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

Surgical treatment and other localized therapy for metastatic soft tissue sarcoma

Chandrajit P Raut, MD, MSc, FACS
Suzanne George, MD
George D Demetri, 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


Soft tissue sarcomas are a heterogeneous group of uncommon tumors arising from mesenchymal cells at all body sites. The malignant precursor cell(s) differentiate along one or several lineages, such as muscle, adipose, fibrous, cartilage, nerve, or vascular tissue. These tumors arise most often in the limbs (particularly the lower extremity), followed in order of frequency by the abdominal cavity/retroperitoneum, trunk/thoracic region and the head and neck. (See "Clinical presentation, histopathology, diagnostic evaluation, and staging of soft tissue sarcoma", section on 'Clinical presentation' and "Clinical presentation, histopathology, diagnostic evaluation, and staging of soft tissue sarcoma", section on 'Introduction'.)

While local complications from primary or recurrent sarcomas can cause significant morbidity and occasional mortality, the most life-threatening aspect of sarcomas is their propensity for hematogenous dissemination. The pattern of tumor spread varies according to tumor type:

For most sarcomas of the extremity, chest wall, and head or neck, the primary metastatic site is the lung [1]. However, there are exceptions. Extrapulmonary metastases to the retroperitoneum, spine, and paraspinous soft tissues predominate with myxoid/round cell liposarcomas, although lung metastases develop eventually in almost all [2]. (See "Clinical presentation, histopathology, diagnostic evaluation, and staging of soft tissue sarcoma", section on 'Pattern of spread'.)

The primary site of failure is locoregional for retroperitoneal and visceral sarcomas; less commonly, these tumors spread hematogenously to the liver, and also to the lungs [3].

Spread to locoregional lymph nodes is rare (≤5 percent) with the exception of clear cell and epithelioid sarcomas, angiosarcomas, and rhabdomyosarcomas [4].

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 17, 2017.
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. Potter DA, Glenn J, Kinsella T, et al. Patterns of recurrence in patients with high-grade soft-tissue sarcomas. J Clin Oncol 1985; 3:353.
  2. Pearlstone DB, Pisters PW, Bold RJ, et al. Patterns of recurrence in extremity liposarcoma: implications for staging and follow-up. Cancer 1999; 85:85.
  3. Spillane AJ, Fisher C, Thomas JM. Myxoid liposarcoma--the frequency and the natural history of nonpulmonary soft tissue metastases. Ann Surg Oncol 1999; 6:389.
  4. Mazeron JJ, Suit HD. Lymph nodes as sites of metastases from sarcomas of soft tissue. Cancer 1987; 60:1800.
  5. Billingsley KG, Burt ME, Jara E, et al. Pulmonary metastases from soft tissue sarcoma: analysis of patterns of diseases and postmetastasis survival. Ann Surg 1999; 229:602.
  6. Jablons D, Steinberg SM, Roth J, et al. Metastasectomy for soft tissue sarcoma. Further evidence for efficacy and prognostic indicators. J Thorac Cardiovasc Surg 1989; 97:695.
  7. Chudgar NP, Brennan MF, Munhoz RR, et al. Pulmonary metastasectomy with therapeutic intent for soft-tissue sarcoma. J Thorac Cardiovasc Surg 2017; 154:319.
  8. McCormack P. Surgical resection of pulmonary metastases. Semin Surg Oncol 1990; 6:297.
  9. Chao C, Goldberg M. Surgical treatment of metastatic pulmonary soft-tissue sarcoma. Oncology (Williston Park) 2000; 14:835.
  10. Quiros RM, Scott WJ. Surgical treatment of metastatic disease to the lung. Semin Oncol 2008; 35:134.
  11. Blackmon SH, Shah N, Roth JA, et al. Resection of pulmonary and extrapulmonary sarcomatous metastases is associated with long-term survival. Ann Thorac Surg 2009; 88:877.
  12. Iagaru A, Chawla S, Menendez L, Conti PS. 18F-FDG PET and PET/CT for detection of pulmonary metastases from musculoskeletal sarcomas. Nucl Med Commun 2006; 27:795.
  13. National Comprehensive Cancer Network (NCCN) guidelines available online at www.nccn.org (Accessed on July 14, 2011).
  14. Roberge D, Hickeson M, Charest M, Turcotte RE. Utility of total body FDG PET/CT imaging in the initial staging of soft-tissue sarcoma (abstract #10531). J Clin Oncol 2009; 27:543s.
  15. Pfannschmidt J, Klode J, Muley T, et al. Nodal involvement at the time of pulmonary metastasectomy: experiences in 245 patients. Ann Thorac Surg 2006; 81:448.
  16. Gossot D, Radu C, Girard P, et al. Resection of pulmonary metastases from sarcoma: can some patients benefit from a less invasive approach? Ann Thorac Surg 2009; 87:238.
  17. Choong PF, Pritchard DJ, Rock MG, et al. Survival after pulmonary metastasectomy in soft tissue sarcoma. Prognostic factors in 214 patients. Acta Orthop Scand 1995; 66:561.
  18. van Geel AN, Pastorino U, Jauch KW, et al. Surgical treatment of lung metastases: The European Organization for Research and Treatment of Cancer-Soft Tissue and Bone Sarcoma Group study of 255 patients. Cancer 1996; 77:675.
  19. Frost DB. Pulmonary metastasectomy for soft tissue sarcomas: is it justified? J Surg Oncol 1995; 59:110.
  20. Casson AG, Putnam JB, Natarajan G, et al. Five-year survival after pulmonary metastasectomy for adult soft tissue sarcoma. Cancer 1992; 69:662.
  21. Illuminati G, Ceccanei G, Pacilè MA, et al. Surgical outcomes for liposarcoma of the lower limbs with synchronous pulmonary metastases. J Surg Oncol 2010; 102:827.
  22. Burt BM, Ocejo S, Mery CM, et al. Repeated and aggressive pulmonary resections for leiomyosarcoma metastases extends survival. Ann Thorac Surg 2011; 92:1202.
  23. Ferguson PC, Deheshi BM, Chung P, et al. Soft tissue sarcoma presenting with metastatic disease: outcome with primary surgical resection. Cancer 2011; 117:372.
  24. Dossett LA, Toloza EM, Fontaine J, et al. Outcomes and clinical predictors of improved survival in a patients undergoing pulmonary metastasectomy for sarcoma. J Surg Oncol 2015; 112:103.
  25. Porter GA, Cantor SB, Walsh GL, et al. Cost-effectiveness of pulmonary resection and systemic chemotherapy in the management of metastatic soft tissue sarcoma: a combined analysis from the University of Texas M. D. Anderson and Memorial Sloan-Kettering Cancer Centers. J Thorac Cardiovasc Surg 2004; 127:1366.
  26. Canter RJ, Qin LX, Downey RJ, et al. Perioperative chemotherapy in patients undergoing pulmonary resection for metastatic soft-tissue sarcoma of the extremity : a retrospective analysis. Cancer 2007; 110:2050.
  27. Antman K, Crowley J, Balcerzak SP, et al. A Southwest Oncology Group and Cancer and Leukemia Group B phase II study of doxorubicin, dacarbazine, ifosfamide, and mesna in adults with advanced osteosarcoma, Ewing's sarcoma, and rhabdomyosarcoma. Cancer 1998; 82:1288.
  28. Pogrebniak HW, Roth JA, Steinberg SM, et al. Reoperative pulmonary resection in patients with metastatic soft tissue sarcoma. Ann Thorac Surg 1991; 52:197.
  29. Casson AG, Putnam JB, Natarajan G, et al. Efficacy of pulmonary metastasectomy for recurrent soft tissue sarcoma. J Surg Oncol 1991; 47:1.
  30. Weiser MR, Downey RJ, Leung DH, Brennan MF. Repeat resection of pulmonary metastases in patients with soft-tissue sarcoma. J Am Coll Surg 2000; 191:184.
  31. Yamamoto H, Watanabe K, Nagata M, et al. Surgical treatment for pancreatic metastasis from soft-tissue sarcoma: report of two cases. Am J Clin Oncol 2001; 24:198.
  32. Chen H, Pruitt A, Nicol TL, et al. Complete hepatic resection of metastases from leiomyosarcoma prolongs survival. J Gastrointest Surg 1998; 2:151.
  33. Lang H, Nussbaum KT, Kaudel P, et al. Hepatic metastases from leiomyosarcoma: A single-center experience with 34 liver resections during a 15-year period. Ann Surg 2000; 231:500.
  34. Pawlik TM, Vauthey JN, Abdalla EK, et al. Results of a single-center experience with resection and ablation for sarcoma metastatic to the liver. Arch Surg 2006; 141:537.
  35. Chua TC, Chu F, Morris DL. Outcomes of single-centre experience of hepatic resection and cryoablation of sarcoma liver metastases. Am J Clin Oncol 2011; 34:317.
  36. Berber E, Ari E, Herceg N, Siperstein A. Laparoscopic radiofrequency thermal ablation for unusual hepatic tumors: operative indications and outcomes. Surg Endosc 2005; 19:1613.
  37. Abdalla EK, Pisters PW. Metastasectomy for limited metastases from soft tissue sarcoma. Curr Treat Options Oncol 2002; 3:497.
  38. Rusthoven KE, Kavanagh BD, Cardenes H, et al. Multi-institutional phase I/II trial of stereotactic body radiation therapy for liver metastases. J Clin Oncol 2009; 27:1572.
  39. Rusthoven KE, Kavanagh BD, Burri SH, et al. Multi-institutional phase I/II trial of stereotactic body radiation therapy for lung metastases. J Clin Oncol 2009; 27:1579.
  40. Dhakal S, Corbin KS, Milano MT, et al. Stereotactic body radiotherapy for pulmonary metastases from soft-tissue sarcomas: excellent local lesion control and improved patient survival. Int J Radiat Oncol Biol Phys 2012; 82:940.
  41. Baumann BC, Nagda SN, Kolker JD, et al. Efficacy and safety of stereotactic body radiation therapy for the treatment of pulmonary metastases from sarcoma: A potential alternative to resection. J Surg Oncol 2016; 114:65.