Consequences of local recurrence of soft tissue sarcoma: 205 patients from the Scandinavian Sarcoma Group Register

125I Radioactive Seed Localization vs. Conventional Surgery for the Treatment of Mesenchymal Tumours: A Propensity Score Matching Analysis

PURPOSE

Radioguided localization can assist the surgery of hard-to-find lesions. The aim was to evaluate the results of the 125I Radioactive Seed Localization (RSL) technique to guide a margin-free tumoral resection of mesenchymal tumours compared to conventional surgery and its influence in oncological outcomes.

METHODS

Retrospective observational study of all consecutive patients who underwent 125I RSL for the surgery of a mesenchymal tumour from January 2012 to January 2020 in a tertiary referral centre in Spain. The control group was formed by patients with conventional surgery in the same period and centre. A Propensity Score matching at 1:4 ratio selected the cases for analysis.

RESULTS

A total of 10 lesions excised in 8 radioguided surgeries were compared to 40 lesions excised in 40 conventional surgeries, with equal proportion of histological subtypes in each group. There was a higher proportion of recurrent tumours in the RSL group (80 % [8/10] vs. 27.5 % [11/40]; p: 0.004). An R0 was achieved in 80 % (8/10) of the RSL group and 65 % (26/40) of the conventional surgery group. The R1 rate was 0 % and 15 % (6/40), and the R2 rate was 20 % (2/10 and 8/40) in the RSL group and conventional surgery group, respectively (p: 0.569). No differences were detected in disease-free or overall survival between the different histological subtypes in the subgroup analysis.

CONCLUSION

The 125I RSL technique of a challenging sample of mesenchymal tumours achieved a similar margin-free tumoral resection and oncological outcomes as conventional surgery.

Adult Soft-Tissue Sarcomas of the Extremities

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Soft-tissue sarcomas (STS) in adults comprise a heterogeneous group of tumors of mesenchymal origin that share similar biological patterns of local tumor growth and metastatic dissemination.

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The judicious use of imaging studies, biopsy techniques, and pathological evaluations is essential for accurate diagnosis and for planning treatment strategy.

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Wide local resection and radiation therapy form the cornerstone of management of high-grade STS. The role of adjuvant radiation therapy is questionable in the management of small (≤5 cm) superficial lesions that can be resected with negative margins. Chemotherapy given to patients who have nonmetastatic, high-grade STS results in varying benefit in terms of local tumor control and overall survival.

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Coordinated care by a multidisciplinary team of trained surgeons, medical oncologists, radiologists, radiation oncologists, and pathologists has been documented to improve local tumor control and the overall survival of patients with STS.

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Although considerable progress in tumor diagnostics and targeted therapies has been made over the past 2 decades, recommendations and controversies relating to tumor imaging and margins of resection have not changed.

Assessing the Safety and Utility of Wound VAC Temporization of the Sarcoma or Benign Aggressive Tumor Bed Until Final Margins Are Achieved

BACKGROUND

Local recurrence of microinvasive sarcoma or benign aggressive pathologies can be limb- and life-threatening. Although frozen pathology is reliable, tumor microinvasion can be subtle or missed, having an impact on surgical margins and postoperative radiation planning. The authors' service has begun to temporize the tumor bed after primary tumor excision with a wound vacuum-assisted closure (VAC) pending formal margin analysis, with coverage performed in the setting of final negative margins.

METHODS

This retrospective analysis included all patients managed at a tertiary referral cancer center with VAC temporization after soft tissue sarcoma or benign aggressive tumor excision from 1 January 2000 to 1 January 2019 and at least 2 years of oncologic follow-up evaluation. The primary outcome was local recurrence. The secondary outcomes were distant recurrence, unplanned return to the operating room for wound/infectious indications, thromboembolic events, and tumor-related deaths.

RESULTS

For 62 patients, VAC temporization was performed. The mean age of the patients was 62.2 ± 22.3 years (median 66.5 years; 95% confidence interval [CI] 61.7-72.5 years), and the mean age-adjusted Charlson Comorbidity Index was 5.3 ± 1.9. The most common tumor histology was myxofibrosarcoma (51.6%, 32/62). The mean volume was 124.8 ± 324.1 cm³, and 35.5% (22/62) of the cases were subfascial. Local recurrences occurred for 8.1% (5/62) of the patients. Three of these five patients had planned positive margins, and 17.7% (11/62) of the patients had an unplanned return to the operating room. No demographic or tumor factors were associated with unplanned surgery.

CONCLUSIONS

The findings showed that VAC-temporized management of microinvasive sarcoma and benign aggressive pathologies yields favorable local recurrence and unplanned operating room rates suggestive of oncologic and technical safety. These findings will need validation in a future randomized controlled trial.

Efficacy of hyperthermic isolated limb perfusion in the treatment of locally recurrent high-grade soft tissue sarcoma of the extremities

Background

This novel study compared the use of tumor necrosis factor (TNF)-alpha and melphalan-based isolated limb perfusion (TM-ILP) to the standard treatment of locally recurrent soft tissue extremity sarcoma. The aim was to assess whether TM-ILP positively influences the recurrence-free survival of locally recurrent high-grade soft tissue sarcoma (STS) of the extremities.

Methods

We retrospectively analyzed our clinical database for patients with STS. Variables were analyzed using chi-square test or Mann-Whitney rank-sum test. Furthermore, Kaplan-Meier survival plots were calculated and a proportional hazard regression model was developed.

Results

Out of 448 patients with extraabdominal STS treated between August 2012 and December 2015, 52 cases involving 47 patients had locally recurrent STS. Twenty-eight of these patients were treated with TM-ILP prior to surgical resection (TM-ILP-group), and 24 were treated with standard therapy (without TM-ILP). The 3-year recurrence-free survival for the TM-ILP-group was estimated at 75% (95% confidence interval (CI), 71.5–78.5). Local recurrence-free survival in the standard group was significantly lower (LRFS: 43.4%, 95% CI 38.7–48.1, p = 0.026). Multivariable analysis revealed resection with negative margins, lower number of previous recurrences, and TM-ILP as positive predictors for recurrence-free survival.

Conclusions

TM-ILP and consecutive resection of residual tumor with negative resection margins significantly improves local recurrence-free survival for patients with a first local recurrence of high-grade STS in the extremities.

Intraoperative Localization Using an Implanted Radar Reflector Facilitates Resection of Non-Palpable Trunk and Extremity Sarcoma

BACKGROUND

Resecting non-palpable soft tissue tumors presents a unique challenge, particularly with recurrent disease in which surrounding tissue has been surgically manipulated and often irradiated. SAVI SCOUT^® is a radar-based localization device that was developed for breast tumor localization and was recently FDA-approved for localization of soft tissue tumors. Application of this technology to soft tissue sarcoma has not been previously reported.

METHODS

We assembled a single-institution retrospective case series of patients with trunk and extremity sarcomas resected by five sarcoma surgeons using SAVI SCOUT^® from December 2018 to May 2020. Reflectors were placed preoperatively using image-guidance, and the radar detector was used intraoperatively to localize the target lesion. Clinical variables were abstracted from the electronic medical record including treatment history, pathology, and early oncologic outcomes. Using a focused review, we compared margin status and recurrence rates with previously published cohorts.

RESULTS

Ten SAVI SCOUT^®-localized sarcoma resections were performed. Eight were for locally recurrent disease, of which seven (83%) had prior radiation. The remaining lesions became non-palpable after neoadjuvant chemotherapy. SAVI SCOUT^® facilitated resection in all cases with a margin-negative resection rate (77%) comparable to prior cohorts. In this high-risk population with a median follow-up of 14 months, only one patient recurred locally 7.5 months after SAVI SCOUT^®-localized resection, requiring re-resection.

CONCLUSION

SAVI SCOUT^® technology facilitated resection of non-palpable recurrent sarcoma of the trunk and extremities in all ten cases attempted. In a high-risk patient population, the pattern of recurrence has been primarily distant with one instance of local tumor recurrence.

Cost-effectiveness analysis of imaging surveillance in stage II and III extremity soft tissue sarcoma: an Australian perspective

Background

Surveillance imaging is used to detect local and/or distant recurrence following primary treatment of localised soft tissue sarcoma (STS), however evidence supporting optimal surveillance modality or frequency is lacking. We used prospectively collected sarcoma data to describe current surveillance imaging practice in patients with AJCC stage II and III extremity STS and evaluate its cost-effectiveness.

Methods

From three selected Australian sarcoma referral centres, we identified patients with stage II and III extremity STS treated between 2009 and 2013. Medical records were reviewed to ascertain surveillance imaging practices, including modality, frequency and patient outcomes. A discrete event simulation model was developed and calibrated using clinical data to estimate health service costs and quality adjusted life years (QALYs) associated with alternative surveillance strategies.

Results

Of 133 patients treated for stage II and III extremity STS, the majority were followed up with CT chest (86%), most commonly at 3-monthly intervals and 62% of patients had the primary site imaged with MRI at 6-monthly. There was limited use of chest-X-ray. A discrete event simulation model demonstrated that CT chest screening was the most cost effective surveillance strategy, gaining additional QALYs at a mean incremental cost of $30,743. MRI alone and PET-CT alone were not cost-effective, whilst a combined strategy of CT + MRI had an incremental cost per QALY gained of $96,556.

Conclusions

Wide variations were observed in surveillance imaging practices in this high-risk STS cohort. Modelling demonstrated the value of CT chest for distant recurrence surveillance over other forms of imaging in terms of cost and QALYs. Further work is required to evaluate cost-effectiveness in a prospective manner.

Surgical resection margin classifications for high-grade pleomorphic soft tissue sarcomas of the extremity or trunk: definitions of adequate resection margins and recommendations for sampling margins from primary resection specimens

Adequacy of surgical resection margins for soft tissue sarcomas are poorly defined because of the various classifications and definitions used in prior studies of heterogeneous patient cohorts and inconsistent margin sampling protocols. Surgical resection margins of 166 primary, high-grade, pleomorphic sarcomas of the extremity or trunk were classified according to American Joint Committee on Cancer R and Musculoskeletal Tumor Society categories, as well as by metric distance and tissue composition. None of the cases were treated with neoadjuvant therapy. Multivariable competing risk regression models were evaluated and optimal surgical resection margins for each classification system were defined. Minimum safe tumor clearance was 5 mm without use of adjuvant radiotherapy and 1 mm with adjuvant radiotherapy. Predictive accuracy of margin classification systems was compared by area under receiver-operating characteristic curves generated from logistic regression of 2½-year local recurrence-free survival and other standard tests of diagnostic accuracy. The Musculoskeletal Tumor Society and margin distance classifications performed similarly, both of which showed higher sensitivity and negative predictive value compared to the American Joint Committee on Cancer R classification. The prognostic power of close or positive margins in prediction models significantly increased when six or more slides were submitted for assessment of surgical resection margins. Surgical resection margins for soft tissue sarcoma should be reported using the Musculoskeletal Tumor Society classification or metric distance to the closest resection margin. Musculoskeletal Tumor Society wide/radical margins or tumor clearances of 5 mm (without adjuvant radiotherapy) or 1 mm (with adjuvant radiotherapy) appear to define the minimum safe surgical resection margins necessary to decrease the likelihood of local recurrence of high-grade pleomorphic sarcomas of the extremity or trunk.

Efficacy of radio-hyperthermo-chemotherapy as salvage therapy for recurrent or residual malignant soft tissue tumors

BACKGROUND

Recurrence after wide excision or residual tumor after an unplanned excision of a malignant soft tissue sarcoma (STS) is a complex problem, due to a higher recurrence rate and poorer survival rate compared with primary resection. Regional hyperthermia was used, with the expectation that it will enhance the anti-tumor effects of chemotherapy and radiotherapy. This study aimed to assess the efficacy of neoadjuvant concomitant radiotherapy, hyperthermia, and chemotherapy (RHC) for salvage of recurrent or residual malignant STS.

METHODS

We identified 64 patients with recurrent or residual STS treated between 1994 and 2013. After excluding those with low-grade malignancy, with recurrent bone tumor in the soft tissues, with truncal STS, and who declined to participate, 23 patients (7 with recurrence and 16 with residual tumor) underwent RHC. The histologic diagnoses were undifferentiated pleomorphic sarcoma (n = 11), synovial sarcoma (n = 3), leiomyosarcoma and myxoid liposarcoma (n = 2 each), and other histologic types. As primary outcomes, the 5-year overall survival (OS), distant metastasis-free survival (D-MFS), and local control (LC) rates were evaluated by Kaplan-Meier analysis.

RESULTS

The median follow-up period was 112.3 months. The 5-year OS, D-MFS, and LC were 86.4%, 77.4%, and 86.7%, respectively. In the univariate analysis, tumor depth was considered as a negative prognostic factor for OS and D-MFS, and a positive margin was also a negative prognostic factor for OS, D-MFS LC with retained on Cox proportional hazards model in OS, and D-MFS.

CONCLUSION

RHC is an effective option for salvage treatment of recurrent and residual STS.

What Is the Success of Repeat Surgical Treatment of a Local Recurrence After Initial Wide Resection of Soft Tissue Sarcomas?

BACKGROUND

Treatment for patients with locally recurrent soft tissue sarcomas after wide resection is challenging, and few studies have examined the results of treating these patients. In treatment of recurrent tumors, it has been reported that positive margins are correlated to local rerecurrence, but the relationship between surgical margin and survival remains controversial and risk factors for local recurrences after wide resection of soft tissue sarcomas are not well established. This study examined clinical outcomes and factors associated with survival and local rerecurrence in patients with local recurrence after initial surgical treatment who underwent another resection with a goal of negative margins.

QUESTIONS/PURPOSES

The purpose of this study was to determine (1) oncologic outcomes (survival rates and local rerecurrence-free rates) of surgical treatment for patients with local recurrence after wide resection; (2) whether factors associated with survival and local rerecurrence-free rates can be determined; and (3) the proportion of patients treated by amputation at final followup.

METHODS

Between 1992 and 2013, we treated 530 patients with soft tissue sarcoma without metastasis. Of those, 26 (5%) were lost before 3 years of followup but were not known to have died. Of the remainder, 59 have had a local recurrence. Of those with a local recurrence, 34 (58%) were treated with wide resection, whereas 25 (42%) were treated with nonsurgical treatment including chemotherapy and radiotherapy. During that period, our general indications for wide resection were patients (1) without distant metastasis; or (2) without distant lymph node metastasis, and contraindications were distant organ metastasis and/or distant lymph node metastasis. Of those treated with wide resection, 30 (88%) were available for followup. We conducted a retrospective analysis of these 30 patients with local recurrence (17 men, 13 women) who had previously undergone wide resection. Patient followup ranged from 1 to 12 years (median, 5 years). Survivorship (including overall survival and survival free from repeat recurrence) was ascertained by the Kaplan-Meier method. Factors associated with survival were evaluated by the log-rank test. Amputations were performed when limb-sparing surgery was deemed unsuitable because of extensive involvement of the limb by tumor, including invasion of multiple muscle compartments and neurovascular components. Survivorship free from amputation was ascertained by the Kaplan-Meier method.

RESULTS

Overall 5- and 10-year Kaplan-Meier survival rates after resection were 70% (95% confidence interval [CI], 50%-91%) and 44% (95% CI, 12%-76%), respectively, and 12 patients (40%) developed distant metastases after the second operation. Ten patients (33%) had additional local recurrences, and overall 5- and 10-year local rerecurrence-free rates were 66% (95% CI, 48%-85%) and 50% (95% CI, 18%-81%), respectively. A positive margin was associated with further recurrence (5-year local rerecurrence-free rates of positive margin: 20% [95% CI, 0%-52%], negative margin: 89% [95% CI, 74%-100%], p < 0.01) and with survival (5-year survival rates of positive margin: 36% [95% CI, 0%-75%], negative margin: 91% [95% CI, 74%-100%], p < 0.01). The survival rate was lower in patients with recurrence developing after 2 years (5-year survival rates of within 2 years: 46% [95% CI, 2%-90%], after 2 years: 83% [95% CI, 62%-100%], p = 0.01). The overall 5- and 10-year amputation-free rates were 86% (95% CI, 74%-99%) and 81% (95% CI, 67%-96%), respectively.

CONCLUSIONS

A surgical procedure with negative margins appears to be important for reducing the likelihood of local recurrences and improving survival of patients with rerecurrence after wide resection of soft tissue sarcomas. Although these findings need to be confirmed in larger studies, it appears that when tumor recurrence is evident within 2 years from the primary surgery, it is associated with a poor prognosis. Local recurrence within 2 years after wide resection may also be an indicator of aggressive tumor biology.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Higher complications after previous external beam radiation for extremity soft-tissue sarcoma in the surgical treatment of a local recurrence: a comparative retrospective study of one hundred and three patients

PURPOSE

The use of adjuvant radiation in the treatment of soft-tissue sarcoma (STS) is equivocal in selected cases. Our objective was to compare the short-term outcomes in patients operated on for a local recurrence who had radiation for the primary tumour to those who were spared radiation.

METHODS

This was a retrospective study of 103 patients treated for a local recurrence: 48 (47%) with previous radiation and 55 (53%) without. Our primary outcome criterion was to identify the differences in the local treatment provided. Secondary outcomes were the cumulative incidence of a surgical site infection/wound complication (SSI/WC), variables associated with SSI/WC, and local recurrence.

RESULTS

Amputation and the incidence of re-operation were significantly more frequent in patients who received previous radiation compared to patients without previous radiation (27% vs 9%, p = 0.02, for amputation; 26% vs 36% at 2 years for SSI/WC, p = 0.049). Multivariable regression models found previous radiation (p = 0.049), arteriopathy (p = 0.012), location at lower limb (p = 0.09), and use of a flap (0.0048) associated with the risk of SSI/WC.

CONCLUSIONS

Previous radiation is associated with an increased risk of amputation and reoperation for SSI/WC when treating a local recurrence. This information should be accounted for when deciding for the use of radiation.

Local Recurrence of Extremity Soft Tissue Sarcoma

The management of recurrent soft tissue sarcoma is a challenging problem for clinicians and has a significant physical, mental, emotional, and oncologic impact for the patient. Despite excellent limb-preservation therapies, approximately one-quarter of patients may eventually develop recurrence of disease. How to most appropriately manage these patients is a matter of debate. Several treatment options exist, including surgical resection, irradiation, systemic chemotherapy, amputation, and regional therapies. This article highlights the management of recurrent extremity soft tissue sarcoma.

CT guided cryoablation for locally recurrent or metastatic bone and soft tissue tumor: initial experience

Background

Historically, local control of recurrent sarcomas has been limited to radiotherapy when surgical re-resection is not feasible. For metastatic carcinomas to the bone or soft tissue, radiotherapy and some interventional radiology treatment along with other systemic therapies have been widely advocated due to the possibility of disseminated disease. These techniques are effective in alleviating pain and achieving local control for some tumor types, but it has not been effective for prolonged local control of most tumors. Recently, cryoablation has been reported to have satisfactory results in lung and liver carcinoma treatment. In this study, we analyzed the clinical outcome of CT-guided cryoablation for malignant bone and soft tissue tumors to elucidate potential problems associated with this procedure.

Methods

Since 2011, 11 CT-guided cryoablations in 9 patients were performed for locally recurrent or metastatic bone and soft tissue tumors (7 males and 2 females) at our institute. The patients’ average age was 74.8 years (range 61–86) and the median follow up period was 24.1 months (range 5–48). Histological diagnosis included renal cell carcinoma (n = 4), dedifferentiated liposarcoma (n = 2), myxofibrosarcoma (n = 2), chordoma (n = 1), hepatocellular carcinoma (n = 1), and thyroid carcinoma (n = 1). Cryoablation methods, clinical outcomes, complications, and oncological outcomes were analyzed.

Results

There were 5 recurrent tumors and 6 metastatic tumors, and all cases had contraindication to either surgery, chemotherapy or radiotherapy. Two and 3 cycles of cryoablation were performed for bone and soft tissue tumors, respectively. The average length of the procedure was 101.1 min (range 63–187), and the average number of probes was 2.4 (range 2–3). Complications included 1 case of urinary retention in a patient with sacral chordoma who underwent prior carbon ion radiotherapy, 1 transient femoral nerve palsy, and 1 minor wound complication. At the final follow up, 4 patients showed no evidence of disease, 2 were alive with disease, and 3 died of disease.

Conclusions

Reports regarding CT-guided cryoablation for musculoskeletal tumors are rare and the clinical outcomes have not been extensively studied. In our case series, CT-guided cryoablation had analgesic efficacy and there were no cases of local recurrence post procedure during the follow-up period. Although collection of further data regarding use of this technique is necessary, our data suggest that cryoablation is a promising option in medically inoperable musculoskeletal tumors.

Novel MR imaging method--MAVRIC--for metal artifact suppression after joint replacement in musculoskeletal tumor patients

Background

Standard imaging modality for the follow-up after prosthetic replacements for musculoskeletal tumor patients has been conventional radiography. This technique is effective in detecting subtle changes in bone adjacent to metal implants, but in many cases, radiographs do not lead to definitive diagnosis of postoperative adverse events such as acute infection, local recurrence of soft tissue tumor or soft tissue local recurrence of osseous sarcoma. Conventional MRI sequences have not been effective due to metal artifacts. In this study, we tried to elucidate the effectiveness of metal artifact suppression using novel sequence, multiacquisition variable-resonance image combination (MAVRIC), after musculoskeletal tumor surgeries.

Methods

We retrospectively analyzed 5 cases of malignant bone and soft tissue sarcoma patients who were reconstructed with metal prosthesis after wide resection of tumors. Images obtained using MAVRIC and short tau inversion recovery (STIR) were compared side by side. The paired MAVRIC and STIR images were qualitatively compared independently by two specialists for 4 parameters: visualization of bone - implant interface, visualization of surrounding soft tissues, image blurring, and overall image quality. Quantitatively, paired images were reviewed to identify the slice where the metal artifact was maximal, and a region of interest encompassing the implant and surrounding artifact was drawn using Advantage Workstation (GE Healthcare, Japan).

Results

There were no local recurrences that were detected. By utilizing MAVRIC, visualization of the bone - implant interface and visualization of the surrounding soft tissue were significantly improved in MAVRIC compared to STIR. Although blurring was worse on the MAVRIC acquisitions, the overall image quality was still better on MAVRIC. Quantitatively, the area of metal artifact measured using MAVRIC was markedly less compared to STIR (61.4 cm² vs 135.9 cm²).

Conclusion

Despite the relatively small number of cases in the present study, our observation strongly suggests that MAVRIC is able to improve the quality of images by decreasing the artifact caused by endoprosthesis, frequently utilized in reconstruction of musculoskeletal tumor patients. Further installments of conventional imaging sequences with the addition of gadolinium - enhancement will enable increased accuracy in diagnosing local recurrences of sarcoma patients.

Clinical practice guidelines for the diagnosis and treatment of patients with soft tissue sarcoma by the Spanish group for research in sarcomas (GEIS)

Soft tissue sarcomas (STS) constitute an uncommon and heterogeneous group of tumours, which require a complex and specialized multidisciplinary management. The diagnostic approach should include imaging studies and core needle biopsy performed prior to undertaking surgery. Wide excision is the mainstay of treatment for localized sarcoma, and associated preoperative or postoperative radiotherapy should be administered in high-risk patients. Adjuvant chemotherapy was associated with a modest improvement in survival in a meta-analysis and constitutes a standard option in selected patients with high-risk STS. In metastatic patients, surgery must be evaluated in selected cases. In the rest of patients, chemotherapy and, in some subtypes, targeted therapy often used in a sequential strategy constitutes the treatment of election. Despite important advances in the understanding of the pathophysiology of the disease, the advances achieved in therapeutic results may be deemed still insufficient. Moreover, due to the rarity and complexity of the disease, the results in clinical practice are not always optimal. For this reason, the Spanish Group for Research on Sarcoma (GEIS) has developed a multidisciplinary clinical practice guidelines document, with the aim of facilitating the diagnosis and treatment of these patients in Spain. In the document, each practical recommendation is accompanied by level of evidence and grade of recommendation on the basis of the available data.

Surgical resection of massive liposarcomas at the extremities: a 10-year experience in a referral musculoskeletal sarcoma unit

Background

There is still no consensus regarding the management of patients with massive liposarcomas located in the extremities. Several discrepancies related to the aggressiveness of the surgery and the application of concomitant radiotherapy and chemotherapy treatments remain controversial. The purpose of this study was to analyse the clinicopathological characteristics, prognostic factors and outcomes of a series of patients with massive liposarcomas of the extremities who were treated at a referral hospital specializing in musculoskeletal oncology.

Methods

This was an observational, descriptive and retrospective case series covering 10 years of clinical practice. The records of 26 adults, 14 men and 12 women, with localized massive liposarcomas in the extremities were studied. The average age was 53 years. The patients were treated from January 2003 until January 2012. Wide surgical resections with limb-sparing surgeries were performed for most patients (96.2 %).

Results

The average tumour size was 15.1 ± 6.8 cm in the greatest dimension. Regarding the histological subtypes, there were 11 well-differentiated or atypical lipomatous tumours (42.3 %), 10 myxoid (38.5 %) and 5 (19.2 %) round cell and pleomorphic liposarcomas. Regarding the malignancy grades, 19 cases (73 %) were classified as low grade. Among these low-grade tumours predominated the well-differentiated subtype (57.9 %). Within high-grade tumours, the round cell and pleomorphic subtype was most frequent (57.1 %; p = 0.011). Radiotherapy was additionally applied to 12 patients (46.2 %) and adjuvant chemotherapy to 5 (19.3 %). Tumour recurrence was observed in only 2 cases (7.7 %). Only 1 of these cases developed lung metastatic dissemination.

Conclusions

Across the entire series, these massive tumours did not compromise the survival of the patients. The histologic subtype and the malignancy degree were closely related. Proper and early diagnosis and therapeutic management of these patients via the application of wide-margin surgical excision are essential to ensure long-term survival.

Long-term outcome after local recurrence of soft tissue sarcoma: a retrospective analysis of factors predictive of survival in 135 patients with locally recurrent soft tissue sarcoma

BACKGROUND

The aim of this study was to identify prognostic indicators of survival in patients with locally recurrent soft tissue sarcoma (STS) through a long-term follow-up.

METHODS

We retrospectively assessed the relationship between post-recurrence survival (PRS) and potential prognostic factors in 135 patients who had experienced local recurrence, which was suitable for further surgical treatment. The median follow-up time after initial recurrence was 12.3 years (95% confidence interval (CI): 10.4-14.2 years).

RESULTS

The 5-year estimate of the PRS rate was 53.1% (95% CI: 44.3-61.2%) for the entire series. Patients with negative margins after the final surgery experienced improved survival compared with patients with positive margins (5-year survival: 46.7% (35.2-57.5%) vs 35.5% (23.4-47.8%); P=0.01). In a multivariate analysis, the significant prognostic indicators for PRS were histologic grade, tumour site, time to initial recurrence, the number of recurrences and the surgical margin status attained at the last resection.

CONCLUSIONS

Complete surgical resection with microscopically clear margins is desirable in patients with locally recurrent STS. However, when achieving clear surgical margins will require major functional impairment of the extremity, a radical surgical approach should be weighed for the patient in each case.

Surgical procedures and prognostic factors for local recurrence of soft tissue sarcomas

BACKGROUND

Patients with local recurrence of soft tissue sarcomas are predisposed to future recurrences because treatment is challenging and complicated by prior therapy. This study investigated clinical outcomes following surgical procedures for locally recurrent soft tissue sarcomas and risk factors for re-recurrence and metastasis.

METHODS

A retrospective analysis was conducted with 105 patients (52 males, 53 females) who underwent surgical procedures for local recurrence without distant metastasis of soft tissue sarcoma between 1987 and 2009. Patient follow-up ranged from 1 to 12 years (mean 4.9 years).

RESULTS

Overall 5- and 10-year survival rates were 83.4 and 67.7%, respectively. Twenty-one patients (20.0%) had additional local recurrences, and 23 (21.9%) had distant metastases. Amputation rate was 10.5% at the time of surgical procedures and 17.1% at final follow-up. Locations deep within muscles in the upper limb or trunk and surgical margins <1 cm wide were risk factors for further local recurrence. Locations deep within muscles, tumor sizes >10 cm, high-grade malignancy, and local recurrence after radical surgery were risk factors for distant metastasis.

CONCLUSIONS

Surgical margin and location were independent prognostic factors for local control, and a wider margin was especially important for recurrent tumors located in the trunk and upper extremity. For high-grade sarcomas with local recurrence after radical surgery, new approaches are needed to prevent distant metastases.

Predictors and clinical significance of local recurrence in extremity soft tissue sarcoma

BACKGROUND

Limb salvage surgery (LSS) has gained widespread acceptance as the current treatment for treating extremity soft tissue sarcoma (STS) and has been greatly refined since its inception. Combined with improved adjuvant treatment modalities, rates of local relapse have greatly decreased. Nonetheless, local recurrence still occurs and identifying the cause and the subsequent effects of local recurrence can provide valuable insights as LSS continues to evolve.

METHODS

This retrospective study evaluated 278 patients treated for STS of the extremities between 2000 and 2006. Of these, 41 patients developed a local recurrence while 247 did not. Tumor characteristics and prognostic outcomes were analyzed. Wilcoxon rank sum test and either χ(2) or Fisher's exact was used to compare variables. Kaplan Meier and Gray's test for cumulative risk were also performed.

RESULTS

Patients who had a positive margin were 3.76 times more likely to develop local recurrence when compared to those with negative margins. This corresponds to a 38% risk of local recurrence if the margins were positive after six years vs. 12% if the margins were negative. In patients who underwent a re-excision, the presence or absence of residual disease upon re-excision did not have any bearing on local recurrence (p = 0.27). In comparing patients with and without local recurrence, there was no statistically significant difference in the rate and the proportion encountering distant metastasis and death due to sarcoma (p > 0.05).

CONCLUSIONS

Despite advancements in surgery, radiation and imaging, positive margins still occur, and the presence of positive margins following definitive treatment continues to remain as a strong predictor for local recurrence. While local recurrence represents a negative outcome for a patient, its impact on future prognosis is influenced by a variety of factors such as time to local recurrence as well as the tumor's inherent biological characteristics.

Adult soft tissue sarcoma local recurrence after adjuvant treatment without resection of core needle biopsy tract

BACKGROUND

Core needle biopsies of sarcomas allow a diagnosis in a high percentage of patients with few complications. However, it is unclear whether the tract needs to be excised to prevent recurrences.

QUESTIONS/PURPOSES

We therefore determined the rates of recurrence and metastases in patients with Stage III extremity sarcomas, who underwent wide local resection without excision of the needle tract and also received adjuvant treatment.

METHODS

We retrospectively reviewed 59 adult patients with deep, larger than 5 cm, high-grade soft tissue sarcomas of the upper or lower extremity treated between January 1999 and April 2009. All the patients underwent a core needle biopsy. Resection was performed with wide margins. The biopsy tract was not resected during the definitive surgery. Fifty-seven patients (97%) received preoperative and/or postoperative radiation, whereas 49 patients (83%) received chemotherapy. Local recurrence and distant recurrence rates were determined. The minimum followup was 24 months (median, 56 months; range, 24-122 months).

RESULTS

The local recurrence rate was 9%. Fifteen patients (25%) developed metastasis after diagnosis. Seven of the 59 patients (12%) had microscopic positive margins at resection.

CONCLUSIONS

Our data demonstrate no increase in local recurrence rates or rates of metastatic disease compared with previously published studies when resection of the core biopsy tract was not performed.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Prognostic factors and metastatic patterns in primary myxoid/round-cell liposarcoma

Background. This study aimed to investigate prognostic factors for patients with myxoid/round-cell liposarcoma (MRCLS), in particular the significance of the round cell component, and to identify metastatic patterns as well as possibly suggest a suitable strategy for followup. Methods. Clinical, morphologic, and follow-up data from 160 patients with MRCLS was reviewed and statistically analysed. Results. Of 130 tumours with the round cell component evaluated, 61 had no round cell component, 27 had <5% round cell component, and 42 had >5%. All patients underwent surgical excision, 15 requiring amputation. 107 patients received adjuvant radiotherapy. Local recurrence occurred in 19 patients (12%), predominantly in patients with marginal or intralesional margins and a round cell component. Overall disease specific survival was 75% at 5 years and 56% at 10 years and was related to the proportion of round cell component. Of 52 patients who developed metastases, 38 (73%) had purely extrapulmonary metastases. We could not identify any factors predicting the site of metastases developing. Conclusions. The occurrence of any round cell component is the most important adverse prognostic factor for patients with MRCLS; patients with >5% round cell component are at higher risk of local recurrence, metastasis and tumour-related death and should be considered for adjuvant radiotherapy and possibly chemotherapy. The best method of monitoring extrapulmonary metastases remains to be established.

Clinical outcome of limb-salvage surgery after wide resection of sarcoma and femoral vessel reconstruction

BACKGROUND

Malignant sarcomas of the femur present major challenges in their management. Radical resection of sarcoma frequently requires concomitant major femoral vessel resection and reconstruction. We describe the clinical outcomes of vascular reconstruction, the long-term patency of vascular repair, and complications involved, and also discuss possible solutions to the problems associated with this procedure.

METHODS

In the past 15 years, 15 patients underwent wide resection of sarcoma of the femur with curative intent, including vascular reconstruction of the femoral arteries and/or veins. Arterial reconstruction was performed in 14 patients. In 12 patients, femoropopliteal reconstruction was performed with a contralateral great saphenous vein graft. In two cases involving femoroinguinal reconstruction, expanded polytetrafluoroethylene grafts were used because of unacceptable discrepancy. Myocutaneous flaps were used for covering of soft-tissue in 12 patients.

RESULTS

One patient developed a local recurrence and eight died because of their tumor. Seven patients remained completely free of recurrence after a mean follow-up time of 69 months. One case showed gradual deterioration with ischemic pain in the affected lower extremity requiring amputation. The remaining 14 cases showed sufficient vascularity primarily. Complications after surgery were noted in nine cases, with the most common being leg edema in five cases, wound infection in three, and lymphatic fistula in two. The average Musculoskeletal Tumor Society score at the final assessment was 24 points (80%).

CONCLUSIONS

For patients with sarcoma involving major vessels in the lower limb, wide resection followed by vascular reconstruction provides long-term local control and limb salvage with acceptable function. The complication rate from extensive resection and associated vascular reconstruction is high. The great saphenous vein graft produced results that were superior to prosthetic graft. Aggressive use of musculocutaneous flap transfers may help to minimize complications and reduce postoperative severe edema.

[Soft tissue sarcomas: clinical practice guidelines]

Soft tissue sarcomas (STS) constitute a rare heterogeneous group of tumours that include a wide variety of histological subtypes, which require a multidisciplinary and, frequently specialized and complex management. Despite advances in our understanding of the pathophysiology of the disease, there are no consensus multidisciplinary recommendations about its diagnosis and treatment in our country. The objective of these guidelines is to provide practical therapeutic recommendations that may contribute to improve the therapeutic results of this disease in our environment. With this purpose, the Spanish Group for Research in Sarcomas (GEIS) held a meeting with a multidisciplinary group of experts for the study and management of sarcomas. The results of this meeting are compiled in this document, in which recommendations on diagnosis, treatment and monitoring of soft tissue sarcomas are included. In summary, these guidelines aim to facilitate the identification and management of STS for clinical practice in Spain.

Local recurrence after initial multidisciplinary management of soft tissue sarcoma: is there a way out?

BACKGROUND

Multimodality treatment of primary soft tissue sarcoma by expert teams reportedly affords a low incidence of local recurrence. Despite advances, treatment of local recurrence remains difficult and is not standardized.

QUESTIONS/PURPOSES

We (1) determined the incidence of local recurrence from soft tissue sarcoma; (2) compared characteristics of the recurrent tumors with those of the primary ones; (3) evaluated local recurrences, metastases and death according to treatments; and (4) explored the relationship between the diagnosis of local recurrence and the occurrence of metastases.

METHODS

From our prospective database, we identified 618 soft tissue sarcomas. Thirty-seven of the 618 patients (6%) had local recurrence. Leiomyosarcoma was the most frequent diagnosis (eight of 37). The mean delay from original surgery was 22 months (range, 2-75 months). Mean size was 4.8 cm (range, 0.4-28.0 cm). Median followup after local recurrence was 16 months (range, 0-98 months).

RESULTS

Recurrent tumors had a tendency toward becoming deeper seated and higher graded. Nineteen of the 37 patients with recurrence underwent limb salvage (nine free flaps) and six had an amputation. Twenty-two (59%) had metastases, including 10 occurring after the local recurrence event at an average delay of 21 months (range, 1-34 months). Six patients developed additional local recurrences, with no apparent difference in risk between amputation (two of six) and limb salvage (four of 19).

CONCLUSIONS

Patients with a local recurrence of a soft tissue sarcoma have a poor prognosis. Limb salvage and additional radiotherapy remain possible but with substantial complications. Amputation did not prevent additional local recurrence or death.

Do surgical margin and local recurrence influence survival in soft tissue sarcomas?

BACKGROUND

Established prognostic factors influencing survival in soft tissue sarcomas include tumor stage, histopathologic grade, size, depth, and anatomic site. The presence of tumor near or at the margin of resection increases the risk of local recurrence but whether a positive surgical margin or local recurrence affect overall survival is controversial.

QUESTIONS/PURPOSES

We explored the impact of microscopic margin on local recurrence, metastasis, and overall survival in patients with intermediate- to high-grade soft tissue sarcomas of the extremities. We then determined whether local recurrence decreases overall survival.

METHODS

We retrospectively reviewed the medical records of 248 patients who had soft tissue sarcomas of the extremities treated surgically from 1995 to 2008. We estimated survival, local recurrence, and distant metastasis and examined factors potentially influencing these outcomes. The minimum followup was 0.4 years (median, 4.4 years; range, 0.4-13 years).

RESULTS

The 5-year cumulative incidence of local recurrence was 4.1%. Patients who presented with positive margins or a margin of 2 mm or less had a worse survival than patients who had margins of greater than 2 mm and wide margins (5-year survival, 47% versus 70% and 72%). In addition to surgical margin, developing metastasis, tumor response of less than 90% necrosis, high histopathologic grade, high AJCC stage (Stage III), increasing age, and male gender were associated with decreased overall survival. Local recurrence independently predicted decreased overall survival.

CONCLUSIONS

Microscopic surgical margin and local recurrence after surgical treatment should be included as risk factors predicting decreased overall survival for intermediate- to high-grade soft tissue sarcomas of the extremities.

[Surgical treatment of musculoskeletal soft tissue sarcomas]

Treatment of soft tissue sarcomas requires an individual plan which considers interdisciplinary recommendations and the various clinical situations. Anatomical region, histological grading and typing, and tumor size necessitate adjusted methods of reconstruction. The biopsy should be performed at the institution where the patient is treated. In general surgical resection of the tumor will be the treatment of choice. Adjuvant therapies are applied according to anatomical region and size and grading of the tumor. Surgery alone is recommended only in small (<5 cm), superficial, low-grade sarcomas. Sarcomas larger than 5 cm in diameter should be treated by surgery and radiotherapy, achieving excellent results, although in high-grade sarcomas more than 50% of patients still will experience metastatic disease. In case of locally recurrent disease, surgical revision with tumor-free resection margins followed by radiotherapy should be the aim. This applies even for patients who had had radiotherapy after the first excision. In this case brachytherapy is a good modality of tissue-sparing treatment.

Local recurrence of deep-seated, high-grade, soft tissue sarcoma: 459 patients from the Scandinavian Sarcoma Group Register

This study was based on 459 adult patients with deep, high-grade, soft tissue sarcoma of extremities or trunk wall reported to the Scandinavian Sarcoma Group Register (1986-1993). All patients had their definitive surgery for primary tumor at a sarcoma center. The median follow-up was 7.5 (3-12) years. 204 patients are still alive. 68 patients had amputations and 391 underwent limb-sparing surgery. Among 183 patients with intralesional or marginal margins after limb-sparing surgery, 65% had postoperative radiotherapy and 9% of the 198 patients with wide margins. The local recurrence rate after limb-sparing surgery was 26%. The rate with an intralesional or marginal margin was 39% without postoperative radiotherapy versus 24% when radiotherapy was given. It was 25% after a wide margin, and no recurrences were noted among the 10 patients with a compartmental surgical margin. Among patients with a wide margin, a subset fulfilling criteria for a myectomy was defined. The local recurrence rate was 26% among these 62 and there was no advantage of myectomy over other wide margins. More radical surgical margins would improve the local recurrence rate, but this can hardly be achieved in center-operated patients without increasing the amputation rate. Instead, increased use of radiotherapy in all patients with inadequate margins, and to a larger extent in those with wide margins will improve local control.

Liposarcoma: outcome based on the Scandinavian Sarcoma Group register

BACKGROUND

The aim was to study the clinicopathological characteristics, treatment, and outcome of liposarcoma in an unselected, population-based patient sample, and to establish whether treatment was according to the Scandinavian Sarcoma Group (SSG) treatment guidelines.

METHODS

The SSG Pathology Board reviewed 319 liposarcoma cases reported between 1986 and 1998. After the review, 237 patients without metastasis were analyzed for local recurrence rate in relation to surgical margins, radiotherapy, occurrence of metastasis, and survival.

RESULTS

Seventy-eight percent of the patients were primarily operated on at a sarcoma center, 45% with wide margins. All patients operated on outside the center had nonwide margins. Low-grade lesions constituted 67% of cases. Despite nonwide surgery, only 58% of high-grade lesions were treated with postoperative radiotherapy. The risk of local recurrence after nonwide surgery, without irradiation, was 47% for high-grade lesions. The estimated 10-year, local recurrence-free and metastasis-free survival in the low-grade group was 87% and 95%, respectively. In the high-grade group, it was 75% and 61%, respectively. Independent adverse prognostic factors for local recurrence were surgery outside a sarcoma center and histological type dedifferentiated liposarcoma. For metastases, they were old age, large tumor size, high grade, and histological type myxoid liposarcoma with a round cell component. Radiotherapy showed significant effect on local recurrence rate for the same grade and margin.

CONCLUSIONS

Patients with liposarcoma should be treated at specialized centers. Postoperative radiotherapy decreases the local recurrence rate. To maintain quality and provide support for further trials, reporting to quality registers is crucial.

Concomitant arterial and venous reconstruction with resection of lower extremity sarcomas

INTRODUCTION

Limb salvage can now be achieved in many cases of lower extremity sarcoma. Obtaining disease-free margins may require resection of adjacent vascular structures. We present our experience with a consecutive series of patients undergoing resection of lower extremity sarcomas en block with the artery and vein, focusing on the mid- and long-term outcomes of their vascular reconstruction.

METHODS

Records were reviewed retrospectively for patient age, tumor location and type, procedure, and early and late outcomes. Between 1991 and 2004, 10 children (mean age 12 years, range 6-18 years) and 9 adults (mean age 48 years, range 24-73 years) underwent wide resection of lower extremity sarcomas to include the involved arterial and venous segments. All children had bone sarcomas, and because of their skeletal immaturity, they were treated with rotationplasty--a type of intercalary amputation that removes the distal thigh, knee, and proximal tibia while preserving the distal leg and foot. In rotationplasty, the distal residual limb is preserved, rotated 180 degrees, and attached to the thigh, positioning the ankle at the level of the former knee joint. In these cases, the residual vessels were reconstructed by primary anastomosis. All of the adults except one had soft tissue sarcomas; the resected vessels were reconstructed with contralateral saphenous vein. In all cases, the operative approach included shunting of artery and vein during tumor removal and orthopedic reconstruction.

RESULTS

The mean follow-up was 5.7 years. Three patients died of metastatic disease, and one died from a postoperative pulmonary embolism. No patient had local recurrence. Two patients ultimately required above-knee amputation: one child for tissue loss secondary to reperfusion injury, and one adult because of graft thrombosis secondary to progression of peripheral arterial disease. Two patients required early re-exploration for perioperative graft thrombosis. Both required replacement of saphenous vein conduits with polytetrafluoroethylene (PTFE) prosthetic graft; one of the PTFE grafts became infected.

CONCLUSIONS

Limb salvage can be achieved in the majority of patients who have lower extremity sarcomas even when en bloc resection includes the artery and vein. Intraoperative shunting can limit ischemia and is especially useful when immediate vascular repair is delayed by orthopedic reconstruction. The long-term patency rate of the reconstructed vessels is high. Saphenous vein is the preferred conduit when it is of adequate caliber.

Extremity soft tissue sarcoma: adding to the prognostic meaning of local failure

BACKGROUND

We explored the prognostic meaning of local relapse and surgical margins in adult soft tissue sarcoma of the extremities.

METHODS

Out of a series of 1017 patients with extremity soft tissue sarcoma treated over 20 years, we picked a group of 238 patients operated on at our institution for their first local relapse: 88 after their primary operation performed at the same center and 150 elsewhere. At operation for relapse, margins were microscopically negative in 77% and 75% of patients, respectively. Median follow-up was 107 months.

RESULTS

The 10-year mortality rate was 22% in the absence of local relapse, whereas in locally relapsing patients it was 54% and 43%, respectively, for patients first operated on at our institute and for those who were not. The hazard ratio of positive versus negative surgical margins was 1.7 for cause-specific death and 2.1 for distant metastases in patients first operated on at our institute, as opposed to 1.2 and 1.3 for the others.

CONCLUSIONS

Local relapse was an unfavorable prognostic factor. In the face of a consistent surgical policy for local relapse in a single-institution setting, patients relapsing after the first operation performed at our institution received rescue treatment less frequently than those previously operated on outside a referral center. This is likely due to an inherently higher tumor aggressiveness. In the presence of such a higher aggressiveness, the adequacy of surgical margins at operation for first relapse seemed more critical prognostically. This may have clinical and speculative implications.

EFFECT OF RESECTION AND OUTCOME IN PATIENTS WITH RETROPERITONEAL SARCOMA

BACKGROUND

A consecutive series of 47 patients with retroperitoneal sarcoma (RPS) were resected and prospectively followed.

METHOD

Between July 1994 and March 2005, 47 patients (24 men, 23 women; mean age, 56 years; range, 17-82 years) were evaluated.

RESULTS

A total of 23 patients had primary RPS and 24 patients had recurrent RPS. A total of 30 out of 47 patients (64%) underwent removal of contiguous intra-abdominal organs. The peroperative mortality was nil and significant preoperative complications occurred in eight cases only (17%). High tumour grade and incomplete resection were significant variables for a worse survival in all 47 patients, both in the univariate and multivariate analyses (P = 0.008 and P = 0.016, respectively). Among 28 radically resected patients, only histological grade affected overall survival (90% 5-year survival for low-grade tumour vs 26% 5-year survival for high-grade tumour; P = 0.006) with a similar effect noted for disease-free survival.

CONCLUSIONS

Histological grade was the only factor that affected overall and disease-free survival for RPS tumours. An aggressive surgical approach in both primary and recurrent RPS is associated with long-term survival.

Surgical management of sarcomas

Nearly all bone and soft tissue sarcomas will require surgical management. Early consultation with a surgeon who is experienced in sarcomas, before a biopsy is performed, will avoid potential errors that may complicate subsequent surgery. Advances in imaging, neoadjuvant therapies, and reconstructive techniques have improved the ability to resect adequately most bone and soft tissue sarcomas. The use of oncologic and functional outcomes assessment tools facilitates the development of improved treatments for sarcoma patients. Results from major centers reveal that most patients who have a nonmetastatic bone or soft tissue sarcoma will survive 5 years after surgery when combined with either chemotherapy or radiation.

Prognostic factors for survival in patients with locally recurrent extremity soft tissue sarcomas

BACKGROUND

Factors prognostic for survival in patients with locally recurrent extremity soft tissue sarcomas (STS) are poorly defined, thus making it difficult to identify high-risk patients who may benefit from adjuvant therapy.

METHODS

A total of 1421 patients underwent surgical treatment for primary extremity STS at a single institution between 1982 and 2002. Of these, 179 (13%) patients underwent complete surgical resection of an isolated local recurrence and were the subjects of this study. Clinicopathologic factors from both the primary tumor and the local recurrence were analyzed.

RESULTS

The median interval to initial local recurrence was 16 months: 65% developed a local recurrence by 2 years and 90% by 4 years. Only four patients who presented with a low-grade primary tumor progressed to a high-grade local recurrence. Independent prognostic factors for disease-specific survival after local recurrence were a high histological grade (hazard ratio, 5.1; P = .0004), a large local recurrence tumor size (hazard ratio, 1.5; P = .0001), and a short local recurrence-free interval (hazard ratio, 1.6; P = .0001). Patients who developed a local recurrence >5 cm in < or =16 months (n = 44; 0 low grade) had a 4-year disease-specific survival of 18%, compared with 81% for patients who developed a local recurrence < or =5 cm in >16 months (n = 46; 11 low grade).

CONCLUSIONS

Histological grade, local recurrence size, and local recurrence-free interval are independently predictive of survival in patients with locally recurrent extremity STS. A large local recurrence that develops in a short interval indicates a biologically aggressive tumor with a high tumor-specific mortality. Patients who develop such recurrences are ideal subjects for systemic neoadjuvant therapy trials.

Biopsy of musculoskeletal tumours - beware

BACKGROUND

Biopsy of musculoskeletal tumours is hazardous and, when poorly performed, can compromise limb salvage surgery and patient survival. The aim of the present paper is to examine the early management of such patients referred to the Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Sydney, Australia with particular reference to biopsy.

METHODS

We conducted a prospective audit of all patients referred to our musculoskeletal tumour service during 2002. Inclusion criteria were: all patients with primary tumours of the musculoskeletal system. We compared the outcome of patients biopsied prior to referral with that of patients biopsied in a recognized treatment centre.

RESULTS

One hundred and forty-two patients were included. The referring surgeon performed biopsies in 29 cases, of which 20 were malignant lesions. The senior author biopsied the remaining 113 cases, of which 57 were malignant. Definitive treatment was hindered by a badly performed biopsy in 38% of patients biopsied by the referring surgeon. In 25% the definitive treatment had to be changed either to a more radical procedure than would have originally been necessary or to palliative rather than curative intent. Patients biopsied elsewhere were more likely to have an incomplete excision requiring re-excision, more likely to require amputation, and more likely to require adjuvant radiotherapy.

CONCLUSIONS

There is a high complication rate when patients with musculoskeletal tumours are biopsied by surgeons inexperienced in their management. These patients are better served by early referral to a specialist centre where staging investigations including biopsy can be performed with minimal morbidity.

TNFalpha-based isolated perfusion for limb-threatening soft tissue sarcomas: state of the art and future trends

The management of limb-threatening soft tissue sarcomas has not yet been standardized. Although local disease control does not affect overall survival, amputation or highly mutilating surgery may be required, which impairs the patient's quality of life. Various neoadjuvant approaches have been proposed to allow limb-sparing surgery for these locally advanced tumors. With TNFalpha-based hyperthermic isolated limb perfusion, the majority of patients can be spared amputation, with acceptable rates of locoregional and systemic complications. As yet, no other available treatment seems to give comparable results when applied to limb-threatening soft tissue sarcomas. Nevertheless, several issues remain to be addressed, such as the type and dose of drugs, repeatability of the procedure, association with radiotherapy, further indications, and evaluation of response. The authors describe the principles underlying TNFalpha-based hyperthermic isolated limb perfusion, review the worldwide experience so far published, and discuss the above issues. The potential future developments of this locoregional therapeutic approach will also be reported.

Primary adult soft tissue sarcoma: time-dependent influence of prognostic variables

PURPOSE

To define prognostic factors for postrelapse survival and their time-dependent influence for adult soft tissue sarcoma (STS).

PATIENTS AND METHODS

We analyzed 2,123 patients with completely resected localized primary STS treated from 1982 to 1999. Variables studied included tumor site, size, depth, grade, and resection margin but not treatment other than resection. Landmark time frames were used to assess the influence of disease-free interval (DFI) on disease-specific survival (DSS). DSS was estimated with the Kaplan-Meier method. Univariate and multivariate analyses were performed using log-rank test and the Cox proportional hazards regression model. Time-dependent stepwise regression analysis evaluated the time-dependent influence of each variable.

RESULTS

Two thirds of recurrences developed within 2 years of initial resection. Tumor size (P <.001), grade (P <.001), and microscopic resection margin (P <.001) independently predicted DSS for all STS. Size and grade independently predicted early (DFI <or= 3 years) and margin late (DFI > 3 years) DSS. Risk of tumor-related death was the same across all sites 3 years postresection and decreased significantly for extremity/trunk STS when DFI exceeded 3 years (P <.001). Influence of initial high-risk factors for tumor-related mortality in extremity/trunk STS decreased by 40% 3 years postresection, but their influence over DSS for non-extremity/trunk sites remained constant over time. Likelihood of complete resection after recurrence (all sites) increased with DFI (9% and 33% for DFI < 6 and > 36 months, respectively).

CONCLUSION

Tumor size, grade, and resection margin predict outcome for completely resected STS, and their influence for DSS is time- and site-dependent. The influence of prognostic factors changes over the natural history of extremity/trunk STS. Time to recurrence exerts significant influence over complete resection rates for recurrent disease.

Completely resected recurrent soft tissue sarcoma: primary anatomic site governs outcomes

BACKGROUND

We define the natural history and influence of primary anatomic site for completely resected locally recurrent soft tissue sarcoma (STS) without distant metastasis.

STUDY DESIGN

We selected 290 patients having at least one local recurrence (LR) after complete resection of primary STS (all sites) between 1982 and 1999. Of these, 239 patients had complete resection of their first LR: 161 extremity-trunk and 78 retroperitoneal-head and neck-visceral-thoracic sarcomas. Study end points included second local recurrence-free survival, distant recurrence-free survival, and disease-specific survival, estimated by the Kaplan-Meier method. Univariate and multivariate analyses were performed using a log-rank test and Cox's proportional hazards model for extremity-trunk and retroperitoneal (RP; n 39) tumor sites only.

RESULTS

Median followup was 82 months. Complete gross resection rates declined with each subsequent recurrence. Primary tumor site (extremity-trunk: relative risk ERR] 0.74, confidence interval [CI] 0.57 to 0.96, p = 0.03) and microscopic resection margin (negative: RR 0.80, CI 0.62 to 0.99, p 0.04) independently predicted subsequent local control. Extremity-trunk sire and high tumor grade were significant independent predictors of distant disease relapse after complete resection of LR. Site also had a notable influence on disease-specific survival: RP recurrence was associated with 1.4 times increased risk of tumor-related mortality (p = 0.02; 5-year disease-specific survival: extremity-trunk 70% versus RP 57%). High tumor grade was the most marked predictor of tumor-related mortality (RR 1.66, CI 1.28 to 2.18, p<0.001. Nine percent of extremity-trunk and 77% of RP STS-related deaths were caused by advanced LR without synchronous metastasis.

CONCLUSIONS

Site governs local control, distant recurrence-free and disease-specific survival for completely resected locally recurrent sarcoma without metastasis. Distant disease relapse determines outcomes for recurrent extremity-trunk STS, and local recurrence is the determinant of tumor-related death in the RP.

Pleomorphic rhabdomyosarcoma in an adult forearm: a case report

Pleomorphic rhabdomyosarcoma (RMS) is a rare malignancy, and treatment protocols for this tumor are not established. Although Intergroup Rhabdomyosarcoma Study data have led to improvement in overall and disease-free survival for children with juvenile RMS, the applicability of those findings to adult pleomorphic RMS is uncertain. This report presents the case of a 29-year-old man with pleomorphic RMS of the forearm (a location not previously reported in current literature); reviews the immunohistochemical, ultrastructural, and histologic diagnostic criteria; and discusses treatment.