One hundred eighty‐three patients with malignant skeletal (83) or soft tissue sarcoma (100) were entered into the multimodality preoperative limb salvage protocol. Local recurrences were observed in 5 of 183 (2.7%). Six patients required amputation because of complications, and 13 patients died within 1 year from metastatic disease. There was no statistical difference in survival rates between a series of patients who had amputation and adjuvant therapy and patients treated by limb salvage and adjuvant therapy. Overall survival rates for patients with soft tissue sarcoma were 76%. Although the exact reason for the improved local control is not known, it is our belief that it is the result of the multidisciplinary therapy that destroys microscopic disease at the periphery of the primary tumor.

The rationale for amputation for local tumor control of skeletal and soft tissue sarcomas was based on results obtained from surgical therapy alone. However, our previous results from a pilot trial of multimodality therapy of preoperative chemotherapy and radiation therapy followed by surgical resection indicated that limb salvage (without amputation) could be accomplished in most patients with little morbidity and low recurrence rate. This report summarizes our experience in a prospective trial from January 1972 to December 1979. A total of 105 consecutive patients with soft tissue sarcomas (65 patients) or bone sarcomas (40 patients) were treated with preoperative intraarterial adriamycin, 3500 rads of rapid-fraction radiation and radical en bloc resection of primary tumor. Diseased bones were replaced with cadaver allografts (22 patients), metallic endoprostheses (10 patients) autologous bone (2 patients), or no replacement (ilium or fibula-4 patients). Salvage of a viable, neurologically intact, functional extremity was achieved in 98/105 patients (98%); 97% of limb salvage patients were free of local recurrence after a median follow-up period of 28 months. Major complication rate that required amputation was 3/105 patients (2%). Postoperative adjuvant chemotherapy with cyclical adriamycin and high-dose methotrexate was employed for all patients with osteosarcoma and 35 patients with grade III soft tissue sarcomas. The overall disease-free rate is 50% (18/35) for osteosarcomas and 65% (42/65) for soft tissue sarcomas. These results indicate that local tumor control can be achieved in 91% of patients without amputation. Their functional capabilities are excellent with a low complication rate. Since the advent of adriamycin and methotrexate has significantly improved the overall survival for patients with skeletal and soft tissue sarcomas, the quality of this survival has become even more important. Preoperative multimodality therapy is a major advance in this direction and since results of limb salvage procedures appear to be equal or superior to those achieved by amputation we believe these alternatives should be offered to all patients.

Our results indicate that it is technically possible to resect the hemipelvis and maintain a viable extremity. Functional results are remarkably good and tumor control has been equivalent to standard hemipelvectomy. Excision of the ilium with preservation of the extremity in selected cases would appear to be a reasonable alternative to the standard hemipelvectomy, which involves amputation of the extremity. Several reports have suggested that the necessary element for ultimate tumor control is adequate excision of the primary tumor, and that in Some instances 6 g c o m p l e t e 9 > local excision resulted in a cure rate equal to the more radical procedures.~,3.5 H~~~~~~, of this information was derived from treatment of tumors that arose in an anatomic location that did not directly involve the acetabulum.The purpose of our study was to determine the technical feasibility of the hemipelvis, the ilium, ischium and the pubis along with the contiguous sacral ala and the proximal femoral head, preserving a functionally intact distal extremity.to the hemipelvectomy. There were three males and two females, ranging in age from l 7 to 63 years with a median age Of 50 years. There were two patients with osteotwo had chondrosarcoma~ grades I and 11, respectively, and the fifth patient had chronic persistent osteomyelitis of the ilium.patients with osteoSarcoma were treated preoperatively with intraarterial adriamycin, after the placement Of a percutaneous indwelling catheter, to a total dose of 30 mgsOver 24 hours for each Of 3 consecutive days. They then were treated with rapid fraction radiation, 350 radslday for 10 days, to a total dose of 3500 rads to the involved hemipelvis.' Operation followed one week later. Operative ProcedurePatients were placed in a supine position and rotated obliquely to elevate the involved hemipelvis approximately 45". A downward incision began at the post-iliac crest, curved at the anterior iliac spine to: the upper one-third of the lateral aspect of the thigh, widely ellipvelopment of flaps at the level of the superficial muscle fascia, the abdominal muscula-

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Multimodality management of extremity skeletal and soft tissue sarcomas with preoperative intra-arterial Adriamycin and radiation therapy, radical surgical resection and postoperative chemotherapy or chemo-immunotherapy has resulted in preservation of a functional extremity in 13 or 14 patients. Seven of 8 patients with Stage IIIA and IIIB soft tissue sarcomas, managed with preoperative intra-arterial Adriamycin and radiation therapy, followed by en bloc soft tissue resection and 6 patients with bone sarcomas managed by preoperative treatment, followed by bone resection and replacement with cadaver bone allografts, remained free of disease from 4 to 34 months. The results of the combined modality approach were significantly better than the results obtained in patients managed by surgical resection alone, or by combination of operation with another single modality, both in terms of short term-recurrence free survival and salvage of a functional extremity.