Purpose: Lymphoedema is a serious potential complication of the management of extremity soft tissue sarcoma (STS) about which relatively little is known. We aimed to evaluate the incidence of lymphoedema, its severity and associated risk factors following limb salvage for extremity STS.

Method: Lymphoedema severity (EORTC/RTOG) was recorded prospectively in two databases of soft tissue sarcoma patients. Patient’s demographics, tumor characteristics, surgical procedures, radiotherapy dosage, complications and functional outcomes (MSTS, TESS) were also prospectively collected. Charts were also retrospectively abstracted for body mass index (BMI) and medical comorbidities.

Results: 289 patients had sufficient data for analysis (158 male). Mean age was 53 (range 16–88). Mean BMI was 27.4 (range: 15.8–52.1). 209 had lower extremity tumors and 80, upper. Mean tumor size was 8.1 cm (range 1.0–35.6 cm). 77 had no adjuvant radiation, 180 had 50 Gy and 32, 66 Gy. The incidence of lymphoedema was found to be 28.7% (58 mild, 22 moderate, 3 severe). Mean MSTS score was 32 (range: 11–35) and TESS was 89.4 (range: 32.4–100). We grouped cases with lymphoedema grade 0–1 and 2–3. Univariate analysis found significant correlations between the severity of lymphedema and tumor size ≥5 cm (p=0.011), deep location (no patient with a superficial tumor had severe lymphoedema, p=0.001), and radiation dosage 50 vs 66 Gy (p=0.021) but not between upper vs lower extremity (p=0.06).

Conclusion: 9% of STS studied developped significant post-treatment lymphoedema. Large, deep tumors and necessity for 66 Gys were most at risk. This group could be targeted for prophylatic intervention.

Many authors believe that size, histological grade and depth are the best predictors of outcome in soft tissue sarcoma. Enneking’s surgical staging system included compartmental status, and was intended to guide surgical intervention as well as provide prognostic information. Advances in surgical and radiotherapy techniques may mean that extracompartmental status is no longer a poor prognostic factor. We compared a group of popliteal fossa sarcomas with a group from the posterior thigh, and found that although the former group required more extensive surgery to obtain wide margins, their functional and survival outcomes were similar.

No single staging system has been generally accepted for extremity soft tissue sarcoma, although histologic grade, size and depth are widely accepted as prognostic indicators. Enneking outlined a surgical staging system which used compartmental status as a predictor of outcome. However, surgical reconstruction and adjuvant radiotherapy have advanced considerably. We wanted to know if a tumour arising in the popliteal fossa still had poorer survival or functional outcome in the light of these advances.

We identified twenty-three patients who had sarcomas of the popliteal fossa and forty-six patients who had sarcomas of the nearby posterior thigh compartment. Popliteal sarcomas were not of a different size or more likely to present with metastasis. Popliteal tumours more frequently required reconstructive techniques such as local or free tissue transfer and skin grafting than posterior thigh tumours (39.1% v 4.3% respectively). Popliteal tumours were also more likely to undergo a dissection or reconstruction of the major neurovascular structures of the lower limb (30.4% v 0% respectively). There was no difference in local or systemic recurrence rates between the groups. TESS and MSTS 1987 functional scores also showed no difference between the groups.

We conclude that popliteal fossa sarcomas require a greater level of surgical intervention to follow sound principles of sarcoma resection and achieve reconstruction of the ensuing soft tissue defect. However, if these principles are followed in a planned multidisciplinary setting, then survival and functional results similar to the posterior thigh can be expected.

As patients live longer following treatment for soft tissue sarcomas, complications from treatment will continue to emerge. Predicting which patients are at risk allows for improved preoperative planning, treatment, and surveillance. The data presented here suggests that females greater than fifty-five years of age treated with high dose, postoperative radiotherapy in combination with limb salvage surgery for soft tissue sarcomas are at an increased risk of post irradiation fractures. Unlike previous reports, a significantly higher rate of fracture occurred in patients who received higher doses (60 or 66Gy) of radiation versus lower doses (50 Gy).

This retrospective study was performed to determine if the timing and dosage of radiotherapy are related to the risk of post radiation pathologic fracture following combined therapy for lower extremity soft tissue sarcomas. Three hundred sixty-four patients with sarcomas treated with external beam radiation therapy and limb salvage surgery were evaluated. High dose radiation was defined as 60 Gy or 66 Gy; low dose as 50Gy. Radiation timing schedules were preoperative, postoperative, or preoperative with a postoperative boost. Univariate and multivariate analysis was used to determine which factors were associated with fracture risk. Twenty- seven pathologic fractures occurred in twenty-three patients. Twenty- four fractures occurred in twenty patients who were treated with high dose radiation. Sixteen of these patients had postoperative radiation (fourteen patients received 66Gy, two received 60Gy), and four had pre-operative radiation with a postoperative boost (total dose = 66Gy). Three fractures occurred in three patients who received low dose preoperative radiation (50Gy). Both high dose radiation (versus low dose) (p=.001) and preoperative radiation (versus postoperative) (p =0.002) were associated with a risk of fracture. Findings in this study were consistent with previous reports in that females over fifty-five years of age who undergo removal of a thigh sarcoma combined with radiation therapy are at a higher risk of a pathologic fracture, and differs in that there was a significantly higher rate of fracture in patients who received higher doses (60 or 66Gy) of radiation versus lower doses (50 Gy), and when radiation therapy was given postoperatively versus preoperatively.

Lymph node metastasis in soft tissue sarcoma is considered to be a rare event (1.6–8.2%), From 1986 to 2001 1066 patients with extremity soft tissue sarcoma were treated surgically (+/− adjuvant therapy) at our institution.

Thirty-nine patients (3.6%) were identified with lymph node metastasis, most common histological subtypes were: Epitheliod sarcoma (3/15), rhabdomyosarcoma (4/21), clear cell sarcoma (2/18), and angiosarcoma (2/18).

Comparing expected five- year survivorship, we found that surprisingly in this study, extremity soft tissue sarcoma patients initially presenting with lymph node metastases had survival comparable to patients with high grade soft tissue sarcoma and no metastases.

To determine the outcome in patients with soft tissue sarcoma (STS) of the limbs that presented with lymph node metastasis (LNM) at diagnosis or developed them after it, comparing to all STS of limbs population that was treated at our center.

LNM in soft tissue sarcoma is considered to be a rare event (1.6–8.2%) with a devastating effect on the outcome,our study represent one of the largest reported cohorts, and suggest that agressive approach to LNM might contribute to survivorship.

Thirty-nine patients (3.6%) were identified with LNM along their course of disease

Thirteen patients presented with both lymphatic and systemic disease while twenty-six had isolated LNM at time of diagnosis. The mean follow-up from diagnosis of the primary tumor was 46.3 months (range zero to one hundred and forty-eight), and from diagnosis of lymph node involvement was 29.9 months (range zero to one hundred and twenty).

Expected five year survival in patients initially presenting with LNM was comparable to patients with high grade soft tissue sarcoma and no metastases.

From Jan’ 1986 to Dec’ 2001 1066 patients with extremity STS were treated at our institution.

Fifteen patients presented with LNM at time of first diagnosis, and twenty-four subsequently developed LNM after it.

Linear regression analysis and Kaplan-meier curves were used to compare expected survivorship in all patients with STS of limbs.

Comparing expected five- year survivorship, we found that Surprisingly in this study, extremity STS patients initially presenting with LNM had survival comparable to patients with high grade soft tissue sarcoma and no metastases.

We have investigated the significance of the method of treatment on the oncological and functional outcomes and on the complications in 184 patients with soft-tissue sarcomas of the adductor compartment managed at three international centres. The overall survival at five years was 65% and was related to the grade at diagnosis and the size of the tumour. There was no difference in overall survival between the three centres. There was, however, a significant difference in local control with a rate of 28% in Centre 1 compared with 10% in Centre 2 and 5% in Centre 3.

The overall mean functional score using the Toronto Extremity Salvage Score in 70 patients was 77% but was significantly worse in patients with wound complications or high-grade tumours. The scores were not affected by the timing of radiotherapy or the use of muscle flaps.

This large series of soft-tissue sarcomas of the adductor compartment has shown that factors influencing survival do not vary across the international boundaries studied, but that methods of treatment affect complications, local recurrence and function.

Aim: To explore the relationship between anatomical location in lower extremity soft tissue sarcoma and function as measured by the Musculoskeletal Tumour Society (MSTS 93) rating and Toronto Extremity Salvage Score (TESS).

Methods: 207 patients of median age 54 years (15 to 89) were reviewed. 58 tumours were superficial and 149 deep. Deep tumours were allocated to one of 9 locations based on anatomical compartments.

Results: Treatment of superficial tumours did not lead to significant changes in MSTS (mean 90.6% vs 93.0%, p=0.566) or TESS (mean 86.4% vs 90.9%, p=0.059). Treatment of deep tumours lead to significant reductions in MSTS and TESS (mean 86.9% vs. 83.0%, p=0.001. mean 83.0% vs. 79.4%, p=0.015). There were no significant differences in MSTS and TESS when overall scores were compared by anatomical location. Exploratory analysis of MSTS subscales showed groin tumours were more painful than others, and posterior calf tumours had the lowest scores for gait. TESS subscales analysis suggested groin and buttock tumours were associated with difficulty sitting, and groin tumours were associated with difficulty dressing. Further exploratory analysis suggested “conservative” surgical excision of low-grade liposarcomas in all locations was associated with a significant decrease in functional scores.

Conclusion: There is significant variation in MSTS and TESS subscale scores when anatomical locations are compared. The “conservative” surgery used in the treatment of low-grade fatty tumours in all locations has a significant impact on functional scores.

Introduction Morbidity associated with wound complications may translate into disability and quality-of-life disadvantages for patients treated with radiotherapy (RT) for soft tissue sarcoma (STS) of the extremities. Functional outcome and health status of extremity STS patients randomized in a phase III trial comparing pre-operative versus post-operative RT is described.

Methods One hundred and ninety patients with extremity STS were randomized after stratification by tumor size dichotomized at 10 cm. Function and quality of life were measured by the Musculoskeletal Tumor Society Rating Scale (MSTS), the Toronto Extremity Salvage Score (TESS), and the Short Form-36 (SF-36) at randomization, six weeks, and three, six, 12, and 24 months after surgery. One hundred and eighty-five patients had function data.

Results Patients treated with post-operative RT had better function with higher MSTS (25.8 v 21.3, P < .01), TESS (69.8 v 60.6, P =.01), and SF-36 bodily pain (67.7 v 58.5, P =.03) scores at six weeks after surgery. There were no differences at later time points. Scores on the physical function, role-physical, and general health sub-scales of the SF-36 were significantly lower than Canadian normative data at all time points. After treatment arm was controlled for, MSTS change scores were predicted by a lower-extremity tumor, a large resection specimen, and motor nerve sacrifice; TESS change scores were predicted by lower-extremity tumor and prior incomplete excision. When wound complication was included in the model, patients with complications had lower MSTS and TESS scores in the first two years after treatment.

Conclusions The timing of RT has minimal impact on the function of STS patients in the first year after surgery. Tumor characteristics and wound complications have a detrimental effect on patient function.

113 consecutive patients with soft tissue sarcoma treated by excision and reconstructive flaps were studied to assess the risk of complications and to compare local tumour control with those in whom primary wound closure was possible.

Minimum follow-up was 24 months and mean age was 55 years (16–95). The sarcoma was located in the lower extremity in 83 and upper extremity 30 patients. Significant wound complications developed in 37 patients (33%). The most common complications were wound infections or partial necrosis occurring in 16% (18/113) and 13% (15/113) respectively. Complete flap necrosis requiring flap removal occurred in 6 patients (5%). Three patients (2.3%) required amputation as a result of complications. Significant risk factors for development of wound complications include location of tumour in the lower limb compared to upper limb (relative risk 2.3, p=0.02) and use of pre-operative radiotherapy compared to no or post-operative radiotherapy (relative risk 2.05, p=0.02). There was no difference in rates of complications in patients with free or pedicled flaps, tumours < or > 5cm, distal or proximal location of tumour.

The rates of negative excision margins (80%) and wound complications in patients who required reconstructive flaps were not different from that for the other patients treated at our centre who did not require reconstructive flaps.

The use of soft tissue reconstructive flaps did not reduce the risk of positive excision margins or the rates of wound complications. The risk of amputation secondary to flap complication or failure is low.

812 consecutive patients with soft tissue sarcoma of the extremity were studied to compare the characteristics and outcome of patients who had primary amputations and limb preserving surgery.

Patients with primary amputations were more likely to have metastases at presentation, high-grade tumours, larger tumours and were older.

The most frequent indications for primary amputation were tumour excision which would result in inadequate function and large extracompartmental tumours with composite tissue involvement including major vessels, nerves and bone.

The requirement for primary amputation was a poor prognostic factor independent of tumour grade, tumour size and patients’ age.

To determine if rates of local recurrence and metastasis differ in upper versus lower extremity sarcomas.

Prospectively collected data relating to patients undergoing limb-sparing surgery for extremity soft tissue sarcoma between January 1986 and April 1997 were analysed. Local recurrence-free and metastasis-free rates were calculated using the method of Kaplan and Meier. Univariate and multivariate analyses of potential predictive factors were evaluated with the log-rank test and the Cox proportional hazards model.

Of 480 eligible patients, 48 (10. 0%) had a local recurrence and 131 (27. 3%) developed metastases. Median follow-up of survivors was 4. 8 years (0. 1 to 12. 9). There were 139 upper and 341 lower extremity tumours. Upper extremity tumours were more often treated by unplanned excision before referral (89 vs 160, p< 0. 001) and were smaller (6. 0cm vs 9. 3cm, p< 0. 000). Lower extremity tumours were more often deep to or involving the investing fascia (280 vs. 97, p< 0. 003). The distribution of histological types differed in each extremity. Fewer upper extremity tumours were treated with adjuvant radiotherapy (98 vs. 289, p< 0. 000).

The 5-year local recurrence-free rate was 82% in the upper and 93% in the lower extremity (p< 0. 002). Local recurrence was predicted by surgical margin status (hazard ratio 3. 16, p< 0. 000) but not extremity (p=0. 127) or unplanned excision before referral (p=0. 868).

The 5-year metastasis-free rate was 82% in the upper and 69% in the lower extremity (p< 0. 013). Metastasis was predicted by high histological grade (hazard ratio 17. 28, p< 0. 000), tumour size in cm (hazard ratio 1. 05, p< 0. 001) and deep location (hazard ratio 1. 93, p< 0. 028) but not by extremity (p=0. 211).

Local recurrence is more frequent after treatment for upper compared with lower extremity sarcomas. Variation in the use of radiotherapy and differences in histological type may be contributory. Metastasis is more frequent after treatment for lower extremity sarcomas because tumours tend to be large and deep.

We considered whether a positive margin occurring after resection of a soft-tissue sarcoma of a limb would affect the incidence of local recurrence. Patients with low-grade liposarcomas were expected to be a low-risk group as were those who had positive margins planned before surgery to preserve critical structures. Two groups, however, were expected to be at a higher risk, namely, patients who had undergone unplanned excision elsewhere with a positive margin on re-excision and those with unplanned positive margins occurring during primary resection.

Of 566 patients in a prospective database, 87 with positive margins after limb-sparing surgery and adjuvant radiotherapy were grouped according to the clinical scenario by an observer blinded to the outcome. The rate of local recurrence differed significantly between the two low- (4.2% and 3.6%) and the two high-risk groups (31.6% and 37.5%). This classification therefore provides useful information about the incidence of local recurrence after positive-margin resection.

We describe the functional results in 14 patients (7 men, 7 women) after subtotal scapulectomy for primary bone and soft-tissue tumours at a specialist musculoskeletal oncology unit. Eight had chondrosarcomas, two Ewing’s sarcomas, one aggressive fibromatosis and three soft-tissue sarcomas. The mean follow-up was 52 months (6 to 120). Analysis of residual symptoms and of range and strength of movement by physicians used the Musculoskeletal Tumour Society rating scale (MSTS). Physical disability was measured by the patients using the Toronto Extremity Salvage Score (TESS).

All 14 patients are still alive, two with systemic disease. Nine had more than 80% of their scapula resected but the glenohumeral joint was preserved in all cases. Eight had full movement and another two achieved 90° of flexion. The mean functional results were good to excellent in all except three patients (mean MSTS = 71.6 and TESS = 79.9). Two of these three patients had considerable pain as a result of brachial neuropathy.

Scapulectomy gives an excellent functional result if the glenohumeral joint is preserved. The rotator cuff could be removed without a severe functional deficit provided that the deltoid was reattached to the scapular remnant and the trapezius.