Localized, operable soft tissue sarcoma of the lower extremity
C. Collin, S. I. Hadju, J. Godbold, M. H. Shiu, B. I. Hilaris and M. F. Brennan
Recent developments in adjuvant treatment of soft tissue sarcomas of the
extremities have altered the surgical approach to this disease. To assess
the effects of changing management on local recurrence rates and to examine
factors governing local failure, we reviewed the records of 315 adults with
operable, nonmetastatic soft tissue sarcoma of the lower extremity who were
treated at one institution over a ten-year period. The median follow-up was
8.2 years. One third of our patients presented with locally recurrent
tumors after initial treatment elsewhere. Sixty-six percent of the lesions
were above the knee, and 60% were high grade. Two thirds of the patients
underwent limb-sparing surgery (LSS), which in the latter half of the study
period outnumbered amputations by four to one. Local recurrence was
directly related to the adequacy of the surgical margins. Adjuvant
radiotherapy and chemotherapy did not significantly decrease local
recurrence in patients who underwent LSS, although favorable trends were
observed. A significantly increased risk of local failure was associated
with age greater than 53 years, presentation with local recurrence, high
tumor grade, deep location, positive nodes, and less than adequate surgical
margins. Local failure also varied significantly with histologic type and
was highest in patients with embryonal rhabdomyosarcoma and
neurofibrosarcoma. Improved local control, particularly in patients with
high-grade tumors, was observed in the latter half of the study period
despite the increased use of LSS. When the data were subjected to
multivariate analysis, the following variables emerged as independent
predictors of local failure: age greater than 53 years, presentation with
local recurrence, high grade, less than adequate margins, embryonal
rhabdomyosarcoma, and neurofibrosarcoma. The key to local control of
sarcomas of the extremities is resection of the tumor with adequate
margins. The role of adjuvant treatment, particularly following LSS, is
still being evaluated. The risk factor profile should be considered when
selecting a treatment program for patients with lower extremity sarcomas.
