Extremity soft tissue sarcoma: The need for a differential surgical approach to primary tumor and local recurrence?

Abstract

9565 Background: To explore the prognostic implications of local recurrence in extremity adult soft tissue sarcoma (eSTS). Methods: From January 1983 to December 2002, 1,017 patients with localized eSTS were treated at Istituto Nazionale Tumori, Milan, Italy. First local recurrence, re-operated with a curative intent, was investigated as a predictor of further recurrence, distant metastasis and cause specific mortality. Such a task was carried out considering recurrent patients earlier operated for primary disease at our institution (Group A, N=88) or elsewhere (Group B, N=150). The follow up of the above patients after recurrence was compared to that of the overall group of 738 patients operated for primary disease at our institution. Analyses were performed by multiple Cox models, in which local recurrence was entered as a time dependent factor, and tumour size, depth, histotype, grade, margins, RT and CT as covariates for the purpose of adjustment. Event-times were computed from the date of diagnosis, with “left censoring” on the time when patients entered our cohort (date of surgery). Results: The hazard ratio estimates of second recurrence, distant metastases and disease-specific mortality in groups A and B were 5.39 vs 2.95 (p<0.001), 3.96 vs 1.54 (p<0.001), and 2.93 vs 1.43 (p<0.001), respectively. The prognostic effect of the covariates on mortality turned out to be not significantly affected by disease local relapse, but a trend for surgical margins in group A could be observed (HR 1.71). Conclusions: Local recurrence correlates with a worse prognosis, in terms of further local recurrence, distant metastases, and death. Such an effect is stronger following surgery at a referral center for eSTS if compared to local recurrence following surgery done elsewhere, i.e. at institutions less likely to perform adequate local treatment for this rare group of tumors. Possibly, this means that “true” local recurrences, not simply due to inappropriateness, single out pts carrying an inherently more aggressive disease. Consistently, these data cannot confirm, but neither rule out that more aggressive surgery (ie, at the cost of a higher amputation rate, in order to avoid contaminated surgical margins) may be needed in pts locally recurring after initial adequate surgery. No significant financial relationships to disclose.