Soft Tissue Sarcomas of the Extremities

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Soft Tissue Sarcomas of the Extremities
Samer Attar, M.D.
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Extremity Soft Tissue Sarcomas

• Evaluation and biopsy
• Evolution from amputation to limb-salvage
• Principles and techniques of limb-salvage

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What is a Sarcoma?

• A rare type of cancer
• Resemble cells of mesodermal origin
• the middle stuff
• bone, fat, muscle, etc.
• Carcinomas (more common)
• Endoderm origin
• Ectoderm origin
• Breast, lung, kidney, prostate, thyroid

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Soft Tissue Sarcomas

• Incidence
• Rare
• Approx 10,000 new cases in US per yr
• (Murray and Ward, CA Cancer J Clin, 2005)
• Most common site of metastasis
• Lung

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Soft Tissue Sarcomas

• Treatment
• Resection with limb preservation
• With/without radiation
• With/without chemotherapy
• Multi-disciplinary approach for each and every
  patient

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Evaluation

• History
• Age
• Painless mass (usually)
• Physical Exam
• Smaller mass ? distal, superficial,
• Larger mass ? proximal, deep

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When is a lump just a lump

• Small masses lt 3 cm can be observed and followed
  for growth
• 3 cm or larger get an MRI
• If you cant tell what it is based on the MRI,
  usually get a biopsy

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MRI

• Something BAD that needs a BIOPSY
• Large (gt 5 cm)
• Deep to fascia
• Heterogeneous signal
• Gadolinium contrast

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Biopsy
SIMPLE TECHNICAL SKILL COMPLEX COGNITIVE SKILL
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Biopsy
Plan the biopsy as carefully as the definitive
resection
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Principles of Musculoskeletal Biopsy

• Any needle or incision tract must be placed in
  line with a potential definitive resection
• Use longitudinal incisions
• If it ends up being cancer, you have to go back
  and cut around it

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Hazards of Inappropriate Biopsy
Mankin et al, JBJS(Am), 1982 Mankin and Simon,
JBJS(Am), 1996

• Looked at consequences of biopsies done at
  referring institutions
• Failure to adhere to these techniques and
  principles
• Altered optimum treatment plan in 20 of patients
• Amputation in 5 of patients

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Principles of Musculoskeletal Biopsy

• Stay in one anatomic compartment
• Minimizes conatmination
• Achieve meticulous hemostasis
• Drop tourniquet before closure
• Place any drains in line with incision

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Biopsy
Surgeon who is to perform the definitive
resection should perform the biopsy
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Biopsy
Communicate with the radiologist or cytologist
for needle biopsies.
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Operative Management

• Evolution of surgical management
• Up until 1950s ? Amputation
• 1950s1970s ? Radical resection
• 1980s ? Limb-Salvage
• (chemotherapy, radiation)

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Operative Management
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Is it resectable?
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BALANCE
Achieving the widest oncologic margins possible
vs Preservation of local anatomy and limb
function
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Emergence of Limb-Salvage
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• Review of 37 patients with sarcomas
• Thesis ? gross anatomic setting is the primary
  criterion for amputation vs resection

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• Understood that sarcomas
• Lack a capsule
• Extend along fascial and lymphatic planes
• Described local excision ? illogical
• Not all sarcomas require amputation

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• Recommendations ? radical resection is a means of
  limb salvage
• Wide ablation of grossly normal tissue
• Removal of entire muscle compartments at origin
  and insertion
• Dissection of lymphatic chains in-continuity

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JBJS (American), April 1976
Growth of Limb-Salvage
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• 54 patients with extremity soft-tissue sarcoma
• 46 treated with adequate radical ablation
• Local recurrence rate ? 2
• 8 treated with inadequate surgery
• Local recurrence rate ? 100

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• Factors affecting local recurrence
• Anatomic location of the sarcoma
• Adequacy of the surgical procedure

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1982

• 1st randomized, prospective clinical trial
• MSK-NY

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Limb-Salvage vs Amputation
Rosenberg et al, Ann Surg, 1982

• Prior to this trial ?
• 50 of patients with STS underwent an amputation
• Some still thought all amputations had to be at
  least one full joint above

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Limb-Salvage vs Amputation
Rosenberg et al, Ann Surg, 1982

• Prospective, randomized trial of 43 patients
• Amputation (16) vs LS RT (27)
• No significant differences at 5 years in
• Local recurrence
• Survival

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Limb-Salvage vs Amputation
Willard et al, Ann Surg, 1992 Davis et al, Arch
Phys Med Rehab, 1999 Stojadinovic et al, Ann Surg
Oncol, 2001 Pardasaney et al, CORR, 2006

• Local control rates are essentially equivalent
• Overall survival is no different
• Functional outcomes are better with LS

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Limb-Salvage vs Amputation
Willard et al, Ann Surg, 1992 Davis et al, Arch
Phys Med Rehab, 1999 Stojadinovic et al, Ann Surg
Oncol, 2001 Pardasaney et al, CORR, 2006

• Todays Standard? Limb Salvage
• Negative margins
• Preserve neurovascular structures

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Principles of Limb-Salvage Surgery

• Include biopsy tract in dissection
• Resect a surrounding cuff of normal tissue
  whenever possible
• Tumor is gradually, circumferentially mobilized
• Flap coverage with skin grafting for large
  defects (plastic/reconstructive surgeon)

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Principles of Limb-Salvage Surgery

• Consider amputation if
• Tumor infiltrates major nerves/blood vessels
• Tumor fungating out of skin

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Unplanned Excisions of STS
Davis et al, J Surg Oncol, 1987 Zagars et al,
Cancer, 2003 Potter et al, CORR, 2008

• OOPS!
• Thought it was benign but pathology comes back
  malignant
• Usually an incomplete resection

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Unplanned Excisions of STS
Davis et al, J Surg Oncol, 1987 Zagars et al,
Cancer, 2003 Potter et al, CORR, 2008

• High potential for residual positive margins
• As high as 70
• Opportunity lost for pre-op radiation
• Post-op radiation requires larger target field

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Unplanned Excisions of STS
Davis et al, J Surg Oncol, 1987 Zagars et al,
Cancer, 2003 Potter et al, CORR, 2008

• Compared to primary excision ? increased rate
• Local recurrence (even with negative margins)
• Local tumor site morbidity

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Unplanned Excisions of STS

• Options
• Close observation
• RT alone (70)
• Re-excision of tumor bed w/wo adjuvant RT

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Unplanned Excisions of STS

• Trend in literature
• Highest rate of local control ? Re-excision of
  tumor bed

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How far have we come in advancing local control?

• Resection with negative margins
• Marginal resection RT
• Local control as high as 90 at 5 years.

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What influences local recurrence?
Rosenberg, Ann Surg, 1982 Tanabe et al, Cancer,
1994 Fleming, J Clin Onc, 1999 Zagars et al,
Cancer, 2003

• Margin of resection
• Negative margins lower risk for local recurrence
• Positive margins increase risk for local
  recurrence

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Radiation Therapy
Pisters et al, J Clin Oncol, 1996 Yang et al, J
Clin Oncol, 1998

• Debates
• Timing pre-op vs post-op
• Route EBRT, IORT, brachy
• Modality photon, proton, carbon ion

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Chemotherapy
Sarcoma Meta-Analysis Collaboration, Lancet,
1997 Frustaci et al, Oncology, 2003 Cormier et
al, J Clin Oncol, 2004 Worden et al, J Clin
Oncol, 2005

• Ongoing and investigational
• Trends in current literature
• Marginal benefit short-term (1 year)
• No benefit long-term (toxic)
• Multi-institutional protocols currently underway
  to elucidate any effective regimens

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Future Directions

• Identification of novel cytotoxic drugs with
  improved efficacy
• DNA microarray technology ? Classification of
  sarcomas based on specific gene signatures
• Targeted molecular therapies
• Genomics
• Proteomics

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Conclusions

• cut it out and close it up
• if you cant close it, get a plastic surgeon
• if you cant do above, consider amputation