Limb-sparing surgery without radiotherapy based on anatomic location of soft tissue sarcoma.

Abstract

From 1980 through 1986, 119 patients with soft tissue sarcomas of the extremities were referred to our tumor center either before surgery (n = 78) or immediately after incisional biopsy or marginal excision (n = 41). The tumors were classified according to anatomic location at admittance as subcutaneous (n = 40), intramuscular (n = 30), and extramuscular tumors (n = 49). Open biopsy was omitted in 75 of the 78 patients referred before surgery; the preoperative diagnosis was based on physical and radiographic findings and fine-needle aspiration cytology. The surgical intention for subcutaneous tumor was to obtain a wide margin, which required a cuff of fat tissue around the tumor and inclusion of the deep fascia beneath the tumor. A wide margin for an intramuscular tumor implied no open biopsy and an unbroken muscle fascia or thick muscle cuff around the tumor (primary myectomy). The 70 patients with subcutaneous and intramuscular tumors were all treated by local surgery. A wide margin was obtained in 56 patients who were not given radiotherapy. During a median follow-up of 5 years (range, 3.5 to 10 years), four of these 56 patients--47 of whom had high-grade malignant tumors--had a local recurrence. We conclude that routine combination of limb-sparing surgery with adjuvant radiotherapy is not necessary in patients with soft tissue sarcoma. Two thirds of soft tissue sarcomas of the extremities are primarily subcutaneous or intramuscular tumors, the majority of which can be treated by local surgery without local adjuvant therapy with a local recurrence rate of less than 10%, irrespective of malignancy grade.

Long‐term outcomes in extremity soft tissue sarcoma after a pathologically negative re‐resection and without radiotherapy

“…13,[19][20][21] Khanfir et al 5 studied the role of adjuvant RT in 133 patients treated with wide excision and a negative microscopic margin. They showed that adjuvant RT improved local control exclusively in patients with a minimal resection (margin <1 cm).…”

Centralization of soft tissue sarcoma

“…Mankin et al ( 1982Mankin et al ( , 1996 found that errors, complications, and changes in the course and outcome were 2-12 times greater when the biopsy was done outside, instead of in a treatment center. Furthermore, in some centers, especially in Scandinavia, many patients are treated without open biopsy; the diagnosis is based on findings from the physical examination, radiological investigations, and fine needle aspiration to avoid local tumor spread (see pages 54-59 and Rydholm et al 1991, Rydholm 1992. In the 1982 report by Mankin et al, one half of the sarcoma patients in the USA were referred only after open biopsy.…”

Soft Tissue Sarcomas

“…However, in Sweden radiotherapy is used to a lesser extent. Both low-grade and high-grade sarcomas which are subcutaneously localized or completely surrounded by a muscle fascia (intramuscular sarcoma) can be treated surgically without radiotherapy, and yet remain at low risk for local recurrence ( < lo%), with little functional loss (23). However, the fascia shall not have been opened by previous biopsy.…”

“…Several published studies of surgery and postoperative radiotherapy report local recurrence rates between 10% and 28% (8,23,(49)(50)(51)(52)(53)(54). The series from the MD Anderson Cancer Center is one of the first and largest, involving 300 patients (7).…”

“…The Scandinavian Sarcoma Group's (SSG) System for classifying tumor localization-subcutaneous, intra-and extramuscular-has no prognostic aims, but off ers guidance for selecting patients who can be treated by local surgery without radiotherapy (23).…”