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Soft
tissue sarcomas are a heterogeneous group of tumors arising from
the supporting extraskeletal mesenchymal tissues of the body—i.e.,
muscle, fascia, connective tissues, fibrous tissues, and fat. They are
rare lesions, constituting less than 1 percent of all cancers. There are
wide morphologic differences among these tumors, probably resulting from
the different cells of origin. However, like bone sarcomas, they all
share certain biological and behavioral characteristics. The clinical,
radiographic, and surgical management of most soft tissue sarcomas is identical, regardless
of histogenesis.
Soft tissue sarcomas are a disease of adulthood, occurring most commonly
in persons between 30 and 60 years of age. The sole exception is rhabdomyosarcoma,
which occurs in young children. Approximately one-half of soft tissue sarcomas are found
in the extremities; the remainder arise in the head/neck and trunk. The
lower extremity is the most common anatomic site; 40 percent of all soft tissue sarcomas
occur in this location. The anterior thigh (quadriceps) is the most common
compartment, followed by the adductors and hamstrings. Most soft tissue sarcomas present
as a painless mass. Systemic signs such as fever, weight loss, or anemia
are rare. There are no useful laboratory screening examinations. Clinical
suspicion is therefore crucial to diagnosis. Any adult presenting with
an extremity mass must be presumed to have a sarcoma until proven otherwise
and should be further evaluated. History of coincident trauma can often
be especially misleading. Unfortunately, a presumptive diagnosis of lipoma,
ganglion, hematoma, or muscle tear is often made, thereby delaying definitive
evaluation and treatment.
At our institution, we treat many high-grade soft tissue with pre-operative
chemotherapy. High-grade sarcomas of soft tissues often recur with surgery
alone. Administration of chemotherapy before surgery shrinks the tumors
(see figure, right) and allows for safer surgery with less risk of tumor
recurrence. This also allows us to avoid using post-operative radiation
therapy in nearly half of these patients. |
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Related
Publications |
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Henshaw
RM, Rubert C, Priebat D, Perry D, Shmookler B, Malawer MM. Survival
After Induction Chemotherapy and Surgical Resection for High-Grade
Soft Tissue Sarcoma. Is Radiation Necessary? Annals of Surgical
Oncology 2001 Jul;8(6):484-95.
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BACKGROUND:
Induction chemotherapy can produce dramatic necrosis in
sarcomas-raising the question of whether or not radiation
is necessary. This study reviews the clinical outcome of
a subset of patients with high-grade extremity soft tissue
sarcomas (STS) who were treated with induction chemotherapy
and surgical resection but without radiation.
METHODS: Nonmetastatic, large, high-grade STS of
the pelvis and extremities were treated with intra-arterial
cisplatin, adriamycin, and, after 1995, ifosfamide. After
induction, oncologic resection and histologic evaluation
were performed. Good responders with good surgical margins
were not treated with radiation.
RESULTS: Thirty-three patients, with a median follow-up
of 5 years, were included. Limb salvage rate was 94%. Median
tumor necrosis was 95%. Four patients developed metastatic
disease with three subsequent deaths. Two local recurrences
occurred; both patients were salvaged with reresection and
adjuvant external beam radiotherapy, although one died of
metastatic disease 10 years later. Relapse-free and overall
survival is 80% and 88% at 5 and 10 years by Kaplan-Meier
analysis.
CONCLUSIONS: Intensive induction chemotherapy can
be extremely effective for high-grade STS, permitting limb-sparing
surgery in lieu of amputation. Radiation may not be necessary
if a good response to induction chemotherapy and negative
wide margins are achieved. All patients with large, deep,
high-grade STS of the extremities should be considered candidates
for induction chemotherapy.
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ARTICLE AS PDF FILE (requires Adobe Reader)
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Felasfa M. Wodajo, MD; James Wittig, MD; Kari Mansour, BS; Dennis
Priebat, MD; Robert M. Henshaw, MD; Martin M. Malawer, MD. Close
Surgical Margins in Soft Tissue Sarcoma Resection Do Not Predict Local
Recurrence When Induction (Neoadjuvant) Chemotherapy is Used in the
Treatment of High Grade Extremity Soft Tissue Sarcoma. Podium
presentation at Society of Surgical Oncology annual meeting, March
2002, Washington, DC; poster presentation at Connective Tissue Oncology
Society annual meeting, November 2001, Palm Beach, FL.
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Henshaw, R., Priebat, DA, Perry, D, et al. Induction Chemotherapy
for High-Grade Extremity Soft-Tissue Sarcoma. In Proceedings
of the American Society of Clinical Oncology (ASCO), pp. Paper
2178, page 533a. Edited, Paper 2178, page 533a, 2000.
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