The Landmark Series: Multimodality Treatment of Extremity Sarcoma
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CONTINUING EDUCATION– SARCOMA
The Landmark Series: Multimodality Treatment of Extremity Sarcoma Christina L. Roland, MD, MS1, Winan van Houdt, MD2, and Alessandro Gronchi, MD3 1
Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; 2Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands; 3Sarcoma Service, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
ABSTRACT Multimodality treatment of primary soft tissue sarcoma has evolved over the last 50 years, including seminal studies in amputation versus limb-sparing surgery, incorporation of radiation therapy (XRT), and the continuing controversy over the utilization and efficacy of systemic chemotherapy. We review the landmark studies in the multimodality management of primary extremity and trunk soft tissue sarcoma.
Multimodality treatment of soft tissue sarcoma (STS), consisting of [ 70 histologic subtypes,1,2 is the standard of care for patients with localized disease. Seminal works, including randomized studies evaluating limb-preservation, radiation sequencing, and systemic chemotherapy in the localized setting, have helped to inform the current recommendations. In this Landmark article, we review seminal studies in surgery, radiation therapy, and systemic chemotherapy to highlight the critical studies informing practice to date.
Ó Society of Surgical Oncology 2020 First Received: 27 May 2020 Accepted: 4 July 2020 A. Gronchi, MD e-mail: [email protected]
SURGERY AND RADIATION THERAPY Amputation Versus Limb-Sparing Resection for Localized Extremity Soft Tissue Sarcoma Purpose and Rationale The infiltrative nature of STS results in local recurrence of 30–50% when simple excision alone is performed for high-grade tumors. These high recurrence rates led to the use of amputation or radical compartment resections for primary treatment of STS, which resulted in a reduction of local recurrence to \ 5%, although with significant long-term morbidity. However, it was noted that, following complete resection via amputation, up to 40% of patients developed distant metastatic disease primarily to the lungs, leading to the introduction of wide local resection followed by radiation therapy (XRT) as an alternative option to obtain local control. This randomized trial was designed to compare local control following amputation versus limb-sparing surgery (LSS) ? XRT in patients with localized extremity STS.3 Study Design and Endpoints Patients with extremity STS treated at the National Cancer Institute (NCI) between 1975 and 1981 were randomized 2:1 to limb-sparing surgery ? XRT versus amputation. Patients were stratified based on primary tumor histology, tumor grade, time from diagnosis, and location (proximal or distal in the extremity). Amputation was performed at or above the joint and included all muscle groups. Patients in the LSS group underwent wide resection to include all gross tumor with several centimeters of surrounding normal t
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