Large, deep, high-grade extremity sarcomas: treating tumors of the flexor fossae

Soft tissue sarcomas of the popliteal fossa: a single-institution retrospective review

BACKGROUND

Soft tissue sarcomas (STSs) arising from the popliteal fossa present a challenge with regard to local control of primary tumors. Due to concerns of functional morbidity and neurovascular compromise, there is debate about what represents the best therapy for these patients.

METHODS

We conducted a retrospective medical record review of patients treated at The University of Texas M. D. Anderson Cancer Center for STS of the popliteal fossa from 1990 to 2008.

RESULTS

There were 47 eligible patients, 28 of whom were male and 19 of whom were female. Synovial sarcoma was the most common diagnosis, with 12 cases. Most patients had T2b tumors (31 patients; 66%). The median duration of follow-up was 3.8 years (range, 0.6-17.9 years). The 5- and 10-year overall survival rates were 63% and 51%, respectively. Metastasis at diagnosis was associated with poorer overall survival (5-year overall survival, 74% versus 13%; P<.001) and poorer recurrence-free survival (5-year recurrence-free survival, 51% versus 0%; P<.001) on univariate analysis. Radiation therapy improved local recurrence-free survival (5-year local recurrence-free survival, 56% versus 17%; P = .004), whereas a trend was observed for surgical margin status (P = .07). Tumor size and neurovascular involvement did not influence outcome. Twenty-two patients had recurrent disease, with 15 patients having local recurrence, and 16 patients died from progressive disease.

CONCLUSIONS

Radiation therapy may play an important role in the treatment of popliteal fossa STS, but further study is needed to better define the best clinical application. Additional study is needed to re-evaluate association of surgical margin status and outcome.

Late recurrent hemarthrosis following knee arthroplasty associated with epithelioid angiosarcoma of bone

We report a case of recurrent hemarthrosis 1 year following total knee arthroplasty in a patient with no bleeding diathesis, the hemarthrosis was found to be related to, and led to the diagnosis of high grade sarcoma of the proximal tibia. Twenty five years earlier, he sustained a lateral tibial plateau fracture and was treated with open reduction and plating. Sarcoma developing in association with a metallic orthopedic prosthesis or hardware is an uncommon, but well-recognized complication. Sarcomas that occur adjacent to orthopaedic prostheses or hardware are of varied types, but are usually osteosarcoma or malignant fibrous histiocytoma.

Surgical outcome of soft tissue sarcomas of the adductor compartment

PURPOSE

To review outcomes and complications of 25 consecutive patients with soft tissue sarcomas in the adductor compartment.

METHODS

Records of 11 men and 14 women aged 20 to 83 (mean, 56) years who underwent resection for soft tissue sarcomas in the adductor compartment were reviewed. Two of the patients had undergone inadequate resection of the tumour elsewhere. No patient had metastases. 20 and 2 patients underwent neo-adjuvant and postoperative radiotherapy, respectively. The interval between radiotherapy and surgery was at least 3 weeks. No neo-adjuvant chemotherapy was given. 24 patients underwent limb salvage surgery and one had external hemipelvectomy. 21 patients had direct wound closure; in 4 a microsurgical free flap was used.

RESULTS

The overall survival rate was 81% and 72% at 3 and 5 years, respectively, and remained unchanged until the end of follow-up. Four patients died from pulmonary metastases and one died from liver metastases. One patient had local recurrence, and 7 (26%) developed major complications. Five patients underwent revision surgery.

CONCLUSION

Good survival and local control rates can be achieved in patients with soft tissue sarcomas in the adductor compartment using limb salvage and radiotherapy.

Space sarcomas: extra compartmental soft tissue tumors of the lower extremities a systematic approach to sarcomas of the femoral triangle, sartorial canal, and popliteal space

BACKGROUND

Extra-compartmental soft tissue sarcomas may grow in virtual spaces in close proximity to major neurovascular structures and thus, require a complex resection. We analyzed the general principles by which these resections are planned.

METHODS

We retrospectively analyzed 53 patients with sarcomas located in the femoral triangle (15), sartorial canal (16), and the popliteal fossa (22). These lesions were grouped into three categories based on involvement of spatial structure; neurovascular involvement = 13, musculofascial involvement = 19 and no involvement = 11.

RESULTS

Limb sparing surgery was feasible in lesions that had either no structural or musculofascial involvement. Amputation, however, was required in 3 of 13 patients with neurovascular involvement because of gross involvement of the surrounding tissues. Overall, limb sparing was feasible in 94% (50 of 53 patients). The 2- and 5-year local recurrence rates were 10% and 14%, respectively. Five-year survival was 88%.

CONCLUSIONS

Limb sparing resection of space sarcomas is feasible in the majority of extra-compartmental sarcomas by utilizing a systematic approach which emphasizes specific planes of resection.

Popliteal sarcomas: presentation, prognosis, and limb salvage

Soft tissue sarcomas of the popliteal fossa are rare diseases. Resection is challenging because of their extracompartmental location and proximity to neurovascular structures. Their prognosis is inferior to intracompartmental extremity soft tissue sarcomas. We ascertained the mode of initial presentation, the rates of local recurrence and distant metastasis, and the morbidity and complications of limb salvage procedures. We retrospectively analyzed the data of 29 consecutive patients operated on between 1989 and 2003. The median followup was 79 months. Sixteen, five, and eight patients were diagnosed with high-, intermediate-, and low-grade tumors, respectively. High-grade tumors were smaller than low- and intermediate-grade tumors. Thirty-one percent of patients presented with localized pain. Of the 26 patients who had primary limb salvage resections, 14 had negative surgical margins, six had close margins, and six had positive margins. Seventeen patients were treated with radiotherapy and 10 patients received chemotherapy. The local recurrence rate was 10.3%, four patients with high-grade tumors had distant metastasis, and the limb-salvage rate was 86.2%. Postoperatively, six patients experienced wound dehiscence and four had mild flexion contractures. Soft tissue sarcomas of the popliteal fossa have an atypical presentation. Limb salvage can be accomplished in most patients with low morbidity and good systemic and local control.

Soft tissue sarcomas of the popliteal fossa: outcome and risk factors

BACKGROUND

Limb salvage surgery of popliteal soft tissue sarcomas may be hampered due to the incomplete anatomical containment of this region and the vicinity of neurovascular structures. The scope of this study was to determine outcome and to define risk factors.

PATIENTS AND METHODS

27 patients (53.3+/-15.8 y; 16/27 male) with popliteal soft tissue sarcomas were assessed. Mean follow-up was 40.9+/-33.8 months (48.5+/-36.7 months in surviving patients). 9/27 patients were included after prior treatment elsewhere (5 after intralesional resections and 4 local recurrences). The lesions were staged IB in 8/27 patients, IIB in 17/27 and III in 2/27. Immediate amputations were performed in 7/27 patients. 15/27 patients were subjected to radiation therapy (preoperative in 6/15 cases), 8/27 patients received chemotherapy (5/8 preoperatively).

RESULTS

Overall survival and disease-free survival at 5 y was 63.0% and 59.5%. Local recurrence occurred in 2 patients. 8/27 patients developed metastatic disease after 28.9+/-9.8 months. Survival (p=0.397) and disease-free survival (p=0.113) did not differ in patients after amputations vs limb salvage. Application of radiation therapy was associated with a better survival (p=0.003). Complications related to the surgical intervention were recorded in 2/27 patients, complications related to radiation therapy occurred in 6/15 patients.

DISCUSSION

Despite being extra-compartmental, popliteal sarcomas can be treated with a high rate of limb salvage while equal safety compared to amputations is maintained. Irradiation improved survival in our patient population. In cases with involvement of neurovascular structures, preoperative down-staging with radio or chemo-therapy may prevent amputation.

Preoperative Chemoradiotherapy (Modified Eilber Protocol) Provides Maximum Local Control and Minimal Morbidity in Patients With Soft Tissue Sarcoma

BACKGROUND

Local recurrence rates of 15% to 30% after treatment of soft tissue sarcoma (STS) are still common but unacceptable. Our hypothesis was that a refined neoadjuvant chemotherapy and radiation protocol (modified Eilber protocol) improves local control rates while minimizing major morbidity.

METHODS

Consecutive patients with STS deep to the fascia of the extremity or trunk during 1984 to 1996 were treated with 3 days of doxorubicin (30 mg/day) and sequential radiation (300 cGy/day for 10 days). Wide excision with limb preservation was performed 4 to 8 weeks after radiation completion. Treatment complications, margins, local recurrence, and survival were prospectively documented.

RESULTS

Of 75 patients, 66% had tumors >5 cm, and 71% were grade 2/3. In eight patients, negative margins were not achieved, and four of these had amputation (95% limb salvage). Three of the remaining four had local recurrence with a 5- and 7-year actuarial local control rate of 50% and 25%, respectively. In contrast, of the 67 patients with negative margins, a local control rate of 97% at 5 years and 94% at 7 years and an overall survival of 63% were achieved. Although margin (P = .001) and stage (P = .035) were correlated, these were not significant on multivariate Cox regression analysis. Risk factors for death included tumor stage (hazard ratio, 1.54; P = .001) and tumor grade (hazard ratio, 1.4; P = .02). Three patients (4%) required reoperation for tissue loss, and eight patients (10.6%) developed minor wound complications.

CONCLUSIONS

This modified Eilber protocol seems to maximize local control and minimize major wound complications for extremity/truncal STS.