Recurrent Sarcoma Research Articles

Distinguishing Between Well-Differentiated and Dedifferentiated Retroperitoneal Liposarcomas in the Preoperative Setting: A Work in Progress in the Era of Precision Medicine

This issue of Annals of Surgical Oncology includes a retrospective study evaluating the predictive value of preoperative biopsy for patients affected by retroperitoneal liposarcoma. This study aimed to investigate the contribution of preoperative histologic diagnosis to multimodal treatment planning. The authors hypothesized that neoadjuvant treatment may be underused for patients affected by dedifferentiated (DD) liposarcoma due to the lack of preoperative biopsy accuracy. They accordingly reviewed 256 patients affected by well-differentiated (WD) liposarcoma and DD liposarcoma of the retroperitoneum who underwent surgery at the MD Anderson Cancer Center during a 20-year span. Of the patients in this series, 120 (46.8 %) had undergone preoperative biopsy and were retrospectively analyzed. Compared with the final pathologic diagnosis, the preoperative biopsy was able to identify WD liposarcoma with 85 % accuracy, which was significantly higher than the accuracy for identifying DD liposarcoma (37 %). The authors claim that these different accuracy rates lead to significant undertreatment of DD liposarcoma. The report by Ikoma et al. also gives an interesting insight into the multimodal treatment strategy for retroperitoneal soft tissue sarcomas and the appropriateness of adjuvant treatment. To date, standard treatment for primary retroperitoneal sarcoma is surgery with complete en bloc tumor resection. Whether this should be different for the two liposarcoma entities still is debated. Some authors advocate an extended systematic approach for both, whereas others, including the authors of the current report, are in favor of a more conservative resection for WD liposarcoma. In this perspective, correct preoperative diagnosis is essential for making the proper decision because the two entities cannot be distinguished intraoperatively. The role of neoadjuvant treatment still is debated because, to date, no randomized trials of preoperative treatment for retroperitoneal sarcoma have been concluded and reported. The National Comprehensive Cancer Network (NCCN) guidelines offer the option of preoperative radiation therapy, chemotherapy, or both based on lowerlevel evidence without a uniform consensus. The European Society for Medical Oncology (ESMO) guidelines, on the other hand, consider adjuvant/neoadjuvant chemotherapy as an individualized (or investigational) indication and preoperative radiation therapy as only investigational for retroperitoneal sarcomas. One randomized trial currently is recruiting patients in Europe and North America. It explores the impact of preoperative radiation therapy in primary retroperitoneal sarcoma and includes both WD and DD liposarcomas (EORTC-62092-22092, STRASS, NCT01344018). Outside of the investigational setting, therefore, the use of neoadjuvant therapies must be decided by a multidisciplinary sarcoma board in the context of high-risk disease or a locally advanced (and/or nearly unresectable) presentation. The main prognostic factors to be considered in decision making for local recurrence and distant metastasis of retroperitoneal sarcomas are histology subtype and tumor grade. Dedifferentiated liposarcomas are known to exist in at least two variants: intermediate and high grade. The former has a predominant risk of local recurrence, whereas the latter carries a risk reaching 40 % for distant metastasis. For this reason, patients affected by high-grade DD retroperitoneal liposarcoma may be considered for neoadjuvant Society of Surgical Oncology 2014

Prognostic factors for reoperation of recurrent retroperitoneal sarcoma: The role of clinicopathological factors other than histologic grade.

Reoperation is recommended for resectable retroperitoneal sarcoma (RS) recurrence; however, the long-term overall survival (OS) benefit varies. Although histologic grade is an important OS predictor after primary tumor resection, its prognostic value tends to diminish with subsequent reoperations. The objective of this study was to identify prognostic factors of OS after reoperation for recurrent RS. The medical records of 95 patients who underwent resection for RS at Seoul National University Hospital between January 1999 and July 2011 were retrospectively reviewed. Of the 95 patients, 50 patients underwent second resection for recurrence, and 26 of these patients underwent third resection. Prognostic factors were analyzed at each reoperation. Higher histologic grade and gross residual disease were poor prognostic factors of OS after first resection. After second resection, higher histologic grade and time since previous operation of within 1 year were poor prognostic factors. After third resection, only contiguous organ resection was a significant independent prognostic factor. The significance of prognostic factors changes with repetitive reoperations for RS recurrence. The prognostic value of histologic grade diminishes after the third resection, whereas other clinical factors such as time since previous operation and contiguous organ resection achieve significance.

P-030 Cryoablation in the Cervical Spine

PurposeTo demonstrate the feasibility in treating primary and metastatic lesions to the cervical spine and paraspinal soft tissues using CT-guided cryoablation. To share techniques of avoiding/displacing critical structures and the...

Long-term recurrence of soft tissue sarcomas: prognostic factors and implications for prolonged follow-up.

To the authors' knowledge, the incidence of late recurrence (> 5 years after initial management) is unknown and no prognostic factors for late events have been characterized in patients with soft tissue sarcomas. Follow-up data from patients with localized soft tissue sarcoma who were included in the French Sarcoma Group database from January 1990 to June 2005 were reviewed. The outcomes of interest were the cumulative probabilities of late (> 5 years) local and metastatic disease recurrence with death as a competing event. Estimations and 95% confidence intervals (95% CIs) were computed with the cumulative incidence function. A total of 719 patients who were alive and event free > 5 years after their initial diagnosis were included in the current study. Sixty-seven patients (9.3%) developed a late local recurrence and 42 patients (5.8%) developed a late metastatic recurrence, respectively. On multivariate analysis, internal trunk location (hazard ratio [HR], 3.9; 95% CI, 2.2-6.7 [P < .001]) and tumor size > 100 mm (HR, 2.1; 95% CI, 1.1-4 [P = .035]) were the 2 factors found to be independently associated with an increased risk of late local recurrence. Grade > 1 (graded according to the French Federation of Cancer Centers Sarcoma Group) (HR, 4.7; 95% CI 1.1-21 [P = .04]) was the sole factor found to be independently associated with an increased risk of late metastatic recurrence. Late recurrence of soft tissue sarcoma is relatively uncommon. However, the results of the current study emphasize the critical role of long-term follow-up to detect late local disease recurrence in patients with retroperitoneal or very large soft tissue sarcomas, and late metastatic recurrence in patients with high-grade disease. Conversely, the prolonged follow-up of patients with grade 1 disease is not needed.

Undifferentiated embryonal liver sarcoma in childhood: A case report.

In order to improve the diagnosis and therapy of undifferentiated embryonal liver sarcoma (UELS), the present study presents the case of a 9-year-old female with UELS and discusses UELS in childhood. The patient presented with abdominal pain and fever. The laboratory tests, radiographic examination and pathological features presented by the female were similar to those of typical cases of UELS reported in childhood. The patient initially received surgical treatment and the immunohistochemical findings suggested that the patient had UELS. The patient’s parents refused adjuvant chemotherapy and demonstrated a right prerenal mass 6 months post-surgery. Microscopic examination revealed that the tumor was evidence of undifferentiated embryonal sarcoma recurrence. However, the patient was comfortable and physical examination revealed no abnormal conditions. In addition, the laboratory results were normal. Abdominal computed tomography scan and ultrasound were performed every 3 months to monitor the tumor recurrence. At the time of writing, it has been 6 months after the second surgical procedure and there has been no appearence of abnormalities. Previous studies have shown that patients who receive combined therapy with complete tumor resection and adjuvant chemotherapy have a longer survival time than those who undergo surgical therapy alone. Complete tumor resection combined with adjuvant chemotherapy may reduce the risk of recurrence and enhance the survival time in patients with UELS.

Phase II trial of cixutumumab in combination with temsirolimus in pediatric patients with recurrent or refractory sarcoma: A report from the Children’s Oncology Group.

10066 Background: The combined inhibition of insulin-growth factor type 1 receptor (IGF-1R) and the mammalian target of rapamycin (mTOR) has shown activity in preclinical models of pediatric sarcom...

Prognostic factors for local recurrence and mortality in adult soft tissue sarcoma of the extremities and trunk wall

Background and purpose — Previous studies of soft tissue sarcoma (STS) have identified a number of possible prognostic factors; however, the majority of these include highly selected populations, with unclear validation of data and insufficient statistical methods. We identified prognostic factors in a validated, population-based 30-year series of STS treated at a single institution, using an advanced statistical approach.Patients and methods — Between 1979 and 2008, 922 adult patients from western Denmark were treated at the Aarhus Sarcoma Center for non-metastatic STS in the extremities or trunk. The endpoints were local recurrence (LR) and disease-specific mortality (DSM). Prognostic factors were analyzed using a proportional hazard model, including continuous variables as cubic splines. Directed acyclic graphs were used to depict the causal structure.Results — The 5-year LR was 16% and the 5-year DSM was 24%. Important prognostic factors for both LR and DSM were age, duration of symptoms, tumor size, grade, margin, and radiotherapy, while anatomical location (upper, lower extremity, trunk) was prognostic for DSM.Interpretation — In this population-based series of adult, non-metastatic STS, we included directed acyclic graphs, cubic splines, and a competing risk model in order to minimize bias, and demonstrated that these statistical methods are feasible. Using these statistical methods on a large, validated dataset, we excluded depth as a prognostic factor and established that age, duration of symptoms, size, grade, margin, and radiotherapy were important prognostic factors for both local recurrence and disease-specific mortality.

Role of FNAC in palpable chest wall lesions in developing country

Palpable chest wall lesions are unusual manifestation of an underlying thoracic pathology and it is difficult to diagnose them with their diverse spectrum ranging from benign to malignant. Considering the exposure of patient to invasive biopsy/excision and the risk of local complications, FNAC is now being increasingly used in the primary assessment of these lesions. Objectives of this study were to report the spectrum of chest wall lesions in the population of a developing country and evaluating the diagnostic role of FNAC. All the patients who presented with palpable cutaneous or subcutaneous chest wall swelling during a period of January 2003 to August 2010 were reviewed retrospectively. May Grunwald Giemsa and Papanicolaou stained aspirates were examined, along with special stains. Seven hundred seventy-three cases were subjected to chest wall FNAC, of which 726 (93.9%) cases were satisfactory. Age ranged from 1 to 93 years with M:F = 0.92:1. 358 (49.3%) were diagnosed as inflammatory and 368 (50.7%) were neoplastic lesions. Two-hundred thirty four cases (32.2%) were diagnosed as mycobacterial abscess (likely tuberculous). Of the neoplastic lesions, 153 were malignant with carcinomas being predominant (88.2%). Malignant cases comprised of scar site recurrence in breast carcinoma (73 cases), metastatic carcinomas (62 cases), primary sarcomas (eight cases), hematological neoplasms (six cases), and miscellaneous group (four cases). Overall malignant lesions accounted for 21.1% (153/726) of satisfactory chest wall aspirates. FNAC is very useful and simple investigation for early diagnosis of chest wall abscesses, cutaneous metastases from visceral malignancies, and scar site recurrence in breast carcinoma.

Standardization of selection criteria for percutaneous image-guided cryoablation of recurrent soft-tissue sarcomas

Percutaneous image-guided cryoablation has not been validated for local management of recurrence of soft tissue sarcoma (STS) of the trunk or limbs. This study aims to identify selection criteria for cryoablation in order to standardize indications of this treatment. Between 2000 and 2010, 46 patients (57 tumors) presenting local recurrences of STS of the trunk or limbs and treated following standards of care were selected from our institutional database. Eligibility for cryoablation was assessed by two radiologists according to predefined criteria: maximal diameter size of the tumor ≤10cm, distance to skin >5mm, distance to neurovascular structures 3mm at least, absence of articular involvement and planned cryoablation covering the entire lesion volume. Characteristics and outcomes were compared. There was nearly perfect agreement for all criteria (k coefficient ranging from 0.83 to 0.98) between both readers. A subgroup of 13patients was identified as eligible for cryoablation. Locations to the trunk, pelvic girdle or shoulder were significantly more present in the cryoablation group (P=0.002). In this group, tumors were mainly located deeply (P=0.002) with great axes ≤5cm (P=0.044). High local tumor aggressiveness (P=0.016) and differentiated myxoid liposarcoma or myxofibrosarcoma (P=0.007) were more frequent in the eligible group. Based on these criteria, two groups of patients with local relapse of STS can be identified. These results may improve the standardization of selection of patients who could be candidates for cryoablation.

Evaluation of soft-tissue lesions with 18F-FDG PET/CT

Purpose of the report Although MRI is utilized for planning the resection of soft-tissue tumors, it is not always capable of differentiating benign from malignant lesions. The risk of local recurrence of soft-tissue sarcomas is increased when biopsies are performed before resection and by inadequate resections. PET associated with computed tomography using fluorodeoxyglucose labeled with fluorine-18 (18F-FDG PET/CT) may help differentiate between benign and malignant tumors, thus avoiding inadequate resections and making prior biopsies unnecessary. The purpose of this study was to evaluate the usefulness of 18F-FDG PET/CT in differentiating benign from malignant solid soft-tissue lesions. Materials and methods Patients with solid lesions of the limbs or abdominal wall detected by MRI were submitted to 18F-FDG PET/CT. The maximum standardized uptake value (SUVmax) cutoff was determined to differentiate malignant from benign tumors. Regardless of the 18F-FDG PET/CT results all patients underwent biopsy and surgery. Results MRI was performed in 54 patients, and 10 patients were excluded because of purely lipomatose or cystic lesions. 18F-FDG PET/CT was performed in the remaining 44 patients. Histopathology revealed 26 (59%) benign and 18 (41%) malignant soft-tissue lesions. A significant difference in SUVmax was observed between benign and malignant soft-tissue lesions. The SUVmax cutoff of 3.0 differentiated malignant from benign lesions with 100% sensitivity, 83.3% specificity, 89.6% accuracy, 78.3% positive predictive value, and 100% negative predictive value. Conclusion 18F-FDG PET/CT seems to be able to differentiate benign from malignant soft-tissue lesions with good accuracy and very high negative predictive value. Incorporating 18F-FDG PET/CT into the diagnostic algorithm of these patients may prevent inadequate resections and unnecessary biopsies.

Funktionelle Langzeitergebnisse nach Sarkomresektionen

Multimodal treatment of malignant tumors of the musculoskeletal system with R0 in sano resection plays a key role in prevention of local recurrence in soft tissue and bone sarcoma. In cases of unavoidable neuromuscular or osseous defects, current plastic and orthoplastic reconstruction techniques avoid limb amputation in the majority of patients. Clinical long-term results demonstrate that large resection defects do not necessarily result in impaired limb function if multidisciplinary procedures are integrated. In oncologically necessary major limb amputation, segmental resection and replantation of distal limb parts should be considered which provide end-bearing long stump formation. The functional conditions of long-term surviving elderly patients should be integrated into surgical decision-making and rehabilitation efforts.

Detection of Soft-Tissue Sarcoma Recurrence: Added Value of Functional MR Imaging Techniques at 3.0 T

To determine the added value of functional magnetic resonance (MR) sequences (dynamic contrast material-enhanced [DCE] and quantitative diffusion-weighted [DW] imaging with apparent diffusion coefficient [ADC] mapping) for the detection of recurrent soft-tissue sarcomas following surgical resection. This retrospective study was approved by the institutional review board. The requirement to obtain informed consent was waived. Thirty-seven patients referred for postoperative surveillance after resection of soft-tissue sarcoma (35 with high-grade sarcoma) were studied. Imaging at 3.0 T included conventional (T1-weighted, fluid-sensitive, and contrast-enhanced T1-weighted imaging) and functional (DCE MR imaging, DW imaging with ADC mapping) sequences. Recurrences were confirmed with biopsy or resection. A disease-free state was determined with at least 6 months of follow-up. Two readers independently recorded the signal and morphologic characteristics with conventional sequences, the presence or absence of arterial enhancement at DCE MR imaging, and ADCs of the surgical bed. The accuracy of conventional MR imaging in the detection of recurrence was compared with that with the addition of functional sequences. The Fisher exact and Wilcoxon rank sum tests were used to define the accuracy of imaging features, the Cohen κ and Lin interclass correlation were used to define interobserver variability, and receiver operating characteristic analysis was used to define a threshold to detect recurrence and assess reader confidence after the addition of functional imaging to conventional sequences. There were six histologically proved recurrences in 37 patients. Sensitivity and specificity of MR imaging in the detection of tumor recurrence were 100% (six of six patients) and 52% (16 of 31 patients), respectively, with conventional sequences, 100% (six of six patients) and 97% (30 of 31 patients) with the addition of DCE MR imaging, and 60% (three of five patients) and 97% (30 of 31 patients) with the addition of DW imaging and ADC mapping. The average ADC of recurrence (1.08 mm(2)/sec ± 0.19) was significantly different from those of postoperative scarring (0.9 mm(2)/sec ± 0.00) and hematomas (2.34 mm(2)/sec ± 0.72) (P = .03 for both). The addition of functional MR sequences to a routine MR protocol, in particular DCE MR imaging, offers a specificity of more than 95% for distinguishing recurrent sarcoma from postsurgical scarring.

Long-term outcome after local recurrence of soft tissue sarcoma: a retrospective analysis of factors predictive of survival in 135 patients with locally recurrent soft tissue sarcoma

Background:The aim of this study was to identify prognostic indicators of survival in patients with locally recurrent soft tissue sarcoma (STS) through a long-term follow-up.Methods:We retrospectively assessed the relationship between post-recurrence survival (PRS) and potential prognostic factors in 135 patients who had experienced local recurrence, which was suitable for further surgical treatment. The median follow-up time after initial recurrence was 12.3 years (95% confidence interval (CI): 10.4–14.2 years).Results:The 5-year estimate of the PRS rate was 53.1% (95% CI: 44.3–61.2%) for the entire series. Patients with negative margins after the final surgery experienced improved survival compared with patients with positive margins (5-year survival: 46.7% (35.2–57.5%) vs 35.5% (23.4–47.8%); P=0.01). In a multivariate analysis, the significant prognostic indicators for PRS were histologic grade, tumour site, time to initial recurrence, the number of recurrences and the surgical margin status attained at the last resection.Conclusions:Complete surgical resection with microscopically clear margins is desirable in patients with locally recurrent STS. However, when achieving clear surgical margins will require major functional impairment of the extremity, a radical surgical approach should be weighed for the patient in each case.

Insufficiency fracture of the clavicle after neck dissection: imaging features

Insufficiency fracture of the clavicle is a rare complication that can occur in patients who have undergone neck dissection. The differential diagnoses of this entity include recurrent metastatic disease, post-radiation sarcoma, trauma, and infection. We reviewed the images of seven lesions in six patients who had undergone neck surgery and had stress fractures of the clavicle without tumor metastasis. All lesions involved clavicular fractures and had mass formation around the bone fracture. Two lesions mainly comprised sternoclavicular joint (SCJ) surface destruction, and six mainly comprised fractures of the proximal end of the clavicle. Five (71%) had increased clavicular bone density. Six lesions (86%) had fluid collection in the SCJ, and three of these lesions (in two patients) were complicated by infection. fluorodeoxyglucose-positron emission tomography (FDG-PET) showed relatively weak uptake (SUVmax 0.96-3.09).

Surgical procedures and prognostic factors for local recurrence of soft tissue sarcomas

BackgroundPatients with local recurrence of soft tissue sarcomas are predisposed to future recurrences because treatment is challenging and complicated by prior therapy. This study investigated clinical outcomes following surgical procedures for locally recurrent soft tissue sarcomas and risk factors for re-recurrence and metastasis. MethodsA retrospective analysis was conducted with 105 patients (52 males, 53 females) who underwent surgical procedures for local recurrence without distant metastasis of soft tissue sarcoma between 1987 and 2009. Patient follow-up ranged from 1 to 12 years (mean 4.9 years). ResultsOverall 5- and 10-year survival rates were 83.4 and 67.7 %, respectively. Twenty-one patients (20.0 %) had additional local recurrences, and 23 (21.9 %) had distant metastases. Amputation rate was 10.5 % at the time of surgical procedures and 17.1 % at final follow-up. Locations deep within muscles in the upper limb or trunk and surgical margins <1 cm wide were risk factors for further local recurrence. Locations deep within muscles, tumor sizes >10 cm, high-grade malignancy, and local recurrence after radical surgery were risk factors for distant metastasis. ConclusionsSurgical margin and location were independent prognostic factors for local control, and a wider margin was especially important for recurrent tumors located in the trunk and upper extremity. For high-grade sarcomas with local recurrence after radical surgery, new approaches are needed to prevent distant metastases.

Analysis of Risk Factors of Local Recurrence in Soft Tissue Sarcomas of the Limbs: Review of the Literature

Analysis of Risk Factors of Local Recurrence in Soft Tissue Sarcomas of the Limbs: Review of the Literature

Breast sarcoma: A rarity

Delays in breast cancer diagnosis are associated with negative clinical effects. The main causes are protocol violations, clinical errors, radiological errors, pathological errors and patient fault. Although rare, breast lump that is clinically benign, but has undergone rapid growth should alert the clinician of the possibility of underlying sarcoma. We report a case of a 42-year-old female patient with breast sarcoma who developed recurrence of sarcoma along with ipsilateral pleural effusion. Owing to rarity of the disease and controversies involved in the management, there is no protocol for management of these patients.

Recurrent low-grade endometrial stromal sarcoma with intracaval and intracardiac tumor thrombus: diagnosis, treatment, and surgical management

Low-grade endometrial stromal sarcoma (LG-ESS) accounts for approximately 1 % of malignant tumors in the uterine corpus, grows slowly, and frequently expresses ER and PR. The 5-year survival of patients with primary LG-ESS was shown to be over 90 %. However, approximately 50 % of cases will recur, with recurrence commonly occurring more than 10 years later. Lymph-vascular space invasion is frequently observed, and several cases of LG-ESS with extension into the major vessels have been reported previously. We herein present a case of a 65-year-old Japanese woman diagnosed with recurrent LG-ESS 16 years after receiving primary treatment. Recurrent tumors were located in the left ovary and also in the para-aortic region below the left renal vein, extending into the inferior vena cava and the right atrium through the left renal vein and left lumbar segmental veins. We judged primary total resection of all tumors to be impossible and described the surgical procedure, risks associated with removing intracaval and intracardiac tumor thrombus, and hormone therapy in this case conference.

Common gene variants in RAD51, XRCC2 and XPD are not associated with clinical outcome in soft-tissue sarcoma patients

BackgroundDNA repair mechanisms play a major role in cancer risk and progression. Germline variants in DNA repair genes may result in altered gene function and/or activity, thereby causing inter-individual differences in a patient's tumor recurrence capacity. In genes of the DNA repair pathway the gene variants RAD51 rs1801320 G>C, XRCC2 rs3218536 G>A and XPD rs13181 A>C have been previously related to genetic predisposition and prognosis of various cancer entities. In this study we investigated the association between these polymorphisms and time to recurrence (TTR) and overall survival (OS) in soft-tissue sarcoma (STS) patients after curative surgery. MethodsTwo hundred sixty STS patients were included in this retrospective study. Germline DNA was genotyped by 5′-exonuclease (TaqMan) technology. Kaplan Meier curves and multivariate Cox proportional models were calculated for TTR and OS. ResultsA statistically significant association was observed between tumor grade and adjuvant radiotherapy and TTR and between tumor grade and OS. No association was found between RAD51 rs1801320 G>C, XRCC2 rs3218536 G>A and XPD rs13181 A>C and TTR and OS in univariate and multivariate analysis. ConclusionOur results underline a prognostic effect of tumor grade and adjuvant radiotherapy in STS patients but indicate no association between RAD51 rs1801320 G>C, XRCC2 rs3218536 G>A and XPD rs13181 A>C and clinical outcome in STS patients after curative surgery.

Limb preservation surgery with extracorporeal irradiation in the management of malignant bone tumor: the oncological outcomes of 101 patients

BackgroundEn bloc resection, extracorporeal irradiation (ECI) and reimplantation have been used selectively at our centers as part of limb preservation surgery of malignant bone tumors since 1996. We report the long-term oncological outcomes. Patients and methodsOne hundred one patients were treated with ECI at two Australian centers between 1996 and 2011. A single dose of 50 Gy was delivered to the resected bone segments. The irradiated bones were reimplanted immediately as a biological graft. Patients were treated with chemotherapy as per standard protocol. The three main histological diagnoses were Ewing's sarcoma (35), osteosarcoma (37) and chondrosarcoma (20). There were nine patients with a range of different histologies. ResultsThere was one local recurrence (2.86%) in Ewing's sarcoma and the 5-year cumulative overall survival was 81.9%. There was no local recurrence in osteosarcoma and five distant recurrences. The 5-year cumulative overall survival was 85.7%. The local recurrence rate was 20% (4 of 20) in chondrosarcoma, and the 5-year cumulative overall survival was 80.8%. Limb preservation was achieved in 97 patients. For the 64 patients with disease in the pelvis or lower limb, 53 (82.3%) could walk without aids at the time of last follow-up. ConclusionsThis large series of ECI shows an excellent long-term local control. It is a good alternative reconstruction method in selected patients. The overall survival is comparable to other published series.