Fungating Soft Tissue Sarcoma: A Complex Treatment Dilemma.

Abstract

Fungating soft tissue sarcoma (STS) occurs in up to 3.7% of STS cases, ulcerate or protrude directly from the skin. Several studies have examined past treatments and outcomes of patients with such tumors and suggest that management can be especially challenging. Considering this, it is plausible that fungating extremity tumors may warrant an individualized treatment approach that differs from standard treatment for non-fungating STS. We sought to examine treatment and outcome trends for fungating extremity STS to guide future treatment considerations. A comprehensive literature review of the PubMed database identified 1515 articles. Inclusion criteria included human subjects, adult population, extremity tumors and fungating tumors. Studies published prior to 1982 were excluded. 10 articles were relevant and met all criteria. Outcomes compare fungating STS with non-fungating STS. Patients with fungating STS are more likely to receive amputations as primary or secondary treatment (23-35 vs. 7.8-12%). Metastatic disease is more common among patients with fungating STS (20-33% vs. 9-15%). Patients with fungating STS have been found to have a higher likelihood of local recurrence (LR) (20.0% vs. 16.5%). 5-year overall survival (OS) is significantly decreased in patients with fungating STS (18.0-26.0% vs. 56.8-71.3%).Patients with fungating STS who receive limb sparing surgery (LSS) are more likely to require plastic surgical intervention (65% vs. 25%). Fungating STS is strongly associated with decreased mean time to death (13.8-16.2 months vs 29.0-30.4 months). Complication rates following surgical treatment of fungating STS are as high at 75% following amputation and 43% following LSS with up to 17% of those requiring reoperation. Infection and flap necrosis are the most common complications described. Though limited, current literature persistently reveals fungation as a poor prognostic factor for patients with soft tissue sarcoma. Expedient primarysurgical treatment may be appropriate given the higher metastatic potential and increased rate of complications associated with fungating STS. Limb salvage surgery is appropriate for primary, non-metastatic surgical treatment, though fungating tumors are treated with primary amputation more often than non-fungating STS, which may reduce postoperative complications in high-risk patients. Fungation is well established as an indication for palliative amputation. Increased rates of primary amputation in fungating STS may correspond to higher rates of metastatic disease at time of initial presentation for fungating STS. Timing of XRT should be carefully considered, as neoadjuvant XRTcoupled with a fungating tumor may result in a higher incidence of pre and postoperative complications and increased need for plastic surgical closure techniques. Adjuvant XRT is appropriate though used less often in patients with fungating STS.