EXTREMITY STS

Dr. S. SRIVATSAN
Dr. M. ANTO, Dr. THIRUMURUGANAND
Prof. K.S.RAVISHANKAR UNIT
 50 % of STS- Extremity STS
• Extremity sarcomas represent almost half of all patients
with STS.

• Much of the treatment of sarcomas at non-extremity sites

has been extrapolated from evidence in clinical trials of
patients with extremity sarcomas.
 STAGING STS EXCEPTIONS
• Sixth edition of AJCC staging system applies to
all soft tissue sarcomas with the exception of

• Malignant mesenchymoma
• Angiosarcoma,
• Infantile fibrosarcoma
• Dermatofibrosarcoma.

Mnemonic: MAID
 STAGING – KEY POINTS
STAGE 1- All low grade lesions
STAGE 2- High grade, small, large &
superficial lesions
STAGE 3- High grade , large & deep lesions
STAGE 4- Any nodal or distant Mets
 N1 is Stage IV - “CARES”
Sarcoma Type Nodal Metastases (%)
Clear cell sarcoma 25-50

Angio sarcoma 11-40

Rhabdomyosarcoma 11-36

Epithelioid sarcoma 17-80

Synovial sarcoma 2-17

 Grade of the tumor

The best indicator of a tumor's biologic

aggressiveness and metastatic potential is its
grade, regardless of - Histological type
 Grade of the tumor

• Cellularity
• Differentiation
• Pleomorphism
• Necrosis (most important)
• Mitosis
 TUMOUR GRADE VITAL
• The central importance of histologic grade in the
staging system is unique to STS.

• Histologic grade, tumor size and depth are the

primary determinants of AJCC stage.

• Histologic grade is the most important factor in

predicting the risk for distant metastasis and
tumor-related death
 TUMOUR SIZE
• <5 cm or > 5 cm
• a- Superficial to Deep fascia
• b- Deep to or involves Deep fascia.
 Prognosis
POOR GOOD

• Proximal vs Distal
• Deep vs Superficial
• More than 5 cm vs Less than 5 cm
• High grade vs Low grade
 HISTOLOGY OF EXTREMITY
STS
PROXIMAL EXTREMITY DISTAL EXTREMITY
• Malignant fibrous • Synovial sarcomas
Histiocytomas( MFH) • Epithelioid sarcomas
• Liposarcomas • Clear cell sarcomas
• Leiomyosarcomas
FEET
HAND
•Synovial sarcoma
•Epithelioid sarcoma
•Clear cell sarcoma
 METASTASIS
• The most common site of metastases for
extremity sarcomas is the lung.
• Other sites of metastases include the
lymph nodes and bone.
• Epithelioid and clear cell Sarcoma – Lymph
node Mets
 PROGNOSIS
• Most important factor in predicting local
recurrence is the presence of positive
margins on surgical excision.
LIPOSARCOMA OF RIGHT ARM
LIPOSARCOMA OF RIGHT
THIGH
 CLINICAL PRESENTATION
• Most common presentation of a soft tissue
sarcoma is a painless mass.
• Most commonly occur proximally in the hip
and shoulder regions
• The patient may first notice the mass when
an unrelated injury occurs to the affected
extremity.
 LOCAL STAGING
• Physical Examination
• Assessment of tumour size, depth and
involvement of major neurovascular
structures
• MRI or CT?
• Operative planning for limb/ function
preserving surgery in 95 % of cases
 Pre operative MRI vs CT
• MRI may be most useful for determining
the extent of soft tissue and neurovascular
invasion.

• CT can be useful for determining the extent

of local invasion as well as the extent and
degree of any bone invasion
Liposarcoma – Thigh addductor
compartment
MFH of Popliteal region
 DIAGNOSIS AND EVALUATION

• Pretreatment biopsy – Helpful not useful always

• Pretreatment biopsy is mandatory when the
tumor seems to involve critical structures or when
neoadjuvant therapy is considered
• Most commonly, core needle biopsy is used and
provides adequate tissue diagnosis
 DIAGNOSIS AND EVALUATION

• Principles of biopsy
• Assess extent of local disease
• Assess presence or absence of distant
mets
 PRINCIPLES OF BIOPSY
• Incision to be placed longitudinally
• Avoid rising flaps
• Perfect haemostasis to be achieved
• Avoid using drains while taking biopsy
• Biopsy site must be included in the
definitive surgery.
Biopsy tract - cells
 METASTATIC WORK-UP
• CXR or CT CHEST
• PET Scan- Not performed routinely

Current Trends:
FDG-PET + CT – To predict disease free
survival in pts receiving neo-adjuvant
treatment
 SURGERY FOR STS
• AMPUTATION

• COMPARTMENTAL EXCISION

• WIDE LOCAL EXCISION WITH NEGATIVE

MARGINS
 Limb function preserving Surgery-
PRINCIPLES
• Surgical resection with 2cm margin

• The resected tissue should include the

unviolated tumor, pseudocapsule, and reactive
zone with a wide margin
Any previous biopsy site or scars should be
contained within the final specimen.

Incisions should be placed longitudinally to

facilitate resection with minimal violation
 Limb function preserving Surgery-
PRINCIPLES
• A barrier to tumor infiltration can include tissues
such as fascia, joint capsule, tendon, epineurium,
and the vascular sheath.
• The guidelines dictate that if a barrier to spread
exists, the tumor should be removed outside of
that barrier (ie, without violation).
 “Don’t see the tumour”

• If there is no barrier to spread, the tumor is

removed with a broad margin.
• Drain sites should be placed in proximity to
the surgical incision to facilitate the safe
inclusion in radiotherapy field.
Adductor Muscle Group
Excision
“If a positive margin is obtained at the time of
resection, a re-resection should be performed with
the goal of obtaining a negative margin.”
 Limb-sparing resection –
Contraindications

1. Groin involvement. .
2. Extracompartmental extension.
3. Intrapelvic extension.
4. Superficial femoral artery or common femoral
artery involvement.
5. Femur involvement.
6. Palliation.
 RECONSTRUCTION
• Vascular reconstruction to salvage limb?
• Graft or flap for wound closure?
• Pre-op vs post- op RT?

“Vascular reconstruction to
salvage limb confers no added
advantage , though it increases
the morbidity of the procedure.”
Graft/ flap cover planned simultaneously
 RADIOTHERAPY
• External beam radiation is delivered Monday
through Friday over the course of 6 to 7 weeks.

• Brachytherapy is usually employed

postoperatively with treatment delivered over
several hours or days.

• Wide excision of STS followed by adjuvant

radiotherapy results in local control rates in
excess of 80%
 RADIOTHERAPY
• Use of radiotherapy is associated with an
improvement in local control after surgical
resection without any influence on
overall survival or distant metastases.
 PRE-OP vs POST –OP RT
BENEFITS OF PRE-OP RT

• Higher likelihood of obtaining a margin-negative

resection for large tumors.
• Radiation doses used preoperatively tend to be
lower than those used postop (typically, 50 Gy
compared with 60 to 70 Gy).
• Radiation fields tend to be smaller in the
preoperative setting
• Reduced long-term toxicity
 PRE-OP vs POST –OP RT
BENEFITS OF POST-OP RT
 Less risk of surgical wound complications
 Allows selection of patients at the highest
risk for recurrence based on surgical
pathology.
 PRE-OP vs POST –OP RT
VERDICT
• In patients with large, marginally resectable
lesions, a preoperative approach is
typically preferred to improve the likelihood
of a margin-negative resection and to allow
a greater likelihood of function preservation
 PRE-OP vs POST –OP RT
VERDICT
• For patients in whom the risk of wound complications is
prohibitively high, specially in smaller more readily
respectable lesions, a postoperative approach may be
preferred to decrease this risk while accepting an increased
risk of late toxicity.

• Small, superficial, or low-grade lesions or those with a

questionable pathologic diagnosis, a postoperative
approach may be preferred to allow a determination of the
appropriateness of adjuvant radiotherapy.
 BRACHYTHERAPY ON POD 5
• For delivering radiation at the time of surgery
(intraoperatively) or shortly thereafter
• Involves placing catheters within the tumor bed at
the time of surgery
• Radioactive sources can then be placed in the
catheters to deliver radiation to the tissues
surrounding the resection cavity, typically after
postoperative day 5 to minimize wound
complications
 Brachytherapy useful for high grade
tumours
• Found to be effective in providing excellent rates
of local control for high-grade tumors; however,
• It does not appear to be effective in the
management of low-grade tumors
• Benefit of brachytherapy is that more normal
surrounding tissue can be spared from radiation
• Brachytherapy is technically challenging and
should only be used by practitioners familiar with
its use in this setting
 RADIOTHERAPY- FINAL WORD
• Radiation can enhance local control after
surgical resection
• Radiotherapy does not compensate for
suboptimal resection
• Use of adjuvant radiotherapy should not be
seen as the alternative to a margin-
negative resection, even if re-resection is
required.
 RADIOTHERAPY- FINAL WORD

Can we exclude a subset of pts from RT?

• Patients with small, low-grade lesions that

are resected with widely negative margins
 Special considerations: distal
extremities

• Distal extremity sarcomas present a unique

challenge based on the anatomic and
functional constraints.
• Lesions involving the wrist, hand, ankle, or
feet more frequently are in proximity to or
involve vital neurovascular structures or
muscles, joints, and tendons critical to
function.
 DISTAL EXTREMITY-
CONSERVATIVE SURGERY VS
AMPUTATION
• Use of surgery alone for patients with distal
extremity lesions results in a higher rate of
local recurrence
• Use of limited surgery and radiotherapy for
sarcomas of the hand-wrist and ankle-foot
complex to obtain local control while
maintaining a functional distal extremity
 DISTAL EXTREMITY-
CONSERVATIVE SURGERY VS
AMPUTATION
When do you prefer Amputation for distal extremity STS?

1. For patients who decline conservative surgery and radiotherapy

2. Instances in which negative margins cannot be obtained
3. When amputation is expected to have minimal functional
consequences (ie, ray amputation)
4. Limited surgery with reconstruction may lead to inferior functional
outcomes when compared with amputation with prosthesis
 ADJUVANT CHEMO
• At this time, the role of chemotherapy for resected
extremity soft tissue sarcomas is uncertain.
• Patients with a high risk of metastatic disease
appear to benefit from chemotherapy.
• These patients include those with large, high
grade, and deep lesions.
• The recommendation to deliver chemotherapy
must be individualized based on the risk of distant
failure balanced with the risks of chemotherapy.
ADJUVANT CHEMO- STUDIES
• There was a significant improvement in
distant relapse-free interval and in overall
recurrence- free survival with the addition
of Adriamycin-based adjuvant
chemotherapy;
• However, there was no benefit in overall
survival
 Neoadjuvant therapy for locally
advanced high grade STS
• Mesna, Adriamycin, ifosfamide, and dacarbazine
(MAID).

Pre op MAID + RT

Surgical resection

Adjuvant Chemo
 NEOADJUVANT THERAPY
• Currently, the neoadjuvant approach
remains investigational based on the lack
of randomized data supporting its use and
the significant toxicity that results from this
approach
 Recurrence depends on
• High grade tumors
• Tumor Size > 5 cm
• Violation of tumor ‘capsule’
• Positive margins
“Early recurrence is Grade &
Late recurrence is Size”
Recurrent tumors – Popliteal region
 RECURRENT DISEASE
• Isolated local recurrence- evaluted and
treated as a new primary
• Isolated metastasis- metastatectomy

• Widely disseminated disease- palliative

therapies, including surgery,
chemotherapy, radiotherapy, embolization,
and ablation procedures
FOLLOW UP-NCCN Guidelines
• Patients should be followed up with a history and
physical examination
• Every 3 to 6 months for 2 to 3 years,
• Every 6 months for the next 2 years, and then
annually
• For stage I tumors, chest imaging (radiography or
CT) should be performed every 6 to 12 months;
• For stage II and III tumors, chest imaging should
be performed more frequently, every 3 to 6
months for 5 years and then annually.
FOLLOW UP NCCN GUIDELINES
Periodic imaging with MRI or CT of the primary site
should be considered if the combination of factors
places the patient at increased risk for
locoregional recurrence, especially if the location
or depth of the lesion makes physical
examination unreliable for this determination.

Ultrasound, instead of MRI and CT, can also be

considered as the mode of surveillance in these
circumstances.
FOLLOW UP NCCN GUIDELINES

After 10 years, the chance of local recurrence

if the patient remains disease free becomes
much smaller, and the requirement for
surveillance imaging after this time point
should be individualized.
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