to: Dr L orna W eir, Br itish Columbia Cancer Ag ency, 60 0W est 1 0th Ave, Vancouver, Br itish Columbia V5Z 4E 6, Canada. Tel: (60 4) 87 7-6000; F ax: (604) 8 77-0505; E -mail: lweir@bccancer.bc.ca 1357-714Xprint/136 9-1643online/00/030 113-05 2000T aylor & Francis Ltd DOI: 10 .1080/135 77140020008075 114 L. M.Weir et al. management c onsisted o f anything othe r than limb- Table 1. Patient a nd tumour ch aracteristics sparing WLE for ex tremity s ites an d WL E for tr unk sites. I n t he latter part of the 1980s, adjuvant Patients Age a t d iagnosis Median 63 chemotherapy with doxorubicin a nd DT IC w as used. Gender Male 25 Three p atients in t his study h ad p ost-oper ative Female 21 chemotherapy as part of their in itial m anagement. Tumours All patien ts were ev aluated pr ior to surgical r esec- Size <5 cm 24 tion b y a mu ltidis ciplin ary team inc luding 5± 9.9 cm 8 Ort hopaedics, R adiation O nc ology, M e di ca l ‡ 10 cm 8 Oncolog y , Radiolo gy a nd P athology . For t hose Unknown* 6 Location Super® cial 17 patients r eferr e d a fter an i nc omplet e excisio n Deep 29 elsewhere,the de® n itive su rgical re section was carried out b y an e xperienced su rgical o ncologist at the Trunk 5 Buttock 7 tertiary care r eferral ho spital affiliated to the BCCA. Proximal U/ E 7 The tu mour o r tu mour be d was resected en bloc with Proximal L/ E 18 an a ttempt to resect a t least 1 cm m argin o f normal Distal U/E 4 tissue ar ound th e tumour in all planes. A ny p revious Distal L/E 5 drain s ites o r bi opsy s cars wer e in cluded i n the resec- Histology MFH 23 Synovial sarcoma 3 tion. T he re section sp ecimen was reviewed by an Liposarcoma 8 experienced p athologist and by the multidisciplinary Fibrosarcoma 3 team after surgery. Patients w ere ex cluded if the de® ni - Leiomyosarcoma 6 tive (i.e. ® nal) surgical m argin was positive. A mar gin Other 3 was considered p ositive i f tumour ce lls w ere s een MFH=maligant ® brous histiocy toma, U/E = upper within 1 mm o f the inked re section m argin. P atients extremity, L /E = lower ex tremity. who w ere n ot con sidered appropr iate for surg ery a lone *No in formation on siz e a vailable, tumour rese cted pr ior to included th e following: thos e w ho had a substantial referral. amount of disease in a re-excision s pecimen after survival rate s a re s hown in F igs 1 ± 3. The 5 -year prior e xcisional bi opsy; tho se w ith `satellite’ nodules; actuarial local c ontrol r ate was 87%. The 5 -year and pa tients whose s urgery i ncluded an an ticipated actuarial disease-speci® c s urvival an d ov erall s urvival close m argin (e.g . in the region of a neurovascular rates w ere 75% and 68% , respectively. A total of 15 bundle o r bo ne). patients died d uring t he observation p eriod, 1 2 of All p atients were fo llowed ev ery 3 ± 6 months for 5 disease and 3 from u nrelated c auses. years an d t hen an nually af ter de® n itive s urgical r esec- tion. Lo cal, regional an d d istant re currences w ere The ® nal su rgical m argin wa s stated to be n ega- recorded, as well as disease-speci® c a nd n on-speci® c tive, with no m easurement g iven in 21 cases. In 4 patient deaths. O verall s urv ival, disease-s peci® c cases, t he re-excision s pecimen co ntained no tu mour. survival and lo cal and d istant r ecurrence rates w ere The di stance of the closest ® nal m argin was 1± 4 mm calculated fro m the time o f de® n itive s urgical r esec- in 11 cases, 5 ± 10 mm i n 7 cases and >10 mm i n 3 tion us ing the Kaplan± Meier s tatistical method. cases. Six p atients had an LR a nd 11 patients had a distant r ecurrence. A b reakdown of the recurrences Results is as follows: loc al on ly, 2; local an d r egional, 1; local A total of 145 patients aged 16 or o lder wer e id enti- followed by regional, 1; local/regional foll owed b y ® ed thr ough the computerized dat abase of the BCCA distant, 1; distant o nly, 9; and d istant fo llowed by as having h igh- gr ade S TS o f the extremi ty or local, 1. super® c ial tr u nk, r eferred f rom Jan uary 1984 to Of t he 6 patients who h ad an LR , 3 had butto ck December 199 5 and h aving su rgery alo ne as initial primaries (fro m a total of 7 buttock p rimaries) an d 3 treatment. Ex clusions wer e as follows: 79 cases with had pr imary tum ours ‡ 10 cm in siz e (fr om a total of metastatic or lo cally re current d isease a t presenta- 8 primaries o f that size). Fiv e of the six had b iopsies tion; 10 cases ha ving am putations; and 10 cases ha ving prior t o referral, an d 1 patient had an ` untouched’ their pr imary tr eatment d elivered at another c entre. tumour p rior to referral. A ll LR s o ccurred i n patien ts This left a total of 46 cases, wh ich ar e t he subject of with deep t umours; n o p atient with a super® c ial this review. Patient and t umour d etails ar e p resented tumour had an LR . In 2 cases t he ® nal m argin was in T a ble 1. Only 9 patients had ` untouched’ tumours said to be ne gative, wi th no m easurement g iven. F or prior to referral. T he re maining 37 patients were the remaining 4 cases, the closest ® nal m argins wer e referred after having e ither an in cisional or an e xci- 4 mm, 5 mm, 10 mm an d 15 mm. sional bio psy w ithout a pre-operative d iagnosis or Patients with an LR had r epeat ex cision an d/or imaging. radiation the rapy. Tw o o f the six r emained d isease- Median follow -up was 4.4 years ( range 3 ± 14 years). free after a minimum fo llow-up o f 3 years.Th e othe r Local control, d isease-speci® c su rvival an d ov erall 4 patients developed m etastatic d isease o r h ad Excision alone fo r so ft-tissue sarcoma 115 Figure 1. Local control rates. Figure 2. Disease-speci® c sur vival r ates. synchronous d istant meta stases a nd a ll eventually died recurred lo cally. Patients who had had a previous of their d isease. No patient had an am putation for biopsy or m arginal ex cision at another ce ntre w ere LR. O f the 9 patients who had d istant m etastases included in thi s group and d id n ot h ave a higher alone, 1 had a resection of a pulmonary m etastasis recurrence rate. and re mains d isease-free aft er 10 years. Th e o ther 8 Intramuscular t umours w ere tr eated wi th myec- patients died o f metastatic disease. tomy, with adjacent muscles r esected if there was no fascial boundary betw een t hem. O nly pa tients withou t a previous open biopsy w ere t reated th is way. Rydholm Discussion reported that 2 of 24 patients had an LR a fter a minimum fol low-up of 3.5 years. T w enty of these The li terature is n ot re plete wi th information abou t cases we re h igh-grade s arcomas. T he s ubsequent high-grade sarc oma tr eated with limb-salvage su rgery clinical cou rse of the patients wit h LR i s not descr ibed, without radiotherapy. In Sc andinavia the re has been but he c oncluded that a local f ailure rate of 10% does a tradition of treating s elected p atients with sarcomas not ju stify adjuvant radiation tre atment. in in tramuscular an d su bcutaneous s ites w ith surgery alone a nd th is experience h as been r eviewed b y Karakousis et al. reporte d o n a gr oup o f 152 Rydholm. The s urgery f or tum ours in su bcutaneous primary e xtremity STS s, trea ted i n a variety of ways. sites inv olved an en bloc resection wh ich in cluded t he In t his group t here w ere 9 7 patients with high-grade deep f ascia, a 3± 5 cm m argin of surrounding tiss ue tumours tre ated wi th wide ex cision, wi th or with out and u sually the skin over lying the tumour. M ost chemotherapy, with an L R r ate of 12%. patients required s kin g r afting. A fter a me dian Gibbs et al. reviewed a group o f 62 patients with follow-up o f 9 years, 4 of 59 high-grade tu mours subcutaneous ex tremity s arcomas, 3 5 of whom had 116 L. M.Weir et al. Figure 3. Overall sur vival r ates. wide ex cision a lone. Patients with better pr ognostic 9 patients with an LR , 4 had syn chronous d istant factors (lower g rade, s maller s ize an d wid er m argins) metastases an d 3 died o f metastatic sarcoma. Qu ality tended to be s elected for su rgery al one. T here w ere of life an alysis s howed t hat there was a persistent no loc al re currences in thi s group afte r a median reducti on i n j oint m otion a nd a transien t, but follow-up of 56 months. signi® can t, increase in l imb w eakness a nd oe dema i n Tw o r andomized stu dies co mparing su rgery alon e the patients who r eceived r adiation ther apy. However, with surgery and r adiation h ave been p ublished. global qu ality of life and p erformance in ac tivities of Pisters et al. reported on t he outcome of patients daily living w ere no t d ifferent in the two groups. randomized to surgery alone v ersus s urgery with Because o f the small n umber of local fai lures, n o r isk brachytherapy, after a median f ollow-u p o f 76 factors co uld be id enti® ed fo r L R (oth er than lack of months. One h undred and si xty-four pat ients with radiation). T he au thors c oncluded that , while rad ia- extremity or su per® c ial tr unk s arcomas wer e r and- tion d id r educe the LR r ate, no p atients with widely omized. A fter a gross to tal resection of the tumour, negative m argins tre ated wi th surgery alo ne had an patients were r andomized in tra-operatively to receive LR. Th erefore, fo r s elected patien ts in who m t he brachytherapy or not. On de® nit ive hist ological assess - toxicity of radiation i s ex pected to be hig h and the ment, 2 9 patients were f ound to have positive m argins LR rate is e xpected to be low , surgery alone m ay be (tumour with in 1 mm o f a margin). T hese patie nts the treatment o f choice. were d istributed ev enly in bo th arms of the study. We e valuated pa tients treated with limb-sparing Thirty-four patien ts in each g roup a lso r eceived p ost- surgery for ex tremity S TS a nd WLE for su per® c ial operative c hemotherapy. In th e group w ith high- trunk S TS. A s a matter of policy, i f the margins wer e grade les ions ( N=119), actuarial freedom fr om l ocal clear (n o tu mour c ells wi thin 1 mm of the inked recurrence a t 5 years w as 89% for brac hytherapy and resect ion m argi n), a djuv ant radiation w as not 66% for n o br achytherapy ( p=0.003). The be ne® t routinely g iven. Th e d istance o f the ® nal su rgical was con® n ed to patients with high-grade tu mours. margin va ried fr om 1 mm to 20 mm. Th e LR rate There was no di fference i n d isease-speci® c su rvival was 13% at 5 years. T he d isease-speci® c a nd ov erall or fr eedom fr om d istant m etastases b etween the two surviv al rates o f 75% and 68%, respectively, wer e arms. comparable to other r eported se ries w here ad juvant Yang . published the results o f a randomized radiation was given ro utinely. Among the patients et al study c omparing s urgery al one w ith surgery and with an LR , tu mours loc ated in the buttock a nd external b eam rad iation in p atients with extremity tumours 10 cm o r m ore in siz e w ere ov er-represented. STS. A to tal of 141 patients were ran domized. These patien ts may not b e su itable c andidates fo r Patients with high-grade t umours ( =91) were r and- treatment wi th surgery alone. In a ddition, the LRs omized t o have limb -spari ng s ur gery plus were se en on ly in p atients with deep tu mours. chemothe rapy vers us l imb -spari ng s urgery plus In the present s eries, n o p atient had an a mputation concurrent chem otherapy a nd r adiation. P atients wit h for LR . In Y an g et al.’ s study, there w ere 6 patients a limited po sitive m argin we re i ncluded. A fter a in the no rad iation g roup w ho had a n LR w ithout median fol low-up o f 9.6 years, the actuarial local distant m etastases.T w o of these re quired an am puta- failure r ate in the chemotherapy alo ne ar m was 22%. tion. B y way of comparison, C atton et al. reported There wer e n o LR s in the chemoradiation ar m. The re that 7 of 25 patients required am putation fo r LR was no d ifference in the 10-year rate of distant me tas- after initial tr eatment with limb-sparing s urgery and tases or ov erall su rvival be tween the two arms. Of the radiation. Stinson et al. reported that 3 of 145 Excision alone fo r so ft-tissue sarcoma 117 patients r equire d a n a mp utation f or t reatmen t Ta nguy A, Ver nhes JC et al. Local con trol an d su rvival in soft tissue sarco mas of the l imbs, trunk walls and complications aft er limb-sparing su rgery an d r adia- head an d ne ck: a study o f 113 case s. Int J Radiation tion. Even w ith these sm all n umbers of patients, it Oncology Biol Phys 1986;12:579± 8 6. does no t a ppear that avoidance of radiation u ltimately 8 B arkley HT , Martin RG, Romsdahl MM, L indberg R, leads to a higher am putation rat e because o f LR. Zagars GK.Treatment of soft tissue sarcom as by preop- These dat a con® r m other r eports tha t surgery alon e erative ir radiation and c onservative su rgical r esection. is an a cceptable treatment f or c arefully s elected Int J Radiation Oncology Biol Phys 1988;14:693± 9 . 9 W illiard WC, Hajdu SI, Casper ES, Brennan M F. patients with high-grade S TS of the extremity an d Comparison of amputation wit h limb -sparing opera- super® c ial tr unk. LR rates o f 10± 15% after surgery tions for adult so ft tissue sarcom a of the e xtremity. Ann alone m ay not j ustify routine adju vant radiation in Surg 1992;215:269± 75 . these c ases.T he lowes t re currence r ate is s een in th e 10 Le Va y J, O’ Sullivan B, Catto n C , Bell R, Fornasier V , group with super® ci al t umours, ev en whe n an in ci- Cummings B et al. Outcome an d pr ognostic fact ors in sional or e xcisional b iopsy wa s performed pr ior to soft tissue sarcoma in t he adu lt. Int J Radiation Oncology Biol Phys 1993;27:1091± 9 . referral. Dee ply located tu mours are mo re like ly to 11 S tinson S F, DeLaney T F, G reenberg J , Yang J C, recur wi th surgery alo ne, m aking this approach l ess Lampert M H, Hicks JE et al. Acute and lon g-term appropriate. Str ict ad herence to oncological su rgical effects on lim b function of combined m odality lim b principles, c areful an d th orough ass essment o f the sparing therapy for extremity soft tissue s arcoma. Int J pathological s pecimen an d m ultidisciplinary c are ar e Radiation Oncology Bi ol Phys 1991;21:1493± 9 . all essential in s electing pa tients for th is approach. 12 Cost a J, Wesley RA, Glatstein E, Rosenberg S A. The grading o f soft tissue sarco mas. Results of a clinico- pathologic c orrelation in a series of 163 cases . Cancer References 1984;53:530± 4 1. 13 Rydho lm A. Surgery w ithout radi otherapy in s oft tissue 1 Z ahm SH, Fraumeni JF Jr. The epid emiology o f soft sarcoma. Acta O rt hop Scand 1997;68 ( Suppl. tissue sarcom a. Semin Oncol 1997;24:504± 1 4. 273):117± 9 . 2 S imon M A, Enneking WF . The manag ement of soft 14 Karakou sis CP, Proimakis C, Walsh DL. Primary soft tissue sarco mas of the ex tremities. J Bone Joint Surg tissue s arcoma of the e xtremities i n a dults. Br J Surg 1976;58A:317± 27 . 1995;82:1208± 1 2. 3 L eibel S A, Tranbaugh RF, Wara WM, B eckstead J H, 15 Gibbs CP, PeabodyTD , M undt AJ, Montag A G, Simon Bovill E G, Phillips TL. Soft tissue sarc omas of the MA. Oncological o utcomes of operative tre atment o f extremities. Cancer 1982;50:1076± 8 3. subcutaneous soft -tissue sarcomas of the e xtremities. J 4 L indberg RD , Martin RG, Romsdahl MM, Barkl ey Bone Joint Surg 1997;79A:888± 97 . HT. Conserv ative surgery and p ostoperative 16 P isters P W, Harrison LB, Leu ng DH, Woodruff JM, radiotherapy in 3 00 pati ents wit h s oft-tissue sarcomas. Casper ES, Brennan M F. L ong-term r esults o f a Cancer 1981;47:2391± 7 . prospective r andomize d t rial of adjuvant brachy- 5 S uit H D, Mankin H J, Wood W C, Gebhardt MC, therapy in s oft tissue s arcoma. J Clin Oncol Harmon DC, Rosenberg A et al.Treatment o f the p atient 1996;14:859± 6 8. with s tage M o s oft tissue s arcoma. J Clin Oncol 17 Y ang JC, Chang AE, Baker AR, SindelarW F, Danforth 1988;6:854± 6 2. DN, T opalian SI et al. Randomized prospe ctive s tudy 6 Fein D A, Lee WR, Lanciano R M, Corn BW , Herbert of the be ne® t of adjuvant radiation t herapy in t he tre at- SH, Hanlon AL et al. Management of extremity soft ment o f soft tissue sarc omas of the e xtremity. J Clin tissue s arcomas with l imb-sparing s urgery and Oncol 1998;16:197± 2 03. postoperative irradiation: do t otal do se, o verall treat- 18 Catt on C, Davis A, Bell R, O’ Sullivan B, F ornasier V , ment ti me, a nd the sur gery± ra diotherapy interval i mpact Wunder J , McLean M . So ft tissue sar coma of the on l ocal c ontrol? Int J Radiation Oncology Bi ol Phys 1995;32:969± 76 . extremity. Limb salvage after failure of combined 7 Abbatu cci JS, Boulier N , deRanieri J , Mandard AM , conservative the rapy. Radioth Oncol 1996;41:209± 1 4. MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 International Journal of Journal of Immunology Research Endocrinology Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Submit your manuscripts at http://www.hindawi.com BioMed PPAR Research Research International Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Research and Treatment Cellular Longevity Neurology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Sarcoma Hindawi Publishing Corporation

Local Excision Without Radiation for High-Grade Soft-Tissue Sarcoma of the Extremity and Superficial Trunk

Download PDF
6 pages

Loading next page...
 
/lp/hindawi-publishing-corporation/local-excision-without-radiation-for-high-grade-soft-tissue-sarcoma-of-amXrf1qia2

References (17)

Publisher
Hindawi Publishing Corporation
Copyright
Copyright © 2000 Hindawi Publishing Corporation. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ISSN
1357-714X
eISSN
1369-1643
DOI
10.1080/13577140020008075
Publisher site
See Article on Publisher Site

Abstract

Purpose. Limb-sparing surgery c ombined w ith ra diation t reatment has become the ac cepted tre atment for patients wi th high-grade soft -tissue sarcoma. Adjuvant radiation w as not rout inely u sed a t this institution f or patients w ith c lear marg ins after surgery. This retrospective re view analyse s the ou tcome of this group of patients. Patients and meth ods . Patients st udied w ere refer red from 1984 t o 1 995, were ov er 16 y ears of age, w ere d iagnosed wit h primary high-grade soft -tissue sarcoma of the e xtremity or super® cial tr unk, had clear marg ins after excision a nd di d not receive radiati on as a part of their init ial t reatment. A total of 46 patie nts w ere ide nti® e d. Results. At 5 y ears, the loc al c ontrol rate w as 87%, di sease-speci® c s urvival was 75% a nd ov erall survival was 68%. Of the 6 lo cal re currences, 3 were l ocated in t he but tock (from a total of 7 pa tients wit h pr imary tumours of the butt ock), 3 had a primary size of ‡ 10 cm (from a total of 8 pr imary tumours of that s ize) and all were de ep tum ours. Discussion. Our data, and tho se f rom other repo rts, suggest that in c arefully selected patie nts appro priate surgery alone results in a cceptable loc al c ontrol a nd sur vival, and t hat the m orbidity of radiation c an be av oided. Key words: soft tis sue sa rcoma, local excision reported. Because of the morbidity as sociated wi th Introduction adjuvant radiation, it has not b een u sed r outinely at Soft tissue s arcomas ( STSs) ar e r are n eoplasms, our i nstitution in t he management of primary STS. accounting fo r appr oximately 1% of cancer cas es 1 Our pr actice has been to employ l imb-sparing WL E diagnosed an nually in the USA. The tr eatment o f without radiation the rapy for patien ts with negative the primary s ite co ntinues to be re ® n ed w ith the margins fol lowing su rgery. The p urpose o f this study develop ment of ne wer s urg i cal a nd r adiation is to review the outcome o f 46 patients with high- techniques.With sur gical tre atment alon e, lo cal rec ur- grade S TS of the extremity or su per® cia l tr unk t reated rence (LR ) rates ar e c learly re lated to the extent of in thi s fashion. surgery. After am putation or ` radical’ local e xcision, LR r ates o f 2± 13% are re ported, c ompared w ith Methods substan tially high er L R r ates w ith less r adical 2,3 surgery. There a re now many r eports d emonstrating All patie nts aged 16 or m ore t hat presented t o the acceptable LR r ates a fter limb-sparing wide local exc i- British C olumbia Can cer A gency (BC CA) b etween 1 sion (WLE ) combined with pre- or pos t-operative January 1984 and 31 December 1995 with high- 3± 8 radiation tr eatment. Currently, m ost can cer t reat- grade ST S o f the extremity an d s uper® ci al tr unk ment ce ntres h ave adopted l imb-sparing su rgery a nd were r etrospectively reviewed. A ll p atients had a adjuvant radiation a s the treatment o f choice for ST S, pathological d iagnosis o f high-grade S TS c on® r med and am putation fo r p rimary tr eatment i s r ecom- by central p athology review at the BCCA. T he 9,10 mended for v ery few patients. tumours w ere g raded accord ing to the system of Costa The u se o f adjuvant radiation, how ever, is ass oci- et al. Patients wer e e xcluded fr om th e analysis if ated with added m orbidity that is n ot in signi® can t. they had m etastases o r re current di sease a t presenta- Comp lications i nc ludi ng f ra cture , o ed ema , tion, if they received ad juvant radiation tre atment for contractur e an d p oor wo und h ealing h ave been the primary d isease or if the de® n itive s urgical Correspondence to: Dr L orna W eir, Br itish Columbia Cancer Ag ency, 60 0W est 1 0th Ave, Vancouver, Br itish Columbia V5Z 4E 6, Canada. Tel: (60 4) 87 7-6000; F ax: (604) 8 77-0505; E -mail: lweir@bccancer.bc.ca 1357-714Xprint/136 9-1643online/00/030 113-05 2000T aylor & Francis Ltd DOI: 10 .1080/135 77140020008075 114 L. M.Weir et al. management c onsisted o f anything othe r than limb- Table 1. Patient a nd tumour ch aracteristics sparing WLE for ex tremity s ites an d WL E for tr unk sites. I n t he latter part of the 1980s, adjuvant Patients Age a t d iagnosis Median 63 chemotherapy with doxorubicin a nd DT IC w as used. Gender Male 25 Three p atients in t his study h ad p ost-oper ative Female 21 chemotherapy as part of their in itial m anagement. Tumours All patien ts were ev aluated pr ior to surgical r esec- Size <5 cm 24 tion b y a mu ltidis ciplin ary team inc luding 5± 9.9 cm 8 Ort hopaedics, R adiation O nc ology, M e di ca l ‡ 10 cm 8 Oncolog y , Radiolo gy a nd P athology . For t hose Unknown* 6 Location Super® cial 17 patients r eferr e d a fter an i nc omplet e excisio n Deep 29 elsewhere,the de® n itive su rgical re section was carried out b y an e xperienced su rgical o ncologist at the Trunk 5 Buttock 7 tertiary care r eferral ho spital affiliated to the BCCA. Proximal U/ E 7 The tu mour o r tu mour be d was resected en bloc with Proximal L/ E 18 an a ttempt to resect a t least 1 cm m argin o f normal Distal U/E 4 tissue ar ound th e tumour in all planes. A ny p revious Distal L/E 5 drain s ites o r bi opsy s cars wer e in cluded i n the resec- Histology MFH 23 Synovial sarcoma 3 tion. T he re section sp ecimen was reviewed by an Liposarcoma 8 experienced p athologist and by the multidisciplinary Fibrosarcoma 3 team after surgery. Patients w ere ex cluded if the de® ni - Leiomyosarcoma 6 tive (i.e. ® nal) surgical m argin was positive. A mar gin Other 3 was considered p ositive i f tumour ce lls w ere s een MFH=maligant ® brous histiocy toma, U/E = upper within 1 mm o f the inked re section m argin. P atients extremity, L /E = lower ex tremity. who w ere n ot con sidered appropr iate for surg ery a lone *No in formation on siz e a vailable, tumour rese cted pr ior to included th e following: thos e w ho had a substantial referral. amount of disease in a re-excision s pecimen after survival rate s a re s hown in F igs 1 ± 3. The 5 -year prior e xcisional bi opsy; tho se w ith `satellite’ nodules; actuarial local c ontrol r ate was 87%. The 5 -year and pa tients whose s urgery i ncluded an an ticipated actuarial disease-speci® c s urvival an d ov erall s urvival close m argin (e.g . in the region of a neurovascular rates w ere 75% and 68% , respectively. A total of 15 bundle o r bo ne). patients died d uring t he observation p eriod, 1 2 of All p atients were fo llowed ev ery 3 ± 6 months for 5 disease and 3 from u nrelated c auses. years an d t hen an nually af ter de® n itive s urgical r esec- tion. Lo cal, regional an d d istant re currences w ere The ® nal su rgical m argin wa s stated to be n ega- recorded, as well as disease-speci® c a nd n on-speci® c tive, with no m easurement g iven in 21 cases. In 4 patient deaths. O verall s urv ival, disease-s peci® c cases, t he re-excision s pecimen co ntained no tu mour. survival and lo cal and d istant r ecurrence rates w ere The di stance of the closest ® nal m argin was 1± 4 mm calculated fro m the time o f de® n itive s urgical r esec- in 11 cases, 5 ± 10 mm i n 7 cases and >10 mm i n 3 tion us ing the Kaplan± Meier s tatistical method. cases. Six p atients had an LR a nd 11 patients had a distant r ecurrence. A b reakdown of the recurrences Results is as follows: loc al on ly, 2; local an d r egional, 1; local A total of 145 patients aged 16 or o lder wer e id enti- followed by regional, 1; local/regional foll owed b y ® ed thr ough the computerized dat abase of the BCCA distant, 1; distant o nly, 9; and d istant fo llowed by as having h igh- gr ade S TS o f the extremi ty or local, 1. super® c ial tr u nk, r eferred f rom Jan uary 1984 to Of t he 6 patients who h ad an LR , 3 had butto ck December 199 5 and h aving su rgery alo ne as initial primaries (fro m a total of 7 buttock p rimaries) an d 3 treatment. Ex clusions wer e as follows: 79 cases with had pr imary tum ours ‡ 10 cm in siz e (fr om a total of metastatic or lo cally re current d isease a t presenta- 8 primaries o f that size). Fiv e of the six had b iopsies tion; 10 cases ha ving am putations; and 10 cases ha ving prior t o referral, an d 1 patient had an ` untouched’ their pr imary tr eatment d elivered at another c entre. tumour p rior to referral. A ll LR s o ccurred i n patien ts This left a total of 46 cases, wh ich ar e t he subject of with deep t umours; n o p atient with a super® c ial this review. Patient and t umour d etails ar e p resented tumour had an LR . In 2 cases t he ® nal m argin was in T a ble 1. Only 9 patients had ` untouched’ tumours said to be ne gative, wi th no m easurement g iven. F or prior to referral. T he re maining 37 patients were the remaining 4 cases, the closest ® nal m argins wer e referred after having e ither an in cisional or an e xci- 4 mm, 5 mm, 10 mm an d 15 mm. sional bio psy w ithout a pre-operative d iagnosis or Patients with an LR had r epeat ex cision an d/or imaging. radiation the rapy. Tw o o f the six r emained d isease- Median follow -up was 4.4 years ( range 3 ± 14 years). free after a minimum fo llow-up o f 3 years.Th e othe r Local control, d isease-speci® c su rvival an d ov erall 4 patients developed m etastatic d isease o r h ad Excision alone fo r so ft-tissue sarcoma 115 Figure 1. Local control rates. Figure 2. Disease-speci® c sur vival r ates. synchronous d istant meta stases a nd a ll eventually died recurred lo cally. Patients who had had a previous of their d isease. No patient had an am putation for biopsy or m arginal ex cision at another ce ntre w ere LR. O f the 9 patients who had d istant m etastases included in thi s group and d id n ot h ave a higher alone, 1 had a resection of a pulmonary m etastasis recurrence rate. and re mains d isease-free aft er 10 years. Th e o ther 8 Intramuscular t umours w ere tr eated wi th myec- patients died o f metastatic disease. tomy, with adjacent muscles r esected if there was no fascial boundary betw een t hem. O nly pa tients withou t a previous open biopsy w ere t reated th is way. Rydholm Discussion reported that 2 of 24 patients had an LR a fter a minimum fol low-up of 3.5 years. T w enty of these The li terature is n ot re plete wi th information abou t cases we re h igh-grade s arcomas. T he s ubsequent high-grade sarc oma tr eated with limb-salvage su rgery clinical cou rse of the patients wit h LR i s not descr ibed, without radiotherapy. In Sc andinavia the re has been but he c oncluded that a local f ailure rate of 10% does a tradition of treating s elected p atients with sarcomas not ju stify adjuvant radiation tre atment. in in tramuscular an d su bcutaneous s ites w ith surgery alone a nd th is experience h as been r eviewed b y Karakousis et al. reporte d o n a gr oup o f 152 Rydholm. The s urgery f or tum ours in su bcutaneous primary e xtremity STS s, trea ted i n a variety of ways. sites inv olved an en bloc resection wh ich in cluded t he In t his group t here w ere 9 7 patients with high-grade deep f ascia, a 3± 5 cm m argin of surrounding tiss ue tumours tre ated wi th wide ex cision, wi th or with out and u sually the skin over lying the tumour. M ost chemotherapy, with an L R r ate of 12%. patients required s kin g r afting. A fter a me dian Gibbs et al. reviewed a group o f 62 patients with follow-up o f 9 years, 4 of 59 high-grade tu mours subcutaneous ex tremity s arcomas, 3 5 of whom had 116 L. M.Weir et al. Figure 3. Overall sur vival r ates. wide ex cision a lone. Patients with better pr ognostic 9 patients with an LR , 4 had syn chronous d istant factors (lower g rade, s maller s ize an d wid er m argins) metastases an d 3 died o f metastatic sarcoma. Qu ality tended to be s elected for su rgery al one. T here w ere of life an alysis s howed t hat there was a persistent no loc al re currences in thi s group afte r a median reducti on i n j oint m otion a nd a transien t, but follow-up of 56 months. signi® can t, increase in l imb w eakness a nd oe dema i n Tw o r andomized stu dies co mparing su rgery alon e the patients who r eceived r adiation ther apy. However, with surgery and r adiation h ave been p ublished. global qu ality of life and p erformance in ac tivities of Pisters et al. reported on t he outcome of patients daily living w ere no t d ifferent in the two groups. randomized to surgery alone v ersus s urgery with Because o f the small n umber of local fai lures, n o r isk brachytherapy, after a median f ollow-u p o f 76 factors co uld be id enti® ed fo r L R (oth er than lack of months. One h undred and si xty-four pat ients with radiation). T he au thors c oncluded that , while rad ia- extremity or su per® c ial tr unk s arcomas wer e r and- tion d id r educe the LR r ate, no p atients with widely omized. A fter a gross to tal resection of the tumour, negative m argins tre ated wi th surgery alo ne had an patients were r andomized in tra-operatively to receive LR. Th erefore, fo r s elected patien ts in who m t he brachytherapy or not. On de® nit ive hist ological assess - toxicity of radiation i s ex pected to be hig h and the ment, 2 9 patients were f ound to have positive m argins LR rate is e xpected to be low , surgery alone m ay be (tumour with in 1 mm o f a margin). T hese patie nts the treatment o f choice. were d istributed ev enly in bo th arms of the study. We e valuated pa tients treated with limb-sparing Thirty-four patien ts in each g roup a lso r eceived p ost- surgery for ex tremity S TS a nd WLE for su per® c ial operative c hemotherapy. In th e group w ith high- trunk S TS. A s a matter of policy, i f the margins wer e grade les ions ( N=119), actuarial freedom fr om l ocal clear (n o tu mour c ells wi thin 1 mm of the inked recurrence a t 5 years w as 89% for brac hytherapy and resect ion m argi n), a djuv ant radiation w as not 66% for n o br achytherapy ( p=0.003). The be ne® t routinely g iven. Th e d istance o f the ® nal su rgical was con® n ed to patients with high-grade tu mours. margin va ried fr om 1 mm to 20 mm. Th e LR rate There was no di fference i n d isease-speci® c su rvival was 13% at 5 years. T he d isease-speci® c a nd ov erall or fr eedom fr om d istant m etastases b etween the two surviv al rates o f 75% and 68%, respectively, wer e arms. comparable to other r eported se ries w here ad juvant Yang . published the results o f a randomized radiation was given ro utinely. Among the patients et al study c omparing s urgery al one w ith surgery and with an LR , tu mours loc ated in the buttock a nd external b eam rad iation in p atients with extremity tumours 10 cm o r m ore in siz e w ere ov er-represented. STS. A to tal of 141 patients were ran domized. These patien ts may not b e su itable c andidates fo r Patients with high-grade t umours ( =91) were r and- treatment wi th surgery alone. In a ddition, the LRs omized t o have limb -spari ng s ur gery plus were se en on ly in p atients with deep tu mours. chemothe rapy vers us l imb -spari ng s urgery plus In the present s eries, n o p atient had an a mputation concurrent chem otherapy a nd r adiation. P atients wit h for LR . In Y an g et al.’ s study, there w ere 6 patients a limited po sitive m argin we re i ncluded. A fter a in the no rad iation g roup w ho had a n LR w ithout median fol low-up o f 9.6 years, the actuarial local distant m etastases.T w o of these re quired an am puta- failure r ate in the chemotherapy alo ne ar m was 22%. tion. B y way of comparison, C atton et al. reported There wer e n o LR s in the chemoradiation ar m. The re that 7 of 25 patients required am putation fo r LR was no d ifference in the 10-year rate of distant me tas- after initial tr eatment with limb-sparing s urgery and tases or ov erall su rvival be tween the two arms. Of the radiation. Stinson et al. reported that 3 of 145 Excision alone fo r so ft-tissue sarcoma 117 patients r equire d a n a mp utation f or t reatmen t Ta nguy A, Ver nhes JC et al. Local con trol an d su rvival in soft tissue sarco mas of the l imbs, trunk walls and complications aft er limb-sparing su rgery an d r adia- head an d ne ck: a study o f 113 case s. Int J Radiation tion. Even w ith these sm all n umbers of patients, it Oncology Biol Phys 1986;12:579± 8 6. does no t a ppear that avoidance of radiation u ltimately 8 B arkley HT , Martin RG, Romsdahl MM, L indberg R, leads to a higher am putation rat e because o f LR. Zagars GK.Treatment of soft tissue sarcom as by preop- These dat a con® r m other r eports tha t surgery alon e erative ir radiation and c onservative su rgical r esection. is an a cceptable treatment f or c arefully s elected Int J Radiation Oncology Biol Phys 1988;14:693± 9 . 9 W illiard WC, Hajdu SI, Casper ES, Brennan M F. patients with high-grade S TS of the extremity an d Comparison of amputation wit h limb -sparing opera- super® c ial tr unk. LR rates o f 10± 15% after surgery tions for adult so ft tissue sarcom a of the e xtremity. Ann alone m ay not j ustify routine adju vant radiation in Surg 1992;215:269± 75 . these c ases.T he lowes t re currence r ate is s een in th e 10 Le Va y J, O’ Sullivan B, Catto n C , Bell R, Fornasier V , group with super® ci al t umours, ev en whe n an in ci- Cummings B et al. Outcome an d pr ognostic fact ors in sional or e xcisional b iopsy wa s performed pr ior to soft tissue sarcoma in t he adu lt. Int J Radiation Oncology Biol Phys 1993;27:1091± 9 . referral. Dee ply located tu mours are mo re like ly to 11 S tinson S F, DeLaney T F, G reenberg J , Yang J C, recur wi th surgery alo ne, m aking this approach l ess Lampert M H, Hicks JE et al. Acute and lon g-term appropriate. Str ict ad herence to oncological su rgical effects on lim b function of combined m odality lim b principles, c areful an d th orough ass essment o f the sparing therapy for extremity soft tissue s arcoma. Int J pathological s pecimen an d m ultidisciplinary c are ar e Radiation Oncology Bi ol Phys 1991;21:1493± 9 . all essential in s electing pa tients for th is approach. 12 Cost a J, Wesley RA, Glatstein E, Rosenberg S A. The grading o f soft tissue sarco mas. Results of a clinico- pathologic c orrelation in a series of 163 cases . Cancer References 1984;53:530± 4 1. 13 Rydho lm A. Surgery w ithout radi otherapy in s oft tissue 1 Z ahm SH, Fraumeni JF Jr. The epid emiology o f soft sarcoma. Acta O rt hop Scand 1997;68 ( Suppl. tissue sarcom a. Semin Oncol 1997;24:504± 1 4. 273):117± 9 . 2 S imon M A, Enneking WF . The manag ement of soft 14 Karakou sis CP, Proimakis C, Walsh DL. Primary soft tissue sarco mas of the ex tremities. J Bone Joint Surg tissue s arcoma of the e xtremities i n a dults. Br J Surg 1976;58A:317± 27 . 1995;82:1208± 1 2. 3 L eibel S A, Tranbaugh RF, Wara WM, B eckstead J H, 15 Gibbs CP, PeabodyTD , M undt AJ, Montag A G, Simon Bovill E G, Phillips TL. Soft tissue sarc omas of the MA. Oncological o utcomes of operative tre atment o f extremities. Cancer 1982;50:1076± 8 3. subcutaneous soft -tissue sarcomas of the e xtremities. J 4 L indberg RD , Martin RG, Romsdahl MM, Barkl ey Bone Joint Surg 1997;79A:888± 97 . HT. Conserv ative surgery and p ostoperative 16 P isters P W, Harrison LB, Leu ng DH, Woodruff JM, radiotherapy in 3 00 pati ents wit h s oft-tissue sarcomas. Casper ES, Brennan M F. L ong-term r esults o f a Cancer 1981;47:2391± 7 . prospective r andomize d t rial of adjuvant brachy- 5 S uit H D, Mankin H J, Wood W C, Gebhardt MC, therapy in s oft tissue s arcoma. J Clin Oncol Harmon DC, Rosenberg A et al.Treatment o f the p atient 1996;14:859± 6 8. with s tage M o s oft tissue s arcoma. J Clin Oncol 17 Y ang JC, Chang AE, Baker AR, SindelarW F, Danforth 1988;6:854± 6 2. DN, T opalian SI et al. Randomized prospe ctive s tudy 6 Fein D A, Lee WR, Lanciano R M, Corn BW , Herbert of the be ne® t of adjuvant radiation t herapy in t he tre at- SH, Hanlon AL et al. Management of extremity soft ment o f soft tissue sarc omas of the e xtremity. J Clin tissue s arcomas with l imb-sparing s urgery and Oncol 1998;16:197± 2 03. postoperative irradiation: do t otal do se, o verall treat- 18 Catt on C, Davis A, Bell R, O’ Sullivan B, F ornasier V , ment ti me, a nd the sur gery± ra diotherapy interval i mpact Wunder J , McLean M . So ft tissue sar coma of the on l ocal c ontrol? Int J Radiation Oncology Bi ol Phys 1995;32:969± 76 . extremity. Limb salvage after failure of combined 7 Abbatu cci JS, Boulier N , deRanieri J , Mandard AM , conservative the rapy. Radioth Oncol 1996;41:209± 1 4. MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 International Journal of Journal of Immunology Research Endocrinology Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Submit your manuscripts at http://www.hindawi.com BioMed PPAR Research Research International Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Research and Treatment Cellular Longevity Neurology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

Journal

Sarcoma – Hindawi Publishing Corporation

Published: Jan 1, 2000

There are no references for this article.