Soft tissue sarcomas of the extremities: their natural history, treatment, and radiation sensitivity

Use of an Artificial Ligament Decreases Hip Dislocation and Improves Limb Function After Total Femoral Prosthetic Replacement Following Femoral Tumor Resection

BACKGROUND

Hip dislocation is a major complication of total femoral prosthetic reconstruction (TFR) after femoral tumor resection. Hip dislocation can occur because of inadequate functional abductor musculature, inadequate hip capsule repair, or a long lever arm after total femur replacement. To eliminate the negative effects of these factors on the risk of hip dislocation, the use of artificial ligaments may help to increase the stability of the hip joint. We aimed to determine whether application of an artificial ligament would improve limb function and active range of movement (ROM) after TFR.

METHODS

Fifty-eight patients who underwent femoral tumor resection and TFR were included. A band-shaped artificial ligament was wrapped spirally around the proximal site of the total femur prosthesis for periacetabular soft tissue reconstruction in 12 patients. The other 46 patients did not consent to receiving the artificial ligament. Complications including hip dislocation and infection, limb function, and active hip ROM were compared between patients who did and did not receive the artificial ligament.

RESULTS

The hip dislocation rate was lower in the patients who received the artificial ligament. The risk of deep infection did not differ between groups. The group that received the ligament also achieved better limb function and active ROM on flexion and abduction.

CONCLUSION

Patients treated with total femur resection and endoprosthetic replacement with an artificial ligament for periacetabular soft tissue reconstruction had a more stable hip joint, better limb function, and greater active hip ROM than did patients who did not receive an artificial ligament.

Growth Rate of Soft Tissue Sarcomas: A Quantitative Study of 44 Local Recurrences

Local recurrences of soft tissue sarcomas in 44 patients were studied to quantify their growth rate. The geometric mean of the doubling time of 32 cases previously treated with surgery only (14.8 days) was similar to that of 10 cases treated with surgery plus radiotherapy (14.1 days), and was less than that of most malignant human tumors. There was no significant difference in doubling times of first and successive recurrences. From the study it appears that the site of the primary and the age of the patient may affect the behavior of the tumor.

Advances in segmental endoprosthetic reconstruction for extremity tumors: a review of contemporary designs and techniques

BACKGROUND

Improved understanding and advances in treatment regimens have led to increased longevity among patients diagnosed with extremity soft tissue sarcomas. Limb salvage techniques and implants have improved and continue to evolve to accommodate the increasing demands and survival of these patients.

METHODS

The current report is a review of the literature for recent advancements in techniques, implant design, and outcomes in the field of limb salvage therapy using segmental megaprostheses for the treatment of extremity sarcomas. We report on our experience in this field utilizing a classification system of failure mechanisms to outline to discuss current controversies in management.

RESULTS

Five mechanisms of failure have been identified: soft-tissue failure, aseptic loosening, structural failure, infection, and tumor progression. Infection was the most common mode of failure in our series, accounting for 34% of cases. Soft-tissue failure occurred most commonly in the joints that depend heavily on periarticular muscles and ligaments for stability due to their high degree of functional range of motion. We observed a 28% soft-tissue failure rate about the shoulder and hip, aseptic loosening accounted for 19% of implant failures, and structural failure was seen in 17% of cases. Seventeen percent of cases failed due to tumor progression, an etiology that is defined by biological factors, surgical technique, and adjuvant therapies.

CONCLUSIONS

Surgical techniques and megaprosthesis designs are constantly changing in order to meet the challenge of increasing functional demands and longevity in this unique patient population. A classification system defined by treatment failure etiologies provides the framework for discussion of current controversies in limb salvage therapy as well as a guide for advancement and potential solutions in this challenging arena.

The radiation response of sarcomas by histologic subtypes: a review with special emphasis given to results achieved with razoxane

Purpose. Relatively few results are available in the literature about the radiation response of unresectable sarcomas in relation to their histology. Therefore, an attempt was made to summarize the present situation. Materials and methods. This report is based on a review of the literature and the author's own experience. Adult-type soft tissue sarcomas, chondrosarcomas, and chordomas were analyzed. Radioresponse was mainly associated with the degree of tumor shrinkage, that is, objective responses. Histopathologic responses, that is, the degree of necrosis, are only discussed in relation to radiation treatment reports of soft tissue sarcomas as a group. Results. Radiation therapy alone leads to major responses in about 50% of lipo-, fibro-, leiomyo-, or chondrosarcomas. The response rate is less than 50% in malignant fibrous histiocytomas, synovial, neurogenic, and other rare soft tissue sarcomas. The response rates may increase up to 75% through the addition of radiosensitizers such as halogenated pyrimidines or razoxane, or by the use of high-LET irradiation. Angiosarcomas become clearly more responsive if biologicals, angiomodulating, and/or tubulin affinic substances are given together with radiation therapy. Razoxane is able to increase the duration and quality of responses even in difficult-to-treat tumors like chondrosarcomas or chordomas. Conclusions. The available data demonstrate that the radioresponsiveness of sarcomas is very variable and dependent on histology, kind of radiation, and various concomitantly given drugs. The rate of complete sustained remissions by radiation therapy alone or in combination with drugs is still far from satisfactory although progress has been made through the use of sensitizing agents.

The role of preoperative radiotherapy in nonmetastatic high-grade osteosarcoma of the extremities for limb-sparing surgery

PURPOSE

To assess the role of preoperative radiotherapy in patients with nonmetastatic high-grade osteosarcoma of the extremities for limb-sparing surgery and to compare the response of neoadjuvant therapies, local control, and survival with the literature results.

METHODS AND MATERIALS

Forty-six patients with osteosarcoma of the limbs who were treated within a limb salvage protocol including preoperative radiotherapy and chemotherapy between 1987 and 2002, were retrospectively analyzed. Median age was 17 years (range, 14-66 years). Treatment was started with neoadjuvant chemotherapy. Cisplatin, epidoxorubicin, ifosfamide, and methotrexate were used in different combinations. Preoperative radiotherapy was applied, usually between the second and third cycle of chemotherapy. Radiotherapy was given (35 Gy in 10 fractions) to 44 patients. Two patients were treated with 46 Gy at 2 Gy/day. Definitive surgery was administered after the third course of chemotherapy. Chemotherapy was complete 6 courses postsurgery.

RESULTS

Median follow-up time was 44 months (range, 2-154 months). Forty-four patients had limb-sparing surgery, whereas 2 had amputation. Tumor necrosis rate was >/=90% in 87% of the patients (Huvos Grade 3-4). Two patients had local failures, and 26 patients (56.5%) had distant metastases. The 5-year local control and overall survival rates were 97.5% and 48.4%, respectively. On univariate analysis, age </=18 years, Huvos Grade 4, lower-extremity localization, and surgery within 1 month significantly survived better than the others. On multivariate analysis, Huvos grade (p = 0.01), age (p = 0.01), interval between neoadjuvant chemotherapy and surgery (p = 0.02), and extremity localization (p = 0.02) were significant prognostic factors for actuarial survival. Severe complication developed in 20% of the patients.

CONCLUSION

Preoperative radiotherapy helps to increase the chance of extremity-sparing surgery with good local control and necrosis rate when combined with chemotherapy.

Soft-tissue sarcomas of the shoulder girdle: factors influencing local recurrence distant metastases, and survival

BACKGROUND

Prognostic factors and the role of radiotherapy have not been well characterized for soft-tissue sarcomas (STS) of the shoulder girdle.

METHODS

The cases of 70 patients with primary shoulder STS were reviewed for the following information: size, grade and histology of tumors, extent of resection, and use of adjuvant radiotherapy. The influence of these factors on local disease-free survival (LDFS), distant disease-free survival (DDFS), and overall survival (OS) rates was analyzed using univariate analysis.

RESULTS

With a median follow-up of 108 months, the overall 5- and 10-year survival rates for patients with shoulder girdle STS were 82% and 80%, respectively, whereas the 5-year disease-free survival rate was 63%. There were 25 (35%) tumor recurrences: 12 (17%) distant and 13 (18%) local regional. Tumors > 5 cm in size were associated with a significantly decreased 5-year OS rate compared with lesions < 5 cm, and high-grade tumors were associated with significantly decreased DDFS and OS rates. Because most of the patients who underwent amputation had large, high-grade tumors, they had significantly decreased 5-year DDFS and OS rates compared with wide local excision. Radiotherapy produced a significant improvement in LDFS rates, particularly in patients with tumors > 5 cm in size.

CONCLUSIONS

The results indicate that both tumor size and grade are important prognostic factors in shoulder girdle STS. Adjuvant radiotherapy should be considered in large tumors to improve the LDFS and to decrease the need for radical ablative surgery.

Characteristics of the response of soft tissue sarcoma to hyperthermia: the correlation between temperature distribution, radiological examination and histology

Nineteen patients with soft tissue sarcoma were treated by a combination modality of hyperthermia and radiation or chemotherapy. There were 26 treatment sites. The size of the tumours ranged from 2.5 x 2 cm to 24 x 26 cm. Hyperthermic treatments were given twice a week, for a total of five to 14 sessions. Twenty-one tumours were treated by hyperthermia combined with radiotherapy, 2 Gy daily, five times a week, for a total of 40-78 Gy. Three tumours were treated by hyperthermia and arterial infusion of adriamycin, 100-120 mg in five or six treatments. For the superficial tumours the complete response rate was 40 per cent, and for the deep-seated tumours 6.2 per cent. Among the 12 tumours with no response, nine in which the treatment was evaluated as effective histologically (necrosis of the tumour) and by X-ray CT findings (development of a prominent hypodensity area) were included. Six cases were studied to correlate the X-ray CT findings, angiography and histological findings before and after hyperthermic treatment. The data were also used to interpret the thermal curve. The increased hypodensity area was roughly proportional to the development of necrosis, but there was one case in which hypodensity was not correlated with the necrosis. On the contrary, even in the contrast-enhanced area around the tumour in which the presence of residual tumour was strongly suspected clinically, no tumour cells were visualized. Clinical evaluation of the effect by size of the tumour can be supplemented by CT findings and histology, but should be cautiously adopted.

Localized operable soft tissue sarcoma of the upper extremity. Presentation, management, and factors affecting local recurrence in 108 patients

Radical ablative surgery for upper extremity sarcoma often results in significant loss of function. With the recent emphasis on limb preservation, function-sparing excision has been combined with adjuvant radiation and chemotherapy in an increasing number of patients. To assess the effect of changing management on local recurrence rates and identify factors governing local failure, the records of 108 patients with operable, nonmetastatic soft tissue sarcoma of the upper extremity, treated at the Memorial Sloan-Kettering Cancer Center between 1968 and 1978, were reviewed. Median follow-up care was 8.2 years. One third of the patients presented with locally recurrent tumors after initial treatment elsewhere. Over half of the lesions were above the elbow and 62% were high grade. Seventy-three patients (68%) had limb-sparing surgery (LSS), but margins were considered adequate in less than half. Local recurrence was directly related to the adequacy of the surgical margins and was significantly higher in the LSS patients (p = 0.008). Other factors associated with an increased risk of local failure included: presentation with local recurrence, superficial location, and invasion of vital structures (LSS only). Local failure varied significantly with histologic type and was highest in patients with embryonal rhabdomyosarcoma and angiosarcoma. When the data were subjected to multivariate analysis, the following variables emerged as independent predictors of local failure: presentation with local recurrence, surgery by LSS, inadequate margins, angiosarcoma, and invasion of vital structures. These risk factors should be carefully weighed when selecting local treatment for patients with upper extremity soft tissue sarcomas.

Limb salvage for skeletal and soft tissue sarcomas. Multidisciplinary preoperative therapy

One hundred eighty-three patients with malignant skeletal (83) or soft tissue sarcoma (100) were entered into the multimodality preoperative limb salvage protocol. Local recurrences were observed in 5 of 183 (2.7%). Six patients required amputation because of complications, and 13 patients died within 1 year from metastatic disease. There was no statistical difference in survival rates between a series of patients who had amputation and adjuvant therapy and patients treated by limb salvage and adjuvant therapy. Overall survival rates for patients with soft tissue sarcoma were 76%. Although the exact reason for the improved local control is not known, it is our belief that it is the result of the multidisciplinary therapy that destroys microscopic disease at the periphery of the primary tumor.

Primary retroperitoneal soft-tissue sarcomas

Of the 98 soft-tissue sarcomas treated between 1973-1978, 12 were retroperitoneal in origin. Fifty percent underwent one to three previous surgical procedures. All patients were operated on. In 75% (nine out of 12), the tumor was completely resected. The operative mortality for total tumor excision was 11%. There were five liposarcomas, three leiomyosarcomas, two neurofibrosarcomas, and one synovial sarcoma and one unclassified sarcoma. Six of the 12 patients survived five years and three (25%) were alive without evidence of disease at 5 years. Three of the completely resected group received no further treatment; 2/3 survived 5 years; three had postoperative chemotherapy; 3/3 survived; and three others had radiation and chemotherapy subsequent to surgery; all three have died. The two most important prognostic factors were tumor grade and surgical excision. Only one patient with high grade tumor survived. Total surgical excision of the tumor offers the only hope for cure. Aggressive surgery in treating retroperitoneal soft part sarcomas is strongly recommended.

Preoperative radiation therapy of high malignancy grade soft tissue sarcoma. A preliminary investigation

Twenty-three patients with high malignancy grade soft tissue sarcoma received irradiation (about 40 Gy) followed by surgery. The follow-up time was 62 months or more in all patients. The local recurrence rate was 9 per cent (2/23). One of the patients was reoperated and is living free of disease, giving a local control rate of 95 per cent. Thirty per cent (7/23) of the cases developed distant metastases and died of the disease. Delayed wound healing was observed in 2 cases which was possibly due to the radiation therapy. Since surgery was regarded non-radical in 5 cases, the local control obtained by the combined radiation therapy and surgery is good and should be the subject for further investigations.

Adjuvant chemotherapy of adult high-grade soft tissue sarcoma

Of 12 adult patients with high-grade soft tissue sarcoma receiving adjuvant chemotherapy and at risk for 36-84 months, 9 (75%) remain metastasis free and 10 (83%) have adequate local disease control with limb preservation. This is significantly better (P greater than 0.015) than a comparable "historic" control of 48 previously treated patients. The results correlate well with the few similar studies reported.

Management of soft tissue tumours by limited surgery combined with tumour bed irradiation using brachytherapy and supplementary teletherapy

Sixteen of 17 soft-tissue sarcomas were controlled by limited resection combined with high-dose radiation therapy using brachytherapy with or without supplementary cobalt teletherapy. Function was retained with preservation of the limb in all lesions in extremities. Adjuvant chemotherapy was used in four of five pathological Grade III cases.

Is amputation necessary for sarcomas? A seven-year experience with limb salvage

The rationale for amputation for local tumor control of skeletal and soft tissue sarcomas was based on results obtained from surgical therapy alone. However, our previous results from a pilot trial of multimodality therapy of preoperative chemotherapy and radiation therapy followed by surgical resection indicated that limb salvage (without amputation) could be accomplished in most patients with little morbidity and low recurrence rate. This report summarizes our experience in a prospective trial from January 1972 to December 1979. A total of 105 consecutive patients with soft tissue sarcomas (65 patients) or bone sarcomas (40 patients) were treated with preoperative intraarterial adriamycin, 3500 rads of rapid-fraction radiation and radical en bloc resection of primary tumor. Diseased bones were replaced with cadaver allografts (22 patients), metallic endoprostheses (10 patients) autologous bone (2 patients), or no replacement (ilium or fibula-4 patients). Salvage of a viable, neurologically intact, functional extremity was achieved in 98/105 patients (98%); 97% of limb salvage patients were free of local recurrence after a median follow-up period of 28 months. Major complication rate that required amputation was 3/105 patients (2%). Postoperative adjuvant chemotherapy with cyclical adriamycin and high-dose methotrexate was employed for all patients with osteosarcoma and 35 patients with grade III soft tissue sarcomas. The overall disease-free rate is 50% (18/35) for osteosarcomas and 65% (42/65) for soft tissue sarcomas. These results indicate that local tumor control can be achieved in 91% of patients without amputation. Their functional capabilities are excellent with a low complication rate. Since the advent of adriamycin and methotrexate has significantly improved the overall survival for patients with skeletal and soft tissue sarcomas, the quality of this survival has become even more important. Preoperative multimodality therapy is a major advance in this direction and since results of limb salvage procedures appear to be equal or superior to those achieved by amputation we believe these alternatives should be offered to all patients.

Comparison of radiotherapy with and without razoxane (ICRF 159) in the treatment of soft tissue sarcomas

Comparison of the recurrence rates of soft tissue sarcomas treated by radiotherapy (14 patients) or radiotherapy and synchronous administration of razoxane (19 patients) has shown a statistically significant benefit for those patients treated by the combination. No increase in tissue reactions or adverse side-effects (apart from a readily reversible leukopenia) was observed. The implication is that razoxane acts as a well tolerated adjuvant for radiotherapy.

Leiomyosarcomas of the extremities: angiography as a diagnostic aid

Thirteen cases of leiomyosarcomas of the extremities are reported. Most of the cases were operated on without information concerning benignancy or malignancy. Plain radiographs showed amorphous calcification in two cases. Three cases had angiographic study and all revealed malignant neovascularity. In no literature that we reviewed was angiography mentioned in the cases of leiomyosarcomas of the extremities. Venography alone has been done in many reported cases. The leiomyosarcoma of the extremities looks often benign but is notorious for local recurrences and distant metastases.

Limb salvage from a multidisciplinary treatment approach for skeletal and soft tissue sarcomas of the extremity

Multimodality management of extremity skeletal and soft tissue sarcomas with preoperative intra-arterial Adriamycin and radiation therapy, radical surgical resection and postoperative chemotherapy or chemo-immunotherapy has resulted in preservation of a functional extremity in 13 or 14 patients. Seven of 8 patients with Stage IIIA and IIIB soft tissue sarcomas, managed with preoperative intra-arterial Adriamycin and radiation therapy, followed by en bloc soft tissue resection and 6 patients with bone sarcomas managed by preoperative treatment, followed by bone resection and replacement with cadaver bone allografts, remained free of disease from 4 to 34 months. The results of the combined modality approach were significantly better than the results obtained in patients managed by surgical resection alone, or by combination of operation with another single modality, both in terms of short term-recurrence free survival and salvage of a functional extremity.