Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Surgical resection of primary soft tissue sarcoma of the extremities

Mark C Gebhardt, MD
Section Editors
Raphael E Pollock, MD
Robert Maki, MD, PhD
Deputy Editors
Kathryn A Collins, MD, PhD, FACS
Diane MF Savarese, MD


Sarcomas are uncommon 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.

The surgical management of primary soft tissue sarcomas (STSs) of the extremities will be reviewed here. The clinical features, diagnosis, classification, and staging of primary STS of the extremity and radiation-associated sarcomas, as well as an overview of multimodality therapy as used for STS of the extremities and chest wall, are discussed separately. (See "Clinical presentation, histopathology, diagnostic evaluation, and staging of soft tissue sarcoma" and "Radiation-associated sarcomas" and "Overview of multimodality treatment for primary soft tissue sarcoma of the extremities and chest wall".)

Because of their rarity and the frequent need for multimodality treatment, surgical management of STS should ideally be carried out in a center with expertise in the treatment of sarcomas. The surgical expertise of dedicated subspecialists improves clinical outcomes. In one study that examined outcomes of 375 patients with STS of the extremities, local recurrence rates were 1.3-fold higher in those referred only after definitive surgery and were 2.4-fold higher for patients not referred at any time [1]. (See "Clinical presentation, histopathology, diagnostic evaluation, and staging of soft tissue sarcoma" and "Overview of multimodality treatment for primary soft tissue sarcoma of the extremities and chest wall" and "Systemic treatment of metastatic soft tissue sarcoma".)


The goals of treating extremity soft tissue sarcomas (STSs) are to minimize local recurrence, perioperative morbidity, and mortality and to maximize function and long-term survival. To achieve these goals, radiation therapy (RT) combined with wide surgical resection is recommended for most patients with high-grade primary extremity STS, with some exceptions [2]. The role of chemotherapy continues to be debated.

Adjuvant radiation is often used to aid with local control when it is predicted that adequate margins will be difficult to achieve, usually around major nerves and blood vessels. The particular adjunctive therapy (chemotherapy and/or RT) chosen is based upon the size and grade of the tumor but also upon institutional expertise, experience, and preferences. (See 'Adjunctive medical therapies' below and "Overview of multimodality treatment for primary soft tissue sarcoma of the extremities and chest wall", section on 'Radiation therapy' and "Overview of multimodality treatment for primary soft tissue sarcoma of the extremities and chest wall", section on 'Initial chemoradiotherapy for large high-grade STS'.)

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Nov 10, 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 ©2017 UpToDate, Inc.
  1. 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.
  2. 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.
  3. Tepper JE, Suit HD. Radiation therapy alone for sarcoma of soft tissue. Cancer 1985; 56:475.
  4. Dewar JA, Duncan W. A retrospective study of the role of radiotherapy in the treatment of soft-tissue sarcoma. Clin Radiol 1985; 36:629.
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. 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.
  10. Kattan MW, Leung DH, Brennan MF. Postoperative nomogram for 12-year sarcoma-specific death. J Clin Oncol 2002; 20:791.
  11. 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.
  12. 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.
  13. Rydholm A. Surgery without radiotherapy in soft tissue sarcoma. Acta Orthop Scand Suppl 1997; 273:117.
  14. 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.
  15. 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.
  16. 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.
  17. 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.
  18. 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.
  19. 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.
  20. 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.
  21. 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.
  22. 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.
  23. 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.
  24. 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.
  25. Verhey LJ. Comparison of three-dimensional conformal radiation therapy and intensity-modulated radiation therapy systems. Semin Radiat Oncol 1999; 9:78.
  26. 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.
  27. Eilber FR, Eckardt J. Surgical management of soft tissue sarcomas. Semin Oncol 1997; 24:526.
  28. 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.
  29. 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.
  30. 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.
  31. 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.
  32. Parker MJ, Livingstone V, Clifton R, McKee A. Closed suction surgical wound drainage after orthopaedic surgery. Cochrane Database Syst Rev 2007; :CD001825.
  33. 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.
  34. Ferguson PC, Griffin AM, O'Sullivan B, et al. Bone invasion in extremity soft-tissue sarcoma: impact on disease outcomes. Cancer 2006; 106:2692.
  35. Lin PP, Pino ED, Normand AN, et al. Periosteal margin in soft-tissue sarcoma. Cancer 2007; 109:598.
  36. Cannon CP, Ballo MT, Zagars GK, et al. Complications of combined modality treatment of primary lower extremity soft-tissue sarcomas. Cancer 2006; 107:2455.
  37. 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.
  38. 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.
  39. 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.
  40. 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.
  41. 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.
  42. 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.
  43. 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.
  44. 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.
  45. Behranwala KA, A'Hern R, Omar AM, Thomas JM. Prognosis of lymph node metastasis in soft tissue sarcoma. Ann Surg Oncol 2004; 11:714.
  46. 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.
  47. 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.
  48. Riad S, Griffin AM, Liberman B, et al. Lymph node metastasis in soft tissue sarcoma in an extremity. Clin Orthop Relat Res 2004; :129.
  49. 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.
  50. Yoon SS, Maki RG, Asare EA, et al.. Soft Tissue Sarcoma of the Trunk and Extremities. In: AJCC Cancer Staging Manual, 8th, Amin. MB (Ed), AJCC, Chicago 2017. p.507.
  51. 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.
  52. Tunn PU, Andreou D, Illing H, et al. Sentinel node biopsy in synovial sarcoma. Eur J Surg Oncol 2008; 34:704.
  53. 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.
  54. van Akkooi AC, Verhoef C, van Geel AN, et al. Sentinel node biopsy for clear cell sarcoma. Eur J Surg Oncol 2006; 32:996.
  55. Fantini F, Monari P, Bassissi S, et al. Sentinel lymph node biopsy in clear cell sarcoma. J Eur Acad Dermatol Venereol 2007; 21:1271.
  56. 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.
  57. 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.
  58. 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.
  59. Zornig C, Peiper M, Schröder S. Re-excision of soft tissue sarcoma after inadequate initial operation. Br J Surg 1995; 82:278.
  60. 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.
  61. 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.
  62. 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.
  63. 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.
  64. 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.
  65. 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.
  66. 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.
  67. 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.
  68. 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.
  69. 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.
  70. Schwartz A, Rebecca A, Smith A, et al. Risk factors for significant wound complications following wide resection of extremity soft tissue sarcomas. Clin Orthop Relat Res 2013; 471:3612.
  71. 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.
  72. Patel SR, Zagars GK, Pisters PW. The follow-up of adult soft-tissue sarcomas. Semin Oncol 2003; 30:413.
  73. 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.
  74. Nagano S, Yokouchi M, Setoguchi T, et al. Analysis of surgical site infection after musculoskeletal tumor surgery: risk assessment using a new scoring system. Sarcoma 2014; 2014:645496.
  75. Vos LM, Morand PC, Biau D, et al. High Frequency of Polymicrobial Infections After Surgical Resection of Malignant Bone and Soft Tissue Tumors: A Retrospective Cohort Study. Infect Dis Ther 2015; 4:307.
  76. 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.
  77. Peat BG, Bell RS, Davis A, et al. Wound-healing complications after soft-tissue sarcoma surgery. Plast Reconstr Surg 1994; 93:980.
  78. 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.
  79. 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.
  80. Siegel HJ, Long JL, Watson KM, Fiveash JB. Vacuum-assisted closure for radiation-associated wound complications. J Surg Oncol 2007; 96:575.
  81. Bickels J, Kollender Y, Wittig JC, et al. Vacuum-assisted wound closure after resection of musculoskeletal tumors. Clin Orthop Relat Res 2005; 441:346.
  82. Delman KA, Johnstone PA. Vacuum-assisted closure for surgical wounds in sarcoma. J Surg Oncol 2007; 96:545.
  83. Mitchell SY, Lingard EA, Kesteven P, et al. Venous thromboembolism in patients with primary bone or soft-tissue sarcomas. J Bone Joint Surg Am 2007; 89:2433.
  84. 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.
  85. 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.
  86. 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.
  87. Robinson MH, Spruce L, Eeles R, et al. Limb function following conservation treatment of adult soft tissue sarcoma. Eur J Cancer 1991; 27:1567.
  88. 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.
  89. 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.
  90. 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.
  91. Weddington WW Jr, Segraves KB, Simon MA. Psychological outcome of extremity sarcoma survivors undergoing amputation or limb salvage. J Clin Oncol 1985; 3:1393.
  92. Sugarbaker PH, Barofsky I, Rosenberg SA, Gianola FJ. Quality of life assessment of patients in extremity sarcoma clinical trials. Surgery 1982; 91:17.
  93. 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.
  94. 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.
  95. 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.
  96. 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.
  97. Karakousis CP, De Young C, Driscoll DL. Soft tissue sarcomas of the hand and foot: management and survival. Ann Surg Oncol 1998; 5:238.