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STUDIES
IMMUNOLOGICAL
4t.
Sisisioss.
Tumor
49.
R. L.. and Rios,
Cells
Plus BCG.
R. L.: Rios,
Immunotherapy
ANGEI.YN:
Science,
174:
591-593,
ofCancer:
IN
MURINE
317
OSTEOSARCOMA
Immunospecific
Rejection
oflumors
in Recipients
of Neuraminidase-Treated
1971.
LUNDGREN.
GORAN:
and RAY.
P. K.: Immunotherapy
of Methylcholanthrene
Fibrosarcoma
Using
30: 246, 1971.
R. C.: LEVIN.
A. G.: BUCKSBAUM.
H. J.; and MIKE,
V.: Clinical
Trial
of Autogenous
Tumor
Vaccine
for
Treatment
of Osteogenic
Sarcoma.
Proc. Nat. Cancer
Conf.,
7: 91-100,
1972.
Siow.
W. W.: SUllIVAN.
M. P.: and FERNBACH,
D. J.: Adjuvant
Chemotherapy
in Primary
Treatment
of Osteogenic
Sarcoma.
Proc. Am.
Assn. Cancer
Res.,
15: 20, 1974.
TAKASCc;I,
M., and KlEIN,
EVA: A Microassay
for Cell-Mediated
Immunity.
Transplantation,
9: 219-227,
1970.
V.ss;i.
JAN:
Concomitant
Immunity
and Specific
Depression
oflmmunity
by Residual
orReinjected
Syngeneic
TumorTissue.
Cancer Res.,
31:
1655-1662.
1971.
\AINiO.
TAPANI:
K0sKIMIEs,
GILl:
PERI.MANN.
PETER:
PERLMANN.
HEDVIG:
and KLEIN,
GEORGE:
In vitro
Cytotoxic
Effect
of Lymphoid
Cells
trom
Mice Immunized
with Allogeneic
Tissue.
Nature,
204: 453-455,
1964.
Wiisic.
H. T.: KRONMAN,
B. S.: ZBAR,
B.: BoRSos,
T.: and RAPP, H. J.: Immunotherapy
of an Intramuscular
Tumor
in Strain-2
Guinea
Pigs:
Pre’.ention
of Tumor
Growth
by Intradermal
Immunization
and by Systemic
Transfer
of Tumor
Immunity.
J. Nat. Cancer
Inst., 45: 377-386,
1970.
WEXI.FR,
HiI.DA:
Accurate
Identification
of Experimental
Pulmonary
Metastases.
J. Nat. Cancer
Inst.,
36: 641-643,
1966.
WHARAM.
M. D.: PHILLIps,
T. L.: and JACOBS,
E. M.: Combination
Chemotherapy
and Whole
Lung Irradiation
for Pulmonary
Metastases
from
Sarcomas and Germinal Cell Tumors
of the Testis.
Cancer,
34: 136-142.
1974.
ZOAR.
BERTON
. and
TANAKA.
TOMIKO:
Immunotherapy
of Cancer:
Regression
of Tumors
after Intralesional
Injections
of Living
Myeoboeteriun
/fl.5
Science, 172: 271-273.
1971.
SiMsioss.
ANGF.I.YN:
Neuraniinidase.
Fed. Proc.,
50. Sot1uAM.
C. NI.: MARCOVE,
51.
52.
53.
54.
55.
56.
57.
58.
The
BY
Management
MICHAEL
A.
SIMON,
1101??
tlio
of Soft-Tissue
of the
Extremities*
AND
F.
MDI’,
D(./)(jt,?l(’1It
WILLIAM
of OrtI:OjKU’di(
Of fifty-four
patients
with a soft-tissue
of an extremity,
having
a projected
five-year
rate of 62 per cent,
forty-six
treated
by an
surgical
procedure
(either
radical
local
or ablation
at an appropriate
level, depending
on defined
circumstances)
of2 per cent.
procedures
had
a local
another,
the local
recurrence
The combined
recurrence
rate
and the inadequate
procedures
recurrences
were
noted
prior
operatively
and
Histogenesis
recurrence
In the other eight patients,
were
not adequate
for
the
of the
metastases,
sarcoma,
rate was 100 per cent.
after both the adequate
was 16.7 per cent. The
to thirty
months
postprior to sixty months.
one or more recurrences
and treatment
at the time
diagnosis
ship
to
had no significant
recurrence
or
by frozen
the rates
Adequate
comas
as
recurrence
section
of local
rate
whose
surgical
one
reason
or
after
previous
operations,
mediate
definitive
procedure
by an imof biopsy
and
relationmetastasis.
were
identified
sarcoma
and
M.D4,
(Jnive,sitv
()/
ment
of the
modes
tissue
:k
Supported
.
950
East
VOL.
of metastasis,
is the
sarcoma
:: Box 2
Florida
absence
in part
prime
by N.I.H.
and
soft-tissue
high-dose
determines
the
Street.
Chicago,
Illinois
Health
Center,
University
NO.
3.
APRIL
1976
l-F22-AM00995-0I.
60637.
of Florida.
surgery
or
other
surgical
removal
and
adjuvant
sarcomas
retrospective
had
the deficiencies
studies:
namely,
ferent
surgical
approaches,
sequently
reclassified
by
morphological
characteristics.
Some studies
included
different
anatomical
sites
sarcomas
to
and lesions
retrospective
centrally
located
neck,
must
trunk,
retroperitoneum,
be inadequate
because
tures
cannot
be performed
long-term
using
dif-
that were
analysis
of
soft-tissue
sarcomas
but the surgical
located
sarcomas
inherent
in all
many
surgeons
located
approach
is different
peripherally.
than
In
the
and viscera,
resection
removal
of major
vital
and
amputation
subtheir
is not
Gainesville,
pa-
therapy,
cannot
reviews
of surgically
treated
also received
adjunctive
or postoperative
radiation
patients
therapy
adjuvant
often
struc-
an alter-
include
‘
,
immunotherapy.
The results
of these
be construed
as representative
of purely
endeavors.
Most
or
previous
reports
on
surgical
treatment
in
to
the
head,
those
who
preoperative
that
59th
therapy,
advocating
limited
native.
Differences
in the adequacy
of resection
preclude
valid comparison
of data on sarcomas
in all anatomical
sites with the data on sarcomas
in the extremities.
of a soft-
Grant
radiation
Authors
more
in this
the ade-
control
Training
sarcomas.
including
chemotherapy,
have
not had adequate
surgically
treated
controls
with which
to compare
their results
i.I0.25
Past reports
on the surgical
management
of soft-tissue
soft-tissue
local
1 3. JHM
32610.
58-A,
factor
FLORIDA
Galne.su111
f/(/(j
oftherapy,
Previous
In the
GAINESVIlLE.
tient’s
prognosis
2.4
Previous
reports
on surgically
treated
patients
concerned
series that were not well controlled
and
did not define
distinctly
the adequacy
of the surgical
treat-
approach
radical
local resection
controlled
these
sarwell as ablative
surgery
in terms
of local
and
metastasis.
The
significant
factors
affecting
local
recurrence
that
study
were
the location
of the
quacy
of the surgical
procedure.
ENNEKING,
Sirgeiv.
ABSTRACT:
sarcoma
survival
“adequate”
resection
Sarcomas
such
as
chemostudies
surgical
do
not
318
M. A. SIMON
.
-
“4k
.
.
.
,
.
.:
,.
.
.
.
,
.
. .
.
.
.
-
,.
.
.
..
-
?_
*
...
.
..
.-
-..‘.c
...
ia/
.
. .
.
.
F. ENNEKING
:..--.-
-..
.
.
W.
:‘
.-
.
.
.
..
...
.
.
.
:
.
.
AND
.
,:1
;
:
‘
-.
..
:
F..
-
...‘
/,
.9.
/
.
FIG.
Fi;.
I
Section
of a liposarcoma
( T) demonstrating
pseudoencapsulation
. Foci
neoplastic
cells (arrows)
are infiltrating
the connective
tissue
surrounding
the sarcoma.
Excisional
biopsy
through
or around
the
pseudocapsule
(PC) would
leave foci of neoplasm.
The vascular channel
(I:) In the pseudocapsule
is
part of the reactive
vascularity
about such
of
malignant
channels
neoplasms.
which
may
ing proximal
Occasionally.
vascular
and eosin.
(heniatoxylin
specifically
plugs
of
tumor
he embolized
during
operative
occlusion
during
the operative
are
seen
in
these
manipulation.
makprocedure
desirable
2-A
Figs. 2-A and 2-B: This fifty-seven-year-old
white man had an amputation
for recurrent
fibrosarcoma
of the lateral
anterosuperior
aspect of
the right leg. These photographs
of the surgical
specimen
illustrate
the
confinement
of soft-tissue
sarcomas
within
major
intermuscular
and intramuscular
compartments
and their manner
of spread
longitudinally,
both proximally
and distally,
within
these compartments.
Fig. 2-A: Lateral
view of the amputation
specimen.
showing
the relationship
of the sarcoma
to the surrounding
structures.
The common
peroneal
nerve
is seen
as it crosses
the tibular
head. The tumor
(T)
extends
within
the lateral compartment
to the fascia overlying
the soleus
and the anterior
compartment
muscles,
but the soleus.
gastrocnemius,
and anterior
compartment
muscles
are free of gross tumor.
40).
X
describe
the
type
of operative
procedure
per-
or define
whether
the surgical
treatment
was truly
adequate.
Often
the term
‘wide
local excision’
or ‘en
bIot
excision’
is used,
but unless
the adequacy
of nonablative
surgery
is clearly
defined
and controlled,
nonformed
‘
‘
‘
‘
ablative
surgery
its
ability
tics
of
cannot
to control
Our
purpose
be compared
soft-tissue
is to describe
soft-tissue
(the
sarcomas
with
amputation
as to
sarcomas.
the behavioral
characteristics
characterison which
our definitions
of adequate
surgical
treatment
are based)
the basis of our anatomical
and pathological
studies,
and
analyze
the results
of such treatment
and the roles of
different
variables
involved.
We believe
that expansion
this
rigidly
controlled
study
may subsequently
provide
standard
limited
against
surgical
which
to judge
the effectiveness
procedures
combined
with
on
to
the
of
a
of more
adjunctive
Pathological
and
Biological
Soft-Tissue
Based
pathological
been
on
careful
studies
observed
Behavior
of
tumor
(T)
and
microscopic
macroscopic
in our laboratory,
to behave
soft-tissue
locally
in a fairly
sarcomas
charac-
fashion.
They are derived
from mesodermal
tissues
and with few exceptions
are located
in the deeper
planes
of
the musculoaponeurotic
structures.
Despite
differences
in
histogenesis,
analyses
of the rates of local recurrence
and
metastasis
of these sarcomas
reveal
that their rates are almost the same 4.15.27
the only exceptions
being low-grade
fibrosarcoma
and Grade-I
liposarcoma.
Both of these sarare
locally
invasive,
but
do
not
usually
metasta-
size 9.2321,
Because
ot this characteristic,
the surgical
approach
to these lesions
has been more conservative
and has
led to unacceptable
recurrence
rates .2o
and subsequent
dissected
2-B
specimen
of the lateral
and its longitudinal
compartment
tive
Pseudoencapsulation
connective
tissue
sional
gitudinal
and
biopsy
low-grade
lesame
surgical
lesions
by surrounding
fibrous
is a constant
characteristic
The
neoplasm
microscopic
can be found
1). The high
usually
evidence
by careful
recurrence
is further
extension
evidence
occurs
tumor
spread.
amputation.
We approached
both of these
sions
as true sarcomas
and performed
the
procedure
used for more aggressive-appearing
its confines
tion (Fig.
Sarcomas
teristic
comas
shows
tissue
sarcomas.
pseudocapsule
therapy.
have
Fi.
The completely
perforates
this
of tumor
outside
microscopic
examinarate following
exciof this
along
and reacof soft-
extension.
intermuscular
Lonand
in-
tramuscular
fascial
planes
and this was the most
commonly
found
mode
of local extension
by soft-tissue
sarcomas.
In this fashion,
the neoplasm
may spread
up and
down musculoaponeurotic
planes
(Figs.
2-A, 2-B, and 3).
Conversely,
these
lesions
rarely
either
cross
major
intermuscular
septa or cross from one type of tissue
to another
in a transverse
direction.
Local
extension
is enhanced
by
violation
of the tissue
planes
during
biopsy
and subsequently
by postoperative
are transected
transversely
iable
distances
from
the
frequently
remain
and
THE
lead
hematoma.
When
these planes
or opened
longitudinally
at vargross
lesion,
foci of neoplasm
to local
JOURNAL
OF
recurrence.
DONE
AND
Such
JOINT
local
SURGERY
MANAGEMENT
OF
SOFT-TISSUE
SARCOMAS
OF
origin
in both
sions.
from
THE
319
EXTREMITIES
the
transverse
and
the
longitudinal
dimen-
This procedure
requires
excision
of major
their origins
to their insertions
or from joint
as well
tures
as sacrifice
of bone
and
major
neurovascular
within
the tissue
mass being
resected.
Hematogenous
metastasis
is the most
manipulation
ofthe
mode of spread
is through
more common
when the
histiocytoma,
synovial-cell
coma
in a child 3.ii,i.i7.22
gional
lymphatic
extension
Definitions
struc-
common
of distant
spread
of soft-tissue
sarcomas.
result
from tumor-cell
emboli
originating
neovasculature
about
the pseudocapsule
traoperative
muscles
to joint
mode
Metastasis
may
in the reactive
or from
in-
neoplasm.
A less
frequent
the regional
lymphatics.
This is
neoplasm
is a malignant
fibrous
sarcoma,
or rhabdomyosarEven
in these
instances,
reis infrequent.
of Surgical
Procedures
The surgical
procedures
used in the treatment
sarcomas
and the effects
ofthese
procedures
tissue
behavior
can
be defined
I Incisional
by direct incision
as follows:
biopsy
through
.
of softon their
: Part of the neoplasm
the capsule,
usually
is removed
for diagnos-
tic purposes.
This procedure
leaves
residual
gross
and partially
seeds
all fascial
planes
subsequently
taminated
by the operative
hematoma.
The procedure
FIG.
3
Photomicrograph
showing
intramuscular
spread
of a low-grade
fibrosarcoma
in a longitudinal
manner.
Because
of this mode of progression it is mandatory
that muscles
he removed
from origin
to insertion.
This type of extension
is not visible
grossly
and may be found at great
distances
from the visible
lesion (hematoxylin
and eosin,
x 40).
contaminates
the overlying
tissues
which
well as the surgical
instruments,
drapes,
rials in contact
with the lesion.
2.
Excisional
behavior
removal
structures
rounding
cal
plane
suggests
that
of the lesion,
surgical
treatment
all of the anatomical
should
include
structure
or
from
which
the tumor
originates,
and a surzone of normal
tissue
that is one intact anatomicompletely
beyond
the
limits
of the
tissue
of
: The
biopsy
ing pseudocapsule
were incised
as
and other mate-
neoplasm
are removed.
This
tumor
conalso
and
its surround-
procedure
frequently
leaves
microscopic
tumor
both locally
and in all planes
contaminated
by the hematoma
(Fig.
1).
3. Wide
excision:
The neoplasm
is removed
from
within
the anatomical
structure
or structures
involved
by
the lesion
along
with a variable
amount
of
sue attached
to the neoplasm.
The procedure
leaves
microscopic
portions
of tumor
behind
impossible
tensions
to visualize
within
muscle
procedure
is the
is often
equivalent
described
4.
Radical
tissue
microscopic
2-A, 2-B,
as a wide
of an amputation
Structures
involved
level of amputation.
ing
distant
(Figs.
by the
local
tumor
The
resection:
are removed
by dissecting
normal’
tisfrequently
because
it is
‘
intrafascial
exand 3). Such
a
local
done
are
‘ ‘
excision,
so that
left
and
portions
proximal
tumor
along
of
to the
and surroundplanes
that are
separated
from the tumor and its tissue
or tissues
of origin
by at least one uninvolved
anatomical
structure
in both the
longitudinal
and the transverse
planes.
The resected
tissue
includes
the
aponeurotic
FIG.
and transverse
extents (heavy
dotlocal resection
of a soft-tissue
sarcoma
(T) in the
proximal
part of the vastus lateralis.
The origins
and insertions
of all
components
of the quadriceps
muscle
and the sartorius,
including
any
biopsy
site (arrow)
and all of the soft-tissue
structures
anterior
to the
medial and lateral intermuscular
septa. must be resected.
If the bone scan
shows
activity
in the underlying
femur,
the anterior
one-half
of the
femoral
shaft must be removed
with the specimen. The transverse
broken
line indicates
level of transection
drawn
Ofl
right.
Drawings
the longitudinal
4
showing
ted line) of an adequate
VOL.
58-A,
NO.
3.
APRIL
1976
in the
bone
passed
Such
origins
structures,
so-called
or joint
by
the
a resection
and
insertions
any
neurovascular
of
resection
compartment,
if it is contained
within
surrounding
is
an
a soft-tissue
plane
adequate
procedure
for
Such
an ablation
a radical
resection
may
done at an appropriate
of
the
musculo-
structures
and any
the tissue
resection
non-ablative
with-
adjacent
encom(Fig.
4).
operative
sarcoma.
also be accomplished
by
level: that is, proximal
320
M.
Fic.
5-A
A.
SIMON
Fi.
AND
W.
F.
ENNEKING
5-B
5-C
Fi,.
Fic.
5-D
Figs. 5-A through
5-G: This forty-six-year-old
white
woman
had a mass in the posterior
part of the left thigh
for four months.
An incisional
biopsy
performed
prior to referral
had led to the diagnosis
of liposarcoma.
This case illustrates
the value of scanning
in the preoperative
evaluation.
Correlation
of the scan with the gross specimen.
arteriograms.
macrosections,
and specimen
roentgenograms
shows that the scan is the best method
of
determining
the proximity
of lesions
to hone
in the biological
sense.
Resection
without
sacrifice
of the femur in this situation
would
have been the
equivalent
of an excisional
biopsy
and hence not adequate
treatment.
The displacement
of the popliteal
artery is also demonstrated
by angiography.
This patient.
therefore.
had two relative
contraindications
to radical
local resection:
major vascular
displacement
demonstrated
by arteriography,
and
osseous
involvement
of a non-expendable
long bone demonstrated
on the bone scan. Ablation
was performed.
Fig. 5-A: On the lateral roentgenogram
a soft-tissue
mass is visible
in the posterior
supracondylar
region with flO apparent
osseous
involvement.
Fig. 5-B: The arterial phase of the angiograni
shows anterior
displacement
of the femoral
artery and reactive
vessek
about the neoplasm.
Fig. 5-C: The mid-phase
angiogram
outlines
the mass lying next to the femur.
Fig. 5-D: The technetium
polyphosphate
hone scan demonstrates
increased
uptake of the nucleotide
in the distal part of the left femur.
to the
most
proximal
longitudinal
involved
by the neoplasm.
Taking
into account
soft-tissue
the
extent
basic
of the
biological
osseous
reaction
structures
behavior
of
therefore,
the only applicable
surgiis radical
resection,
meaning
either adequate
resection
or an adequate
ablative
procedure.
sarcomas,
cal procedure
radical
local
Preoperative
Work-up
to Localize
the
bone,
histological
sections
of this hone demonstrate
that
actual
invasion
of the bone is infrequent.
However,
when
the roentgenographically
normal
bone adjacent
to the sarcoma
is ‘hot’
there
is invariably
only a narrow
margin
of reactive
tissue
between
the lesion
and the bone.
Under
Lesion
‘
To localize
the neoplasm
accurately
before
operation,
two
diagnostic
studies
have
been
used
extensively:
peripheral
angiography
and
technetium
polyphosphate
bone-scanning.
Peripheral
angiography,
grams,
vasodilators,
and large
rial, is a necessary
step in the
The
surgeon
should
being
sought
and
gether
prior
timum
major
information.
vessels
and
to conclusion
should
of the
what
view
study
the
information
angiograms
to obtain
is
to-
the
‘ ,
these
circumstances,
the bone is likely
using
biplane
roentgenoamounts
of contrast
matepreoperative
work-up
I2.14#{149}
tell the radiologist
they
structures.
Commonly,
no OSSCOUS
involvement
or
is demonstrated
by plain roentgenograms,
tomograms,
or angiographic
techniques.
Although
the bone
scan frequently
shows
increased
uptake
in the adjacent
op-
The early arterial
phase demonstrates
their relationship
to the neoplasm.
The
mid-phase
views
show the actual
tumor
mass and its extents. The late (venous)
phase
demonstrates
the common
veous
drainage
of the neoplasm.
Technetium
polyphosphate
bone scans
aid in determining
the relationship
of a soft-tissue
sarcoma
to adjacent
consistent
Both
dissection
to be followed
with the concept
of adequate
arteriography
and bone-scanning
the decision
to perform
putation.
If arteriography
displaced
putation
with
major
of the tumor
by recurrence
or osseous
in Figures
5-A
reconstruction
through
from
is not
therapy.
to make
or an amvessel
is
bone is involved,
amproblems
associated
prohibitive.
The use of angiography
and
in the selection
of the surgical
procedure
is illustrated
6-F.
surgical
help
a radical
local resection
shows
that a major
or that a non-expendable
is preferable.
The technical
vascular
away
and
5-G
are
usually
of bone-scanning
to be performed
and
6-A
through
1,
1973,
ninety-
Material
From
January
1,
THE
1957,
JOURNAL
to January
OF BONE
AND
JOINT
SURGERY
MANAGEMENT
OF
SOFT-TISSUE
SARCOMAS
OF
THE
321
EXTREMITIES
I
5-E
Fio.
Fig.
5-E:
5-F:
Fig.
Fig. 5-G: A
two
patients
ity
were
FIG.
A hip disarticulation
A lateral
roentgenogram
macrosection
with
Of
without
chemotherapy
excluded
for
metastasis
follow-up,
adequacy
sarcoma
these,
any
when
two
of the
located
fifty-four
adjuvant
and were
the following
included
section
selected
for
therapy
or
radiation
studied,
and twenty-eight
reasons:
fourteen
had
were
distant
they were first seen, three had inadequate
had inadequate
evidence
to verify
the
procedure,
two died of other causes,
five
had either
amputation
as
longest
follow-up
in an extrem-
were
were treated
with prior or subsequent
and two had an inconclusive
diagnosis.
patients
a radical
the definitive
was eighteen
adjunctive
All ofthe
local
surgical
years and
therapy,
fifty-four
resection
or an
procedure.
the shortest,
The
two
years.
The procedures
were performed
under the direction
of a surgical
team
whose
surgical
philosophy
remained
unchanged
during
the period
of study.
The
as well
variables
evaluated
as the
following:
Histogetie.sis
o/t/ie
on by both
Department
included
tuitior:
the Orthopaedic
of Pathology.
age,
All diagnoses
Oncology
race,
were
Group
and
sex
agreed
and
the
Previous
recurrence:
Some
patients
had had one or
more previous
surgical
procedures
and at the time of referral had a recurrent
palpable
mass.
Location:
The tumors
were categorized
according
to
the following
locations:
below
the knee,
thigh
(knee
to
level
of lesser
trochanter),
hip-groin,
buttock-pelvis,
below
the elbow,
arm (elbow
to greater
tuberosity),
and
shoulder
girdle.
Surgical
VOL.
58-A,
NO.
These
/)rO((’dlIreS.
3. APRIL
1976
5-F
included
radical
local
re-
5-G
FIG.
was done. The distal half of the gross specimen
of the specimen
shows no apparent
osseous
the relationship
of the neoplasm
to the femur
soft-tissue
treated.
treatment
shows
5
shows proximity
involvement.
and the narrow
of the sarcoma
pseudocapsule
and amputation.
Adequacy
ofthe
procedure:
of intraoperative
frozen
basis
propriate
osseous
formation
to the femur.
between
This
and
meticulous
was
sections
locations,
preoperative
tissues
done
to identify
in the specimen
in cases
removed,
the lesion and bone.
assessed
from
macroscopic
Immediate
surgery,
definitive
if the
or
including
procedure
criteria
delayed
ap-
tetracycline
labeling
of
areas
of reactive
bone
in which bone was to be
and
microscopic
studies
of both the removed
surgical
specimen
from which
it had been removed.
The procedure
sified as inadequate
not fulfilled.
on the
obtained
already
surgery:
If
and
the bed
was clas-
described
were
no
previous
a biopsy,
had been performed
and the
was carried
out during
the same anes-
thesia
as the biopsy
and without
releasing
the tourniquet
while
the diagnosis
was being
established
by frozen
section, the surgery
was classified
as immediate.
If a biopsy
had been performed
at a previous
procedure,
the surgery
was classified
as delayed.
The other
variables
analyzed
included
postoperative
recurrence,
metastasis,
disease-free
intervals,
and survival
rates.
All of the variables
were analyzed
for significance
using
mine
Fisher’s
exact
their relationship
metastasis
test
and the chi square
test to deterto the incidence
of recurrence
and
21
Results
Descriptive
Data
With
series
were
respect
to age,
comparable
race,
to those
and
sex,
the patients
in other
large
in our
series
of
322
M. A. SIMON
AND
W. F.
ENNEKING
‘I
Fi
6-A
Figs.
through
6-F:
mass
in the anterior
and
was done
and a diagnosis
This
proximal
.
6-A
twenty-five-year-old
part
of the
white
thigh.
An
man
excisional
had
a
biopsy
of liposarconia
was made prior to referral.
The
was reported
to have been located
in the substance
of the rectus
femoris
and its musculotendinous
junction.
This case demonstrates
a
situation
in which
radical
local resection
is applicable.
There
was no
involvement
of a major
vessel
or bone demonstrated
by arteriography
or
hone scan, and even after complete
loss of the quadriceps
mechanism
the
limb would
he preferable
to a prosthesis
for a hip disarticulation.
Fig. 6-A:
A photograph
of the patients
thigh
reveals
the surgical
incision
from
the previous
excisional
biopsy
. There
was no palpable
sarcoma
evidence
of
tumor.
soft-tissue
sarcomas
two
peaks:
gradual
rise,
in the middle
fifty-four
patients,
forty-one
(76
male
one
cent),
and twenty-four
Fibrosarcomas,
histiocytomas
the tumors
in adolescence
decades
(24
seventeen
per
The
1..Ii.Iti.25.27
showed
white.
incidence
the
of life (Chart
other,
a
FIG.
6-B
FIG.
6-C
I). Of the
per cent) were black and
Thirty
(56 per cent) were
(44 per cent)
liposarcomas,
accounted
in this series
age
and
were female.
and malignant
for approximately
(Table
I). The
fibrous
75 per cent of
incidences
of the
different
sarcomas
in this series differed
from those in the
other series because
of the rarity of rhabdomyosarcomas
in
adults.
These
tumors,
when
reviewed
in other
series 22
usually
have
been
reclassified
as malignant
fibrous
histiocytomas.
When
the
fifty-four
seen
by us, twenty-six
after
previous
surgical
seven,
two; two, three
other
twenty-eight
patients
in this
series
were
first
had had from one to six recurrences
procedures:
fifteen
had had one;
or four; and two, five or six. Of the
patients,
sixteen
were
seen
by us within
thirty
twelve
days from the time of their excisional
biopsy
and
had had no previous
surgical
procedures.
About
two-thirds
of the sarcomas
were in the lower
extremities
and one-third
were
in the upper
extremities.
About
20 per cent of the tumors
were distal to the elbow or
knee (Table
II). Sarcomas
distal
to the knee were especially
infrequent.
Twenty-five
of our patients
had a radical
local resection and twenty-nine,
an amputation.
Judged
on the basis
of the pathological
studies
and the surgical
principles
previously
outlined,
eight
of our fifty-four
patients
had inadequate
procedures
because
of technical
problems,
inadequate
preoperative
of our patients
(22
localization,
per cent) had
or both. Only
twelve
immediate
definitive
sur-
Fig.
biopsy
6-B:
shows
An arteriogram
no major vessel
(early
arterial
phase)
two months
after
displacement.
Fig. 6-C: A late-phase arteriogram
shows no apparent
residual
tumor.
A technetium
polyphosphate
bone scan showed
no osseous
reaction.
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
MANAGEMENT
OF SOFT-11SSUE
SARCOMAS
OF THE
323
EXTREMITIES
NUMBER
OF
PATIENTS
I
2
I
DECADES
CHART
Age
the previous
of the thigh
photograph
shows
scar and the femoral
of soft-tissue
I
sarcomas
TABLE
6-D
FIG.
An intraoperative
distribution
the margin
neurovascular
of skin
removed
about
THE
HISTOGENESIS
OF
I
SoFT-TissuE
SARCOMAS
OF THE
EXTREMITIES
bundle in the medial part
No.
finger).
(surgeon’s
of the extremities.
of
Patients
20
37.0
Malignant fibrous histiocytoma
Liposarcoma
Other (leiomyosarcoma,
clear-cell sarcoma
fascia, alveolar soft-part sarcoma,
11
20.4
10
18.5
mesenchymal
of
chondrosarcoma)
Synovial-cell
TABLE
THE
LoCATIoN
OF SOFT-TissuE
7.4
3
5.6
5.6
3
5.6
54
100.0
sarcoma
Total
4
3
sarcoma
Undifferentiated
II
SARCOMAS
OF THE
EXTREMITIES
No. of Patients
intraoperative
photograph
and sartorius
muscles.
on the linea aspera and the femoral
after
removal
of the quadriceps
The adductor
magnus
is seen inserting
artery and vein are well visualized.
Below
the knee
Thigh
Hip/groin
Pelvis/buttock
Lower
Below
extremity
the elbow
Arm
Shoulder
extremity
Total
FIG.
gical
zen
treatment
section.
definitive
Local
after
The
6-F
which
showing
the area of residual
microscopic
tumor
junction
of the rectus femoris
muscle.
the diagnosis
other
was
forty-two
(78
Survival
Rates
per
established
cent)
by frohad
delayed
Surgery.
Recurrence
Versus
Disease-Free
and
Intervals
The over-all
rate of local recurrence
after adequate
and inadequate
surgery
considered
together
was 16.7 per
cent.
The projected
survival
rates
for our patient
population
are shown
in Chart
II. According
to this curve,
VOL.
58-A,
NO.
3. APRIL
1976
after
is applicable
adequate
2
18
5
10
3.7
33.3
9.3
18.5
35
64.8
9
5
girdle
Upper
Part of gross specimen
(T) at the musculotendinous
Per cent
6-E
FIG.
An
cent
Fibrosarcoma
Rhabdomyosarcoma
mechanism
Per
to a population
surgery
val rate to be 62 per
The probability
one
can
cent.
of local
with
expect
recurrence
16.7
9.3
5
9.3
19
35.2
54
100.0
this
the
age grouping,
five-year
survi-
as a function
of
the disease-free
interval
is shown
in Chart
III. If a patient
is disease-free
after thirty
months,
it can be anticipated
that he will not have a local recurrence.
The probability
of metastasis
as a function
of the
disease-free
interval
is shown
in Chart IV. Metastasis
will
occur
with
disease-free
progressively
decreasing
frequency
as
interval
increases
up to forty-eight
months.
this
series
months.
no
metastases
appeared
after
forty-eight
the
In
324
M. A. SIMON
AND
W.
F.
ENNEKING
stasis.
The
absence
dures,
of a recurrence
after
the timing
(immediate
surgery,
nificant
(Tables
of the
sarcoma.
development
of
to be related
the
one or more
or delayed)
and the type of definitive
effect
on the rate of local
III, IV, and V).
The
found
histogenesis
procedure
recurrence
a postoperative
to two
factors:
presence
had no sigor metastasis
recurrence
the location
was
of the neo-
plasm
and the adequacy
of the surgical
procedure
VI). In all five cases of soft-tissue
sarcoma
located
groin,
rence.
these
the
the surgery
Anatomical
patients.
recurrence
inadequate
operation
The
decision
amputation
raphy
and
there had
histogenesis
view
MONTHS
AFTER
DEFINITIVE
OPERATIVE
Life table for survival
coma of an extremity.
A,zalvsi.s
of
of
the
PROCEDURE
II
CHART
fifty-four
patients
with
soft-tissue
sar-
was inadequate
and there was
constraints
were encountered
When the surgical
rate was very low
there
was primarily
bone-scanning
correlating
Of
the
twenty-six
The data were analyzed
of each variable
to both local
to determine
recurrence
the relationship
and distant
meta-
patients
with
with
patients
DISEASE-FREE
CHART
eighteen
with
the
the
re-
definitive
who
had
had
a recurrence,
nine
local resection
and seventeen
(65.4
whereas
among
the twenty-eight
sixteen
performed
to perform
was not
had
radical
also
amputation
significant
revealed
for
(Table
local
resec-
(p > 0.05).
of the tumor
that
there
fibrosarcoma,
VII).
was
but
INTERVAL(months)
Ill
as a function
of the disease-free
interval
soft-tissue
sarcoma
of an extremity.
No
were
seen after
thirty months.
The longest
follow-up
was
years and the shortest.
two years.
DISEASE-FREE
Probability
of local recurrence
in the fifty-four
patients
with
recurrences
or an
by angiogwhether
and ignoring
a retrospective
(42.9 per cent) had amputation
correlation
of the histogenesis
the procedure
a tendency
this tendency
recurrence
no recurrence
tion and twelve
A similar
recurrences
However,
case.
resection
revealed
an insignificant
tendency
to
rather
than radical
local resection
a recurrence
after previous
surgery.
were treated
by radical
per cent),
by amputation,
Variables
a recurin all of
in every
local
based on the findings
without
considering
previous
procedure
performed
perform
an amputation
when there had been
recurrence
a radical
been one or more
of the sarcoma.
(Table
in the
procedure
was adequate
(2.2 per cent),
while after
was
to perform
or
previous
proceof the definitive
CHART
Probability
the fifty-four
of metastasis
patients
with
THE
INTERVAL
(months)
IV
as a function
of the disease-free
soft-tissue
sarcoma
of an extremity.
JOURNAL
OF
BONE
AND
JOINT
interval
SURGERY
in
MANAGEMENT
TABLE
REI.ATiONSII1I’
PREVIOUS
OF
RATE
RECURRENCE.
AND
SARCOMAS
OF THE
TABLE
LOCAl.
TIMING
OF
OF
325
EXTREMITIES
III
OF
TYPE
OF SOFT-TISSUE
RECURRENCE
DEFINiTIVE
RELATIONSHIP
TO
SURGERY,
TIMING
OF
IV
OF RATE
OF METASTASIS
DEFINITIVE
SURGERY,
TO PREVIOUS
AND
TYPE
RECURRENCE,
OF
PROCEDURE
PROCEDURE
Total
Recurrence*
Previous
No
previous
recurrence
Total
p > 0.05
Immediate
Total
p > 0.05
Radical
local
Previous
recurrence
No previous
recurrence
23
4 (15.4)
22
9 ( 16.7)
45
3 (25.0)
6 (14.6)
9
36
9(16.7)
45
3 (12.0)
6 (20.7)
22
23
9(16.7)
45
Total
p > 0.05
54
Immediate
surgery
surgery
Delayed
No Recurrence
5 (17.9)
recurrence
Metastasis*
Total No.
of Patients
resection
Amputation
Total
p
>
*
Percentages
surgery
Total
p > 0.05
54
Radical
local resection
Amputation
p >
18
18
18 (33.3)
36
are
in
27
18 (33.3)
36
01
HIST0;ENESIS
TO
LOCAL
RE
LTRRENCE
AND
18
18 (33.3)
36
Fibrosarcoma
fibrous
Liposarcoma
Malignant
Percentages
are in parentheses.
IN
PATIENT
S WITH
SOFT-TISSUE
SARCOMA
Rhabdomyosarcoma
Synovial-cell
sarcoma
Undifferentiated
sarcoma
Total
Percentages
No Metastasis
3 (15.0)
1 (9.1)
2 (20.0)
0
0
2 (66.6)
1 (33.3)
9(16.7)
6 (30.0)
5 (45.4)
3 (30.0)
0
2 (66.6)
1 (33.3)
1 (33.3)
18(33.3)
TABLE
had
a local
recurrence
after
procedure,
the prognosis
was poor.
such a recurrence,
six subsequently
our
TABLE
metastasis
a local
had
and
RELATIONSHIP
OPERATIVE
OF
OF
THE
ADEQUACY
RECURRENCE
IN
AN
RATE
EXTREMITY
TO
AND
SURGERY
No Recurrence
Location
0
1
S
1
I
0
I
9
Hip/groin
Pelvis/buttock
the elbow
Arm
Shoulder
girdle
Total
Inadequate
Total
(5.6)
(100.0)
(10.0)
(I 1.1)
2
17
OF
AN
WITH
7
4 (36.4)
3 (30.0)
3 (75.0)
3 (100.0)
I
2 (66.6)
2
25
1 (33.3)
29 (53.7)
sarcoma
*
sarcoma
Percentages
13 (65.0)
7
I
0
Other
Undifferentiated
Total
Amputation*
7
histiocytoma
Liposarcoma
Synovial-cell
Son-TISsUE
EXTREMITY
Radical
Local
Resection
fibrous
DEFINITIVE
are in parentheses.
0
(20.0)
(16.7)
9
8
5
4
45
I (2.2)
8 (100.0)
9 (16.7)
45
0
45
p
Percentages
58-A,
TYPE
TABLE
RELATIONSHIP
IN
OF
PATIENTS
WITH
VIII
RECURRENCE
POSTOPERATIVE
SOFT-TISSUE
SARCOMA
TO RATE
OF METASTASIS
OF AN EXTREMITY
No
Surgery
Adequate
VOL.
OF
TO
ON PATIENTS
Rhabdomyosarcoma
Recurrence*
the knee
PERFORMED
Fibrosarcoma
SARCOMA
OF
PROCEDURE
HISTOGENESIS
that was
recurrence.
VI
POSTOPERATIVE
SOFT-TissuE
OF
SARCOMA
Malignant
REI.AlioNsHii-
VII
definitive
Of the nine who
had a metastasis
VIII),
giving
a rate of
that in the patients
without
LOCATION
EXTREMITY
Metastasis*
14
6
7
4
1
2
2
36
THE
THl
AN
are in parentheses.
If a patient
(Table
twice
OF
Metastasis
Recurrence*
17
10
8
4
3
1
2
45
histiocytoma
Other
*
54
0.05
Recurrence
Below
18
11 (37.9)
V
METASTASIS
No Recurrence
Below
Thigh
54
parentheses.
TABLE
RE1.ATi0NSIJ1P
died
about
54
0.05
*
*
No.
of Patients
9
15 (35.6)
7 (28.0)
Total
54
8 (30.8)
10 (35.5)
3 (25.0)
surgery
Delayed
No Metastasis
NO.
are in parentheses.
3. APRIL
1976
<
0.0001
Metastasis
No recurrence
Recurrence
Total
p < 0.05
Metastasis
Per cent
33
12
26.6
3
6
66.6
36
18
33.3
326
M. A. SIMON
The other
three
patients
cause
of their recurrence,
two and about the shoulder
in our series
disease.
who
AND
with local
recurrence
died bewhich
was about
the pelvis
in
girdle in one. Thus,
all patients
had local
recurrences
succumbed
to their
W. F. ENNEKING
with
the
resulting
required
free
planes.
done
sarcomas
variables
evaluate
the
critically,
as possible.
the extremities
from this study,
results
of the
surgical
treatment
of
it is necessary
to eliminate
as many
All ofthe
soft-tissue
sarcomas
not in
and limb girdles
were therefore
as were the tumors
not treated
alone.
In this series the surgical
procedure
by the same team using a consistent
and
gical
studied
approach.
These
constraints
on the population
necessarily
resulted
in a small number
of patients.
The choice
of the surgical
procedure
performed
was
based
primarily
on the location
of the neoplasm,
as determined
by physical
examination,
arteriography,
and bone
scan.
Although
size
minant
in the choice
of the lesion
of procedure,
some effect on the location
ity to important
structures
planning.
Ifradical
per
was not a detersize obviously
had
in terms ofthe
lesion’s
and hence
influenced
local
resection
would
lead
proximtreatment
to a limb
functional
than a prosthesis,
amputation
was performed.
The local recurrence
rate and survival
rate following
this
approach
to date compare
favorably
with those
rates in
previous
series
of surgically
treated
sarcomas
4.15,27.
To
complete
the
evaluation
of the efficacy
of surgery
surgical
alone,
this
histogenesis
significant
of the neoplasm
in this
series
had
relationship
to
the
rate
of
local
‘
stasis
if there
the basis
amputation
however,
successful.
plained
tively
is a local
of local
recurrence
recurrence
the
inadequate’
‘ ‘
to
location
is
valid,
affecting
the
following
the field
view
that
when
first
seen,
and on
by our method
of evaluating
and performing
the resection.
nificant
number
creased
incidence
of radical
local
We
resections
recurrence.
studies
were
and
25
to save
radiation
were
in the
the limb
therapy
microscopic
However,
biopsy
therapy
surgery
is
disease
that
report
left
is based
because
rate
location
of local
is
an
control.
important
Many
recur-
radiation
therapy
are “marginal”,
of treatment.
This finding
supports
whatever
form
of
local
treatment
just
the
is used,
the
and
insertions
of the major
musculoaponeurotic
involved
by the sarcoma
should
be included.
on the use of adjuvant
chemotherapy
after surgical
of
these
soft-tissue
sarcomas
have
been
re-
ported.
spond
the
Established
metastases
of all soft-tissue
to chemotherapy
in about 33 per cent
results
of adjuvant
chemotherapy
be related
to soft-tissue
sarcomas,
promise
sarcomas
of cases
can
in osteosarcomas
this
procedure
reJf
1.10.
may
hold
6,13.26
However,
it
should
be
noted
that
with
recurrence
of disease
has
of drug therapy
suggesting
may
be suppressive
rather
,
adjuvant
been
observed
that adjuvant
than curative.
If adjuvant
chemotherapy
is to cure micrometastasis,
it
would
appear
that the amount
of residual
disease
must be
very small at the time of administration.
Adequate
surgical
control
of the primary
lesion,
an important
consideration.
therefore,
would
seem
to be
patients
preoperaperformed
a sigwithout
an inNOTE:
of local
de-
in which
the soft-tissue
sarcomas
those
in other
large
series
with
size
of the tumors.
Comparison
and
not
the
as effeccame to
or excisional
remaining
surgery.
‘
of
insufficiently
radiation
as radical
on to “cure”
treatment
of this finding
some authors
have recommended
for recurrent
soft-tissue
sarcomas
‘.
Our data,
suggest
that radical
local resection
may still be
This
apparently
conflicting
evidence
is ex-
excision
relied
on a patient
population
differed
markedly
from
the
was
criteria
surgery
controls.
and postoperative
to be as effective
this
the
previous
2,
regimen
or
or meta-
(wide
planning
to
past
process
by
that
that
studies
resection
provided
Although
others
in the
local
we found
according
disease
chemotherapy
risk
im-
8
In
that
a higher
had
as to the eftechnique
is
scanning
and
facilitated
with the non-ablative
they lacked
adequate
of the
chemotherapy
after cessation
has
and
radical
local
as ablation.
surgery
In our patients,
the presence
of a recurrence
at the
time
of referral
to our institution
had no effect
on the rate
oflocal
recurrence
or metastasis.
Previous
studies
indicated
a patient
which
patients
lesion
‘
amputation.
structures
No data
‘
virgin’
‘ ‘
from
no
recurrence
was
lesions
fifty-four
reliable
conclusion
variable
metastasis.
This finding,
which
is substantiated
by data
from previous
series 4.15,16.27
supports
the concept
that the
surgical
management
of soft-tissue
sarcomas
should
not be
influenced
by the specific
tissue of origin.
No attempt
was
made
to relate
the histological
‘grade’
or degree
of aggressiveness
to the rates of recurrence
or metastasis.
the
selected
Limited
origins
The
patients
respect
cidal.
a
was
by our definition)
recently
reported
treatment
tumori-
of
more
same
rences
outside
not
with
retrospective,
defined,
and
the rate of metastasis.
If adjunctive
therapy
(radiotherapy,
chemotherapy,
or both) is used, the so-called
risk interval
will probably
be lengthened
since both of these
types of
though
tumor-
amputation
comparable
of the angiography
procedure
In
therefore
be tumor-suppressive
twelve
scribed,
adequate
tive tumor
control
all patients
must be followed
for at least two years to determine the local recurrence
rate and for five years to establish
may
only
However,
control
less
for
tumor
in
warranted.
se
the
of recurrence,
than
of the
remain
mediate
surgery
in this study,
no conclusion
fectiveness
of the frozen
section-tourniquet
unquestionably
was performed
well defined
sur-
extent
to
not recurred.
interpretation
removed
by surgery
resection
presence
frequently
Since
To
as to the
extensive
In the
more
had
Discussion
uncertainty
a more
but prior
recurrence
The authors
wish
io
thank
Ronald
Marks.
THE
JOURNAL
who
aided
them
in the statistical
analysis
ol the daia.
OF BONE
AND
JOINT
SURGERY
MANAGEMENT
OF SOFT-TISSUE
SARCOMAS
OF THE
327
EXTREMITIES
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