UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Local treatment for primary soft tissue sarcoma of the extremities and chest wall

Authors
Thomas F DeLaney, MD
David C Harmon, MD
Mark C Gebhardt, MD
Section Editors
Robert Maki, MD, PhD
Russell S Berman, MD
Raphael E Pollock, MD
Deputy Editors
Diane MF Savarese, MD
Kathryn A Collins, MD, PhD, FACS

INTRODUCTION

Sarcomas are malignant tumors that arise from skeletal and extraskeletal connective tissues, including the peripheral nervous system. They can arise from mesenchymal tissue at any body site. Soft tissue sarcomas (STS) are uncommon. In the United States, approximately 12,310 cases are diagnosed annually, representing less than 1 percent of all newly diagnosed malignant tumors [1].

Local treatment for primary STS of the extremities and chest wall will be reviewed here. Issues relating to classification, diagnosis, and staging of STS; the use of adjuvant and neoadjuvant chemotherapy; the treatment of STS in locations other than the extremities and chest wall; and treatment of locally recurrent and locally advanced unresectable STS of the extremities are discussed separately. (See "Clinical presentation, histopathology, diagnostic evaluation, and staging of soft tissue sarcoma" and "Adjuvant and neoadjuvant chemotherapy for soft tissue sarcoma of the extremities" and "Head and neck sarcomas" and "Clinical features, evaluation, and treatment of retroperitoneal soft tissue sarcoma" and "Treatment of locally recurrent and unresectable, locally advanced soft tissue sarcoma of the extremities" and "Clinical presentation, histopathology, diagnostic evaluation, and staging of soft tissue sarcoma", section on 'Introduction'.)

IMPORTANCE OF MULTIDISCIPLINARY EVALUATION AND MANAGEMENT

Because of their rarity and the frequent need for multimodality treatment, evaluation and management of soft tissue sarcomas (STS) should ideally be carried out in a center with expertise in the treatment of sarcomas, including surgical oncology, orthopedic surgery, plastic surgery, adult or pediatric medical oncology, and radiation oncology. The multidisciplinary team approach to care of STS optimizes treatment planning, minimizes duplication of diagnostic studies, and reduces the time to implementation of the definitive therapeutic protocol.

Moreover, the expertise gained by dedicated subspecialists improves clinical outcomes. This was illustrated by one study that examined outcomes of 375 patients with STS of the extremities and torso according to the time of referral to a tumor center in the South Sweden Health Care Region [2]. Compared with patients referred preoperatively, local recurrence rates were 2.4-fold higher in patients not referred at any time and 1.3-fold higher in those referred only after definitive surgery.

EXTREMITY SARCOMAS

Our recommended treatment for most patients with an extremity soft tissue sarcoma (STS) who are medically and technically operable is combined surgery and radiation therapy (RT). In most instances, the probability of tumor control is higher, and the late functional and cosmetic result is clearly superior following combined modality therapy than with radical surgery alone.

                                  

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Mon Sep 12 00:00:00 GMT 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2016. CA Cancer J Clin 2016; 66:7.
  2. Gustafson P, Dreinhöfer KE, Rydholm A. Soft tissue sarcoma should be treated at a tumor center. A comparison of quality of surgery in 375 patients. Acta Orthop Scand 1994; 65:47.
  3. Eilber FR, Eckardt JJ, Rosen G, et al. Neoadjuvant chemotherapy and radiotherapy in the multidisciplinary management of soft tissue sarcomas of the extremity. Surg Oncol Clin N Am 1993; 2:611.
  4. Baldini EH, Goldberg J, Jenner C, et al. Long-term outcomes after function-sparing surgery without radiotherapy for soft tissue sarcoma of the extremities and trunk. J Clin Oncol 1999; 17:3252.
  5. Pisters PW, Pollock RE, Lewis VO, et al. Long-term results of prospective trial of surgery alone with selective use of radiation for patients with T1 extremity and trunk soft tissue sarcomas. Ann Surg 2007; 246:675.
  6. Tanabe KK, Pollock RE, Ellis LM, et al. Influence of surgical margins on outcome in patients with preoperatively irradiated extremity soft tissue sarcomas. Cancer 1994; 73:1652.
  7. Gortzak Y, Lockwood GA, Mahendra A, et al. Prediction of pathologic fracture risk of the femur after combined modality treatment of soft tissue sarcoma of the thigh. Cancer 2010; 116:1553.
  8. Pak D, Vineberg KA, Griffith KA, et al. Dose--effect relationships for femoral fractures after multimodality limb-sparing therapy of soft-tissue sarcomas of the proximal lower extremity. Int J Radiat Oncol Biol Phys 2012; 83:1257.
  9. Cannon CP, Ballo MT, Zagars GK, et al. Complications of combined modality treatment of primary lower extremity soft-tissue sarcomas. Cancer 2006; 107:2455.
  10. Holt GE, Griffin AM, Pintilie M, et al. Fractures following radiotherapy and limb-salvage surgery for lower extremity soft-tissue sarcomas. A comparison of high-dose and low-dose radiotherapy. J Bone Joint Surg Am 2005; 87:315.
  11. Dickie CI, Parent AL, Griffin AM, et al. Bone fractures following external beam radiotherapy and limb-preservation surgery for lower extremity soft tissue sarcoma: relationship to irradiated bone length, volume, tumor location and dose. Int J Radiat Oncol Biol Phys 2009; 75:1119.
  12. Duffy GP, Wood MB, Rock MG, Sim FH. Vascularized free fibular transfer combined with autografting for the management of fracture nonunions associated with radiation therapy. J Bone Joint Surg Am 2000; 82:544.
  13. Brooks AD, Gold JS, Graham D, et al. Resection of the sciatic, peroneal, or tibial nerves: assessment of functional status. Ann Surg Oncol 2002; 9:41.
  14. Ghert MA, Davis AM, Griffin AM, et al. The surgical and functional outcome of limb-salvage surgery with vascular reconstruction for soft tissue sarcoma of the extremity. Ann Surg Oncol 2005; 12:1102.
  15. Nishinari K, Krutman M, Aguiar Junior S, et al. Surgical outcomes of vascular reconstruction in soft tissue sarcomas of the lower extremities. J Vasc Surg 2015; 62:143.
  16. Pisters PW, Harrison LB, Leung DH, et al. Long-term results of a prospective randomized trial of adjuvant brachytherapy in soft tissue sarcoma. J Clin Oncol 1996; 14:859.
  17. Yang JC, Chang AE, Baker AR, et al. Randomized prospective study of the benefit of adjuvant radiation therapy in the treatment of soft tissue sarcomas of the extremity. J Clin Oncol 1998; 16:197.
  18. Kachare SD, Brinkley J, Vohra NA, et al. Radiotherapy associated with improved survival for high-grade sarcoma of the extremity. J Surg Oncol 2015; 112:338.
  19. Rosenberg SA, Tepper J, Glatstein E, et al. The treatment of soft-tissue sarcomas of the extremities: prospective randomized evaluations of (1) limb-sparing surgery plus radiation therapy compared with amputation and (2) the role of adjuvant chemotherapy. Ann Surg 1982; 196:305.
  20. Potter DA, Kinsella T, Glatstein E, et al. High-grade soft tissue sarcomas of the extremities. Cancer 1986; 58:190.
  21. Wilson AN, Davis A, Bell RS, et al. Local control of soft tissue sarcoma of the extremity: the experience of a multidisciplinary sarcoma group with definitive surgery and radiotherapy. Eur J Cancer 1994; 30A:746.
  22. Wanebo HJ, Temple WJ, Popp MB, et al. Preoperative regional therapy for extremity sarcoma. A tricenter update. Cancer 1995; 75:2299.
  23. Mundt AJ, Awan A, Sibley GS, et al. Conservative surgery and adjuvant radiation therapy in the management of adult soft tissue sarcoma of the extremities: clinical and radiobiological results. Int J Radiat Oncol Biol Phys 1995; 32:977.
  24. O'Sullivan B, Davis AM, Turcotte R, et al. Preoperative versus postoperative radiotherapy in soft-tissue sarcoma of the limbs: a randomised trial. Lancet 2002; 359:2235.
  25. McGee L, Indelicato DJ, Dagan R, et al. Long-term results following postoperative radiotherapy for soft tissue sarcomas of the extremity. Int J Radiat Oncol Biol Phys 2012; 84:1003.
  26. Cassier PA, Kantor G, Bonvalot S, et al. Adjuvant radiotherapy for extremity and trunk wall atypical lipomatous tumor/well-differentiated LPS (ALT/WD-LPS): a French Sarcoma Group (GSF-GETO) study. Ann Oncol 2014; 25:1854.
  27. Pisters PW, Leung DH, Woodruff J, et al. Analysis of prognostic factors in 1,041 patients with localized soft tissue sarcomas of the extremities. J Clin Oncol 1996; 14:1679.
  28. Al-Refaie WB, Habermann EB, Jensen EH, et al. Surgery alone is adequate treatment for early stage soft tissue sarcoma of the extremity. Br J Surg 2010; 97:707.
  29. Kattan MW, Leung DH, Brennan MF. Postoperative nomogram for 12-year sarcoma-specific death. J Clin Oncol 2002; 20:791.
  30. Fleming JB, Cantor SB, Varma DG, et al. Utility of chest computed tomography for staging in patients with T1 extremity soft tissue sarcomas. Cancer 2001; 92:863.
  31. Fleming JB, Berman RS, Cheng SC, et al. Long-term outcome of patients with American Joint Committee on Cancer stage IIB extremity soft tissue sarcomas. J Clin Oncol 1999; 17:2772.
  32. Rydholm A. Surgery without radiotherapy in soft tissue sarcoma. Acta Orthop Scand Suppl 1997; 273:117.
  33. Cahlon O, Brennan MF, Jia X, et al. A postoperative nomogram for local recurrence risk in extremity soft tissue sarcomas after limb-sparing surgery without adjuvant radiation. Ann Surg 2012; 255:343.
  34. Williard WC, Hajdu SI, Casper ES, Brennan MF. Comparison of amputation with limb-sparing operations for adult soft tissue sarcoma of the extremity. Ann Surg 1992; 215:269.
  35. LeVay J, O'Sullivan B, Catton C, et al. Outcome and prognostic factors in soft tissue sarcoma in the adult. Int J Radiat Oncol Biol Phys 1993; 27:1091.
  36. Manoso MW, Frassica DA, Deune EG, Frassica FJ. Outcomes of re-excision after unplanned excisions of soft-tissue sarcomas. J Surg Oncol 2005; 91:153.
  37. McNeer GP, Cantin J, Chu F, Nickson JJ. Effectiveness of radiation therapy in the management of sarcoma of the soft somatic tissues. Cancer 1968; 22:391.
  38. Canter RJ, Beal S, Borys D, et al. Interaction of histologic subtype and histologic grade in predicting survival for soft-tissue sarcomas. J Am Coll Surg 2010; 210:191.
  39. Talbert ML, Zagars GK, Sherman NE, Romsdahl MM. Conservative surgery and radiation therapy for soft tissue sarcoma of the wrist, hand, ankle, and foot. Cancer 1990; 66:2482.
  40. Johnstone PA, Wexler LH, Venzon DJ, et al. Sarcomas of the hand and foot: analysis of local control and functional result with combined modality therapy in extremity preservation. Int J Radiat Oncol Biol Phys 1994; 29:735.
  41. Karakousis CP, De Young C, Driscoll DL. Soft tissue sarcomas of the hand and foot: management and survival. Ann Surg Oncol 1998; 5:238.
  42. Davis AM, Devlin M, Griffin AM, et al. Functional outcome in amputation versus limb sparing of patients with lower extremity sarcoma: a matched case-control study. Arch Phys Med Rehabil 1999; 80:615.
  43. Robinson MH, Spruce L, Eeles R, et al. Limb function following conservation treatment of adult soft tissue sarcoma. Eur J Cancer 1991; 27:1567.
  44. Stinson SF, DeLaney TF, Greenberg J, et al. Acute and long-term effects on limb function of combined modality limb sparing therapy for extremity soft tissue sarcoma. Int J Radiat Oncol Biol Phys 1991; 21:1493.
  45. Cribb GL, Loo SC, Dickinson I. Limb salvage for soft-tissue sarcomas of the foot and ankle. J Bone Joint Surg Br 2010; 92:424.
  46. Davidge KM, Wunder J, Tomlinson G, et al. Function and health status outcomes following soft tissue reconstruction for limb preservation in extremity soft tissue sarcoma. Ann Surg Oncol 2010; 17:1052.
  47. Weddington WW Jr, Segraves KB, Simon MA. Psychological outcome of extremity sarcoma survivors undergoing amputation or limb salvage. J Clin Oncol 1985; 3:1393.
  48. Sugarbaker PH, Barofsky I, Rosenberg SA, Gianola FJ. Quality of life assessment of patients in extremity sarcoma clinical trials. Surgery 1982; 91:17.
  49. Sadoski C, Suit HD, Rosenberg A, et al. Preoperative radiation, surgical margins, and local control of extremity sarcomas of soft tissues. J Surg Oncol 1993; 52:223.
  50. Herbert SH, Corn BW, Solin LJ, et al. Limb-preserving treatment for soft tissue sarcomas of the extremities. The significance of surgical margins. Cancer 1993; 72:1230.
  51. Trovik CS, Bauer HC, Alvegård TA, et al. Surgical margins, local recurrence and metastasis in soft tissue sarcomas: 559 surgically-treated patients from the Scandinavian Sarcoma Group Register. Eur J Cancer 2000; 36:710.
  52. Zagars GK, Ballo MT, Pisters PW, et al. Prognostic factors for patients with localized soft-tissue sarcoma treated with conservation surgery and radiation therapy: an analysis of 1225 patients. Cancer 2003; 97:2530.
  53. Gronchi A, Lo Vullo S, Colombo C, et al. Extremity soft tissue sarcoma in a series of patients treated at a single institution: local control directly impacts survival. Ann Surg 2010; 251:506.
  54. Al Yami A, Griffin AM, Ferguson PC, et al. Positive surgical margins in soft tissue sarcoma treated with preoperative radiation: is a postoperative boost necessary? Int J Radiat Oncol Biol Phys 2010; 77:1191.
  55. Verhey LJ. Comparison of three-dimensional conformal radiation therapy and intensity-modulated radiation therapy systems. Semin Radiat Oncol 1999; 9:78.
  56. Pan E, Goldberg SI, Chen YL, et al. Role of post-operative radiation boost for soft tissue sarcomas with positive margins following pre-operative radiation and surgery. J Surg Oncol 2014; 110:817.
  57. Kepka L, Suit HD, Goldberg SI, et al. Results of radiation therapy performed after unplanned surgery (without re-excision) for soft tissue sarcomas. J Surg Oncol 2005; 92:39.
  58. Eilber FR, Eckardt J. Surgical management of soft tissue sarcomas. Semin Oncol 1997; 24:526.
  59. Kim B, Chen YL, Kirsch DG, et al. An effective preoperative three-dimensional radiotherapy target volume for extremity soft tissue sarcoma and the effect of margin width on local control. Int J Radiat Oncol Biol Phys 2010; 77:843.
  60. Ferguson PC, Griffin AM, O'Sullivan B, et al. Bone invasion in extremity soft-tissue sarcoma: impact on disease outcomes. Cancer 2006; 106:2692.
  61. Lin PP, Pino ED, Normand AN, et al. Periosteal margin in soft-tissue sarcoma. Cancer 2007; 109:598.
  62. Behranwala KA, A'Hern R, Omar AM, Thomas JM. Prognosis of lymph node metastasis in soft tissue sarcoma. Ann Surg Oncol 2004; 11:714.
  63. Blazer DG 3rd, Lazar AJ, Xing Y, et al. Clinical outcomes of molecularly confirmed clear cell sarcoma from a single institution and in comparison with data from the Surveillance, Epidemiology, and End Results registry. Cancer 2009; 115:2971.
  64. Fong Y, Coit DG, Woodruff JM, Brennan MF. Lymph node metastasis from soft tissue sarcoma in adults. Analysis of data from a prospective database of 1772 sarcoma patients. Ann Surg 1993; 217:72.
  65. Riad S, Griffin AM, Liberman B, et al. Lymph node metastasis in soft tissue sarcoma in an extremity. Clin Orthop Relat Res 2004; :129.
  66. Johannesmeyer D, Smith V, Cole DJ, et al. The impact of lymph node disease in extremity soft-tissue sarcomas: a population-based analysis. Am J Surg 2013; 206:289.
  67. AJCC (American Joint Committee on Cancer). Cancer Staging Manual, 7th edition, Edge SB, Byrd DR, Compton CC, et al (Eds), Springer, New York 2010. p.291.
  68. Maduekwe UN, Hornicek FJ, Springfield DS, et al. Role of sentinel lymph node biopsy in the staging of synovial, epithelioid, and clear cell sarcomas. Ann Surg Oncol 2009; 16:1356.
  69. Tunn PU, Andreou D, Illing H, et al. Sentinel node biopsy in synovial sarcoma. Eur J Surg Oncol 2008; 34:704.
  70. Seal A, Tse R, Wehrli B, et al. Sentinel node biopsy as an adjunct to limb salvage surgery for epithelioid sarcoma of the hand. World J Surg Oncol 2005; 3:41.
  71. van Akkooi AC, Verhoef C, van Geel AN, et al. Sentinel node biopsy for clear cell sarcoma. Eur J Surg Oncol 2006; 32:996.
  72. Fantini F, Monari P, Bassissi S, et al. Sentinel lymph node biopsy in clear cell sarcoma. J Eur Acad Dermatol Venereol 2007; 21:1271.
  73. Al-Refaie WB, Ali MW, Chu DZ, et al. Clear cell sarcoma in the era of sentinel lymph node mapping. J Surg Oncol 2004; 87:126.
  74. Andreou D, Boldt H, Werner M, et al. Sentinel node biopsy in soft tissue sarcoma subtypes with a high propensity for regional lymphatic spread--results of a large prospective trial. Ann Oncol 2013; 24:1400.
  75. Zornig C, Peiper M, Schröder S. Re-excision of soft tissue sarcoma after inadequate initial operation. Br J Surg 1995; 82:278.
  76. Noria S, Davis A, Kandel R, et al. Residual disease following unplanned excision of soft-tissue sarcoma of an extremity. J Bone Joint Surg Am 1996; 78:650.
  77. Goodlad JR, Fletcher CD, Smith MA. Surgical resection of primary soft-tissue sarcoma. Incidence of residual tumour in 95 patients needing re-excision after local resection. J Bone Joint Surg Br 1996; 78:658.
  78. Zagars GK, Ballo MT, Pisters PW, et al. Surgical margins and reresection in the management of patients with soft tissue sarcoma using conservative surgery and radiation therapy. Cancer 2003; 97:2544.
  79. Fiore M, Casali PG, Miceli R, et al. Prognostic effect of re-excision in adult soft tissue sarcoma of the extremity. Ann Surg Oncol 2006; 13:110.
  80. Funovics PT, Vaselic S, Panotopoulos J, et al. The impact of re-excision of inadequately resected soft tissue sarcomas on surgical therapy, results, and prognosis: A single institution experience with 682 patients. J Surg Oncol 2010; 102:626.
  81. Alamanda VK, Crosby SN, Archer KR, et al. Primary excision compared with re-excision of extremity soft tissue sarcomas--is anything new? J Surg Oncol 2012; 105:662.
  82. Rehders A, Stoecklein NH, Poremba C, et al. Reexcision of soft tissue sarcoma: sufficient local control but increased rate of metastasis. World J Surg 2009; 33:2599.
  83. Barkley HT Jr, Martin RG, Romsdahl MM, et al. Treatment of soft tissue sarcomas by preoperative irradiation and conservative surgical resection. Int J Radiat Oncol Biol Phys 1988; 14:693.
  84. Brant TA, Parsons JT, Marcus RB Jr, et al. Preoperative irradiation for soft tissue sarcomas of the trunk and extremities in adults. Int J Radiat Oncol Biol Phys 1990; 19:899.
  85. Bujko K, Suit HD, Springfield DS, Convery K. Wound healing after preoperative radiation for sarcoma of soft tissues. Surg Gynecol Obstet 1993; 176:124.
  86. Cheng EY, Dusenbery KE, Winters MR, Thompson RC. Soft tissue sarcomas: preoperative versus postoperative radiotherapy. J Surg Oncol 1996; 61:90.
  87. Kuklo TR, Temple HT, Owens BD, et al. Preoperative versus postoperative radiation therapy for soft-tissue sarcomas. Am J Orthop (Belle Mead NJ) 2005; 34:75.
  88. Zagars GK, Ballo MT, Pisters PW, et al. Preoperative vs. postoperative radiation therapy for soft tissue sarcoma: a retrospective comparative evaluation of disease outcome. Int J Radiat Oncol Biol Phys 2003; 56:482.
  89. Suit HD, Mankin HJ, Wood WC, Proppe KH. Preoperative, intraoperative, and postoperative radiation in the treatment of primary soft tissue sarcoma. Cancer 1985; 55:2659.
  90. O'Sullivan B, Davis AM, Turcotte R, et al. Five-year results of a randomized phase III trial of pre-operative vs. post-operative radiotherapy in extremity soft tissue sarcoma (abstract). Proc Am Soc Clin Oncol 2004; 23:815a.
  91. Davis AM, O'Sullivan B, Turcotte R, et al. Late radiation morbidity following randomization to preoperative versus postoperative radiotherapy in extremity soft tissue sarcoma. Radiother Oncol 2005; 75:48.
  92. Alektiar KM, Brennan MF, Singer S. Influence of site on the therapeutic ratio of adjuvant radiotherapy in soft-tissue sarcoma of the extremity. Int J Radiat Oncol Biol Phys 2005; 63:202.
  93. Korah MP, Deyrup AT, Monson DK, et al. Anatomic tumor location influences the success of contemporary limb-sparing surgery and radiation among adults with soft tissue sarcomas of the extremities. Int J Radiat Oncol Biol Phys 2012; 82:933.
  94. O'Sullivan B, Griffin AM, Dickie CI, et al. Phase 2 study of preoperative image-guided intensity-modulated radiation therapy to reduce wound and combined modality morbidities in lower extremity soft tissue sarcoma. Cancer 2013; 119:1878.
  95. Wang D, Zhang Q, Eisenberg BL, et al. Significant Reduction of Late Toxicities in Patients With Extremity Sarcoma Treated With Image-Guided Radiation Therapy to a Reduced Target Volume: Results of Radiation Therapy Oncology Group RTOG-0630 Trial. J Clin Oncol 2015; 33:2231.
  96. Alektiar KM, Zelefsky MJ, Brennan MF. Morbidity of adjuvant brachytherapy in soft tissue sarcoma of the extremity and superficial trunk. Int J Radiat Oncol Biol Phys 2000; 47:1273.
  97. Panchal JI, Agrawal RK, McLean NR, Dawes PJ. Early post-operative brachytherapy and free flap reconstruction in the management of sarcomas. Eur J Surg Oncol 1996; 22:144.
  98. Alektiar KM, Brennan MF, Singer S. Local control comparison of adjuvant brachytherapy to intensity-modulated radiotherapy in primary high-grade sarcoma of the extremity. Cancer 2011; 117:3229.
  99. Kraybill WG, Harris J, Spiro IJ, et al. Phase II study of neoadjuvant chemotherapy and radiation therapy in the management of high-risk, high-grade, soft tissue sarcomas of the extremities and body wall: Radiation Therapy Oncology Group Trial 9514. J Clin Oncol 2006; 24:619.
  100. Kraybill WG, Harris J, Spiro IJ, et al. Long-term results of a phase 2 study of neoadjuvant chemotherapy and radiotherapy in the management of high-risk, high-grade, soft tissue sarcomas of the extremities and body wall: Radiation Therapy Oncology Group Trial 9514. Cancer 2010; 116:4613.
  101. Tuma RS. Sometimes size doesn't matter: reevaluating RECIST and tumor response rate endpoints. J Natl Cancer Inst 2006; 98:1272.
  102. Canter RJ, Martinez SR, Tamurian RM, et al. Radiographic and histologic response to neoadjuvant radiotherapy in patients with soft tissue sarcoma. Ann Surg Oncol 2010; 17:2578.
  103. Herrmann K, Benz MR, Czernin J, et al. 18F-FDG-PET/CT Imaging as an early survival predictor in patients with primary high-grade soft tissue sarcomas undergoing neoadjuvant therapy. Clin Cancer Res 2012; 18:2024.
  104. Benz MR, Czernin J, Allen-Auerbach MS, et al. FDG-PET/CT imaging predicts histopathologic treatment responses after the initial cycle of neoadjuvant chemotherapy in high-grade soft-tissue sarcomas. Clin Cancer Res 2009; 15:2856.
  105. Dimitrakopoulou-Strauss A, Strauss LG, Egerer G, et al. Impact of dynamic 18F-FDG PET on the early prediction of therapy outcome in patients with high-risk soft-tissue sarcomas after neoadjuvant chemotherapy: a feasibility study. J Nucl Med 2010; 51:551.
  106. Tateishi U, Kawai A, Chuman H, et al. PET/CT allows stratification of responders to neoadjuvant chemotherapy for high-grade sarcoma: a prospective study. Clin Nucl Med 2011; 36:526.
  107. Tepper JE, Suit HD. Radiation therapy alone for sarcoma of soft tissue. Cancer 1985; 56:475.
  108. Ruka W, Taghian A, Gioioso D, et al. Comparison between the in vitro intrinsic radiation sensitivity of human soft tissue sarcoma and breast cancer cell lines. J Surg Oncol 1996; 61:290.
  109. Chung PW, Deheshi BM, Ferguson PC, et al. Radiosensitivity translates into excellent local control in extremity myxoid liposarcoma: a comparison with other soft tissue sarcomas. Cancer 2009; 115:3254.
  110. Todoroki T, Suit HD. Therapeutic advantage in preoperative single-dose radiation combined with conservative and radical surgery in different-size murine fibrosarcomas. J Surg Oncol 1985; 29:207.
  111. ESMO/European Sarcoma Network Working Group. Soft tissue and visceral sarcomas: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2014; 25 Suppl 3:iii102.
  112. Shah AA, D'Amico TA. Primary chest wall tumors. J Am Coll Surg 2010; 210:360.
  113. Salas S, Bui B, Stoeckle E, et al. Soft tissue sarcomas of the trunk wall (STS-TW): a study of 343 patients from the French Sarcoma Group (FSG) database. Ann Oncol 2009; 20:1127.
  114. Gross JL, Younes RN, Haddad FJ, et al. Soft-tissue sarcomas of the chest wall: prognostic factors. Chest 2005; 127:902.
  115. Greager JA, Patel MK, Briele HA, et al. Soft tissue sarcomas of the adult thoracic wall. Cancer 1987; 59:370.
  116. Gordon MS, Hajdu SI, Bains MS, Burt ME. Soft tissue sarcomas of the chest wall. Results of surgical resection. J Thorac Cardiovasc Surg 1991; 101:843.
  117. Wouters MW, van Geel AN, Nieuwenhuis L, et al. Outcome after surgical resections of recurrent chest wall sarcomas. J Clin Oncol 2008; 26:5113.
  118. Tsukushi S, Nishida Y, Sugiura H, et al. Soft tissue sarcomas of the chest wall. J Thorac Oncol 2009; 4:834.
  119. Peat BG, Bell RS, Davis A, et al. Wound-healing complications after soft-tissue sarcoma surgery. Plast Reconstr Surg 1994; 93:980.
  120. Tseng JF, Ballo MT, Langstein HN, et al. The effect of preoperative radiotherapy and reconstructive surgery on wound complications after resection of extremity soft-tissue sarcomas. Ann Surg Oncol 2006; 13:1209.
  121. Davis AM, O'Sullivan B, Bell RS, et al. Function and health status outcomes in a randomized trial comparing preoperative and postoperative radiotherapy in extremity soft tissue sarcoma. J Clin Oncol 2002; 20:4472.
  122. Baldini EH, Lapidus MR, Wang Q, et al. Predictors for major wound complications following preoperative radiotherapy and surgery for soft-tissue sarcoma of the extremities and trunk: importance of tumor proximity to skin surface. Ann Surg Oncol 2013; 20:1494.
  123. Arbeit JM, Hilaris BS, Brennan MF. Wound complications in the multimodality treatment of extremity and superficial truncal sarcomas. J Clin Oncol 1987; 5:480.
  124. Rosenberg LA, Esther RJ, Erfanian K, et al. Wound complications in preoperatively irradiated soft-tissue sarcomas of the extremities. Int J Radiat Oncol Biol Phys 2013; 85:432.
  125. Lee HY, Cordeiro PG, Mehrara BJ, et al. Reconstruction after soft tissue sarcoma resection in the setting of brachytherapy: a 10-year experience. Ann Plast Surg 2004; 52:486.
  126. Parker MJ, Livingstone V, Clifton R, McKee A. Closed suction surgical wound drainage after orthopaedic surgery. Cochrane Database Syst Rev 2007; :CD001825.
  127. Siegel HJ, Long JL, Watson KM, Fiveash JB. Vacuum-assisted closure for radiation-associated wound complications. J Surg Oncol 2007; 96:575.
  128. Bickels J, Kollender Y, Wittig JC, et al. Vacuum-assisted wound closure after resection of musculoskeletal tumors. Clin Orthop Relat Res 2005; 441:346.
  129. Delman KA, Johnstone PA. Vacuum-assisted closure for surgical wounds in sarcoma. J Surg Oncol 2007; 96:545.
  130. Mariani L, Miceli R, Kattan MW, et al. Validation and adaptation of a nomogram for predicting the survival of patients with extremity soft tissue sarcoma using a three-grade system. Cancer 2005; 103:402.
  131. Dalal KM, Kattan MW, Antonescu CR, et al. Subtype specific prognostic nomogram for patients with primary liposarcoma of the retroperitoneum, extremity, or trunk. Ann Surg 2006; 244:381.
  132. Sampo M, Tarkkanen M, Tukiainen E, et al. A web-based prognostic tool for extremity and trunk wall soft tissue sarcomas and its external validation. Br J Cancer 2012; 106:1076.
  133. Callegaro D, Miceli R, Bonvalot S, et al. Development and external validation of two nomograms to predict overall survival and occurrence of distant metastases in adults after surgical resection of localised soft-tissue sarcomas of the extremities: a retrospective analysis. Lancet Oncol 2016; 17:671.
  134. Anghileri M, Miceli R, Fiore M, et al. Malignant peripheral nerve sheath tumors: prognostic factors and survival in a series of patients treated at a single institution. Cancer 2006; 107:1065.
  135. Lahat G, Dhuka AR, Lahat S, et al. Complete soft tissue sarcoma resection is a viable treatment option for select elderly patients. Ann Surg Oncol 2009; 16:2579.
  136. Al-Refaie WB, Habermann EB, Dudeja V, et al. Extremity soft tissue sarcoma care in the elderly: insights into the generalizability of NCI Cancer Trials. Ann Surg Oncol 2010; 17:1732.
  137. Farshadpour F, Schaapveld M, Suurmeijer AJ, et al. Soft tissue sarcoma: why not treated? Crit Rev Oncol Hematol 2005; 54:77.
  138. Biau DJ, Ferguson PC, Turcotte RE, et al. Adverse effect of older age on the recurrence of soft tissue sarcoma of the extremities and trunk. J Clin Oncol 2011; 29:4029.
  139. Niewald M, Berberich W, Schnabel K, et al. [A simple method for positioning and fixing the extremities during the radiotherapy of soft-tissue sarcomas]. Strahlenther Onkol 1990; 166:295.
  140. Robinson MH, Bidmead AM, Harmer CL. Value of conformal planning in the radiotherapy of soft tissue sarcoma. Clin Oncol (R Coll Radiol) 1992; 4:290.
  141. Kooy HM, van Herk M, Barnes PD, et al. Image fusion for stereotactic radiotherapy and radiosurgery treatment planning. Int J Radiat Oncol Biol Phys 1994; 28:1229.
  142. Information on the VORTEX study is available online at http://clinicaltrials.gov/ct2/show/NCT00423618 (Accessed on April 01, 2011).
  143. Haas RL, Delaney TF, O'Sullivan B, et al. Radiotherapy for management of extremity soft tissue sarcomas: why, when, and where? Int J Radiat Oncol Biol Phys 2012; 84:572.
  144. Tran QN, Kim AC, Gottschalk AR, et al. Clinical outcomes of intraoperative radiation therapy for extremity sarcomas. Sarcoma 2006; 2006:91671.
  145. Gerrand CH, Wunder JS, Kandel RA, et al. Classification of positive margins after resection of soft-tissue sarcoma of the limb predicts the risk of local recurrence. J Bone Joint Surg Br 2001; 83:1149.
  146. Zagars GK, Ballo MT. Significance of dose in postoperative radiotherapy for soft tissue sarcoma. Int J Radiat Oncol Biol Phys 2003; 56:473.
  147. Chan MF, Chui CS, Schupak K, et al. The treatment of large extraskeletal chondrosarcoma of the leg: comparison of IMRT and conformal radiotherapy techniques. J Appl Clin Med Phys 2001; 2:3.
  148. Hong L, Alektiar KM, Hunt M, et al. Intensity-modulated radiotherapy for soft tissue sarcoma of the thigh. Int J Radiat Oncol Biol Phys 2004; 59:752.
  149. Lee N, Chuang C, Quivey JM, et al. Skin toxicity due to intensity-modulated radiotherapy for head-and-neck carcinoma. Int J Radiat Oncol Biol Phys 2002; 53:630.
  150. Alektiar KM, Brennan MF, Healey JH, Singer S. Impact of intensity-modulated radiation therapy on local control in primary soft-tissue sarcoma of the extremity. J Clin Oncol 2008; 26:3440.
  151. Folkert MR, Singer S, Brennan MF, et al. Comparison of local recurrence with conventional and intensity-modulated radiation therapy for primary soft-tissue sarcomas of the extremity. J Clin Oncol 2014; 32:3236.
  152. Levin WP, Kooy H, Loeffler JS, DeLaney TF. Proton beam therapy. Br J Cancer 2005; 93:849.
  153. Rothermundt C, Whelan JS, Dileo P, et al. What is the role of routine follow-up for localised limb soft tissue sarcomas? A retrospective analysis of 174 patients. Br J Cancer 2014; 110:2420.
  154. Krieg AH, Hefti F, Speth BM, et al. Synovial sarcomas usually metastasize after >5 years: a multicenter retrospective analysis with minimum follow-up of 10 years for survivors. Ann Oncol 2011; 22:458.
  155. Trovik CS, Bauer HC. Local recurrence of soft tissue sarcoma a risk factor for late metastases. 379 patients followed for 0.5-20 years. Acta Orthop Scand 1994; 65:553.
  156. Patel SR, Zagars GK, Pisters PW. The follow-up of adult soft-tissue sarcomas. Semin Oncol 2003; 30:413.
  157. Cheney MD, Giraud C, Goldberg SI, et al. MRI surveillance following treatment of extremity soft tissue sarcoma. J Surg Oncol 2014; 109:593.