Do Surgical Margin and Local Recurrence Influence Survival in Soft Tissue Sarcomas?

Abstract

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. Level of Evidence Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Extremity Soft Tissue Sarcoma Resections: How Wide Do You Need to Be?

“…Local recurrence rates have ranged considerably in previous reports, some of which can be attributed to varying inclusion and exclusion criteria and differences in the categorization of quantitative margin (Table 4). Our overall local recurrence rate of 3.4% for negative-margin patients with extremity soft tissue sarcoma echoes recent findings of other investigators [2,3,8,14,18,23,26]. Despite a number of reports suggesting a higher local recurrence rate associated with close margins of 1-2 mm or less [3,8,14,18], the rate of 4.4% in our study would suggest, as long as oncologic resection principles are followed and radiation is used judiciously, close margins can be tolerated to minimize morbidity and maximize function of the patient with limb salvage.…”

“…However, the margin status of the patients lost to followup did not differ from the overall patient population. Third, the followup interval was shorter than some historical reports although previous literature has documented the risk of local recurrence decreases after 3 years and our median followup of 44 months compares favorably to existing literature [3,4,14,18]. Fourth, the pathologic specimens were not all evaluated by the same pathologist and were not rereviewed to ensure consistency in reporting.…”

“…Investigators have attempted to assign quantitative values to various qualitative tissue planes in an effort to determine the appropriate clinical resection guidelines [10][11][12]. Few authors have looked specifically at the relationship between close but negative margins and local recurrence [2,8,14,16,18,19,21]. Evaluation of the literature is complicated by varying inclusion and exclusion criteria and numerous confounders.…”

What Are Risk Factors for Local Recurrence of Deep High-grade Soft-tissue Sarcomas?

“…Patients who develop a local recurrence from a soft-tissue sarcoma have a poor prognosis [1,7,8]. One study suggests the development of a local recurrence is the most important factor associated with decreased survival, and once patients develop a local recurrence, they are about three times more likely to die from disease compared to patients who do not develop a local recurrence [6].…”

“…One study suggests the development of a local recurrence is the most important factor associated with decreased survival, and once patients develop a local recurrence, they are about three times more likely to die from disease compared to patients who do not develop a local recurrence [6]. Novais et al [8] confirmed local recurrence independently predicts survival after adjusting for all major risk factors. Contemporary multimodal treatment of primary soft-tissue sarcoma reportedly reduces the incidence of local recurrence [1,6].…”