Tailoring Surgical Therapy for Extremity Soft Tissue Sarcoma

Abstract

Limb-sparing multimodality therapy for extremity soft tissue sarcoma (ESTS) affords excellent disease control and functional outcomes in the majority of patients.1 In a study of 4977 extremity and superficial trunk STS, 20-25 % experienced recurrence, with some recurrent events occurring more than two decades after initial treatment. 2Determining the optimal surgical approach to minimize the risk of ESTS recurrence is a complex undertaking due to extreme biologic heterogeneity, with more than 100 histologic subtypes.3 The consideration of ESTS as a single entity is a matter of necessity rather than reason. The wide range of ESTS biologic behavior makes it exceedingly difficult to define broad policies or recommendations for most management dilemmas. 4 Bonvalot et al. conducted a retrospective study of 541 ESTS patients to examine the minimum necessary margin and the issue of mandatory re-excision followed unplanned resections.5 As stated in the title, the authors also set out to examine the relationship between local control of ESTS and survival. The lack of a causal link between ESTS local control and survival has been thoroughly verified previously and, as such, will not be the focus of this editorial. 6 Among all patients, 82 % underwent R0 resection and the median margin was 2 mm. The median follow-up of 7 years allows for reasonable survival and recurrence estimates. Local recurrences (LR) were experienced by 8 % and 20 % of patients died from all causes. Predictors of worse OS were grade, leiomyosarcoma subtype, and presence of residual disease upon re-excision. Importantly, 47 % of patients were treated following unplanned excision at other hospitals; 58 % of those patients had residual disease upon re-excision. LR was predicted by specific subtypes, such as myxofibrosarcoma, and a margin less than 1 mm.The impact of residual disease, likelihood of LR occurring before death due to distant metastases, and hence importance of re-excision after unplanned ESTS resection will vary by histologic subtype. In the present study, 22 % of patients had leiomyosarcoma, a disease in which distant recurrence predominates, with only 11 % experiencing isolated LR.7 Fewer than 10 % of patients had subtypes with highly aggressive LR patterns, including myxofibrosarcoma and dermatofibrosarcoma protuberans. Whereas deferring re-excision following an unplanned lower-extremity leiomyosarcoma resection may be appropriate in selected cases given that the outcome is driven by distant recurrence, omission in a myxofibrosarcoma patient would generally be inadvisable. As acknowledged by the authors, consideration of subtype biologic behavior is a critical factor when deciding if re-excision following unplanned ESTS surgery is warranted.The goal of reoperation following unplanned ESTS resection is to eradicate potential residual disease, prevent LR, and improve the likelihood of limb salvage. The majority of unplanned ESTS resections in the present study were indeed inadequate, because 58 % of patient who underwent re-excision were fo...

Working with Orthopedic Oncologists: When to Offer Immediate and when and why to Delay Definitive Reconstruction of an Extremity

“…The lowest rate of recurrence is found in patients with amputative or compartmental (radical) resections [4,5,7,10,24,25]. However, wide, radical excisions or amputative surgery may result in a significant loss of tissue, especially if the tumor is large in diameter.…”

“…Safe surgical margins are a condition sine qua non for optimal long term results. The definition "how much margin is safe" has evolved due to a better understanding of the biological mechanisms of malignancies and, as a result of the expansion of available management options for advanced extremity malignancies, in terms of surgical, including rehabilitative, and non-surgical therapeutic modalities, leading to an increased complexity of clinical decision making [1,2,4,7,10,11,17]. Nevertheless, the pivotal point for reconstructive considerations and CDPs that can be controlled by the patient and the surgeons, are surgical margins.…”

“…Cases where the diagnosis was not firmly established or confirmed, or where the focus was set on sparing the extremity instead of focusing on a long-term cure or patient survival under an established diagnosis, make an argument for delaying definitive reconstruction. Although not always possible in a preoperative or intraoperative setting, collecting the patient's complete clinical information may require the delay of reconstruction, but the delay may reduce the need for additional surgeries resulting from an inaccurate diagnosis or an uncertain situation regarding the margins [4][5][6][7][8][9]. Statistics such as a 25% chance of recurrence after a wide excision of an extremity soft tissue sarcoma, and up to a 95% chance of a high-risk cutaneous squamous cell carcinoma development (e.g., patients with bullous disease, immunosuppressed organ transplant recipients, scar-originating malignancy, deep or perineural invasion) within five years after primary excision, reaffirm the value of staged or delayed definitive reconstruction.…”

“…In other words, if performed without certainty of the diagnosis or the presence of clear margins, or in the event of a change in the clinical situation, the possibility that such a reconstruction might have to be revised or discarded in the future presents an argument for delayed reconstruction or at least a customized approach with defect temporization until all necessary information is known [7,[11][12][13].…”

“…Long term prognostic models have not yet been developed and it is unknown how the combination and the sequencing of the treatment modalities impacts the chance for a permanent cure [4,7,10,17]. The goal of this study was to critically analyze the authors' clinical experience and evaluate whether the rationale regarding the choice of immediate versus delayed reconstruction was optimally balanced.…”