TREATMENT OF HIGH-GRADE SOFT-TISSUE SARCOMAS WITH LIMB SALVAGE SURGERY AND BRACHYTHERAPY PLUS EXTERNAL RADIATION THERAPY

Abstract

In the last fifteen years (1990–2005) at our Institution more than 600 patients affected by soft tissue sarcomas of the limbs and superficial trunk were surgically treated. We investigated the outcome and risk factors in a homogeneous group of 112 patients, affected by high-grade soft tissue sarcomas of the limbs (not metastatic at presentation) and treated with limb-sparing surgery, brachytherapy and conventional postoperative radiation therapy. Postoperative chemotherapy was added in one fourth of the cases.

The histologic types were liposarcoma (21.4%), leiomyosarcoma (19.6%), synovial sarcoma (17.9%), pleomorphic sarcoma or malignant fibrous histiocitoma (14.3%), fibrosarcoma (9.8%), other histotypes (17%).

All the tumors were high-grade (Broders grade 3 or 4). Size of the neoplasm was 10 cm or larger in 8 cases, 6 to 9 cm in 60 patients and 5 cm or smaller in 44 cases.

A limb-sparing surgical excision was performed in all the cases; histologically adequate margins were achieved in 96 cases (85.7 %). In 28 cases a myocutaneous or fasciocutaneous flap was necessary for local reconstruction.

At an average follow-up of six years, 67 patients (59.8%) were continuously disease-free; 8 patients (7.1%) had presented metastatic disease (in one case combined with local relapse) but were alive with no evidence of disease at last follow-up; 3 patients (2.7%) were alive with metastatic disease; 28 patients (25%) had died with disseminated disease; 6 (5.4%) had died of unrelated causes.

Local recurrence occurred in 10 patients (8.9%) requiring an amputation in 2; metastatic disease occurred in 39 patients (34.8%).

Four more patients required an amputation for complications different from recurrence: one early amputation for surgery-related complications and three late amputations for radiation-related complications (two not-healing fractures, one unresolvable wound sloughing).

Wound sloughing occurred in 12 patients (5 surgery-related and 7 radiation-related).

Local control rate, disease-free survival, overall survival and limb salvage rate were examined at 5 and 10 years, aiming also to identify tumor or treatment characteristics with prognostic value for the outcome.

The use of brachytherapy is an important option for achieving a significant boost in radiation within the surgical bed. Combined treatment with limb sparing surgery plus brachytherapy and external beam radiation therapy seems to offer satisfactory results in terms of local control and limb salvage survival. The use of myocutaneous or fasciocutaneous flaps is often useful in this kind of surgery, making possible a limb-sparing procedure with adequate oncological margins. New protocols and randomized studies on chemotherapy need to be introduced to improve systemic control and overall survival.