Treatment of locally recurrent and unresectable, locally advanced soft tissue sarcoma of the extremities
- Thomas F DeLaney, MD
Thomas F DeLaney, MD
- Section Editor — Bone and Soft Tissue Tumors
- Professor of Radiation Oncology
- Harvard Medical School
- Mark C Gebhardt, MD
Mark C Gebhardt, MD
- Frederic W. and Jane M. Ilfeld Professor of Orthopedic Surgery
- Harvard Medical School
- Christopher W Ryan, MD
Christopher W Ryan, MD
- Oregon Health & Science University
- Knight Cancer Institute
- Section Editors
- Robert Maki, MD, PhD
Robert Maki, MD, PhD
- Section Editor — Bone and Soft Tissue Tumors
- Professor of Medicine
- Monter Cancer Center
- Hofstra-Northwell School of Medicine
- Russell S Berman, MD
Russell S Berman, MD
- Section Editor — Skin and Soft Tissue Surgery
- Chief of Surgical Oncology
- New York University Langone Medical Center
- Raphael E Pollock, MD
Raphael E Pollock, MD
- Editor-in-Chief — General Surgery
- Section Editor — Soft Tissue Sarcoma
- Professor of Surgery
- The Ohio State University
Soft tissue sarcomas (STS) are rare malignant tumors that arise from extraskeletal connective tissues, including the peripheral nervous system. They can arise at any body site.
Treatment for locally recurrent and locally advanced, potentially unresectable STS of the extremities will be reviewed here. Issues relating to classification, diagnosis, and staging of STS, local treatment options for localized primary STS of the extremities and chest wall, the use of adjuvant and neoadjuvant chemotherapy for extremity STS, and the treatment of STS in locations other than the extremities and chest wall are discussed separately. (See "Overview of multimodality treatment for primary soft tissue sarcoma of the extremities and chest wall" and "Adjuvant and neoadjuvant chemotherapy for soft tissue sarcoma of the extremities" and "Head and neck sarcomas" and "Breast sarcoma: Epidemiology, risk factors, clinical presentation, diagnosis, and staging" and "Clinical features, evaluation, and treatment of retroperitoneal soft tissue sarcoma" 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 STS should ideally be carried out in a center with expertise in the treatment of sarcomas, including surgical, orthopedic, medical, pediatric, and radiation oncology. The multidisciplinary team approach to the care of STS optimizes treatment planning, minimizes duplication of diagnostic studies, and reduces the time to implementation of the definitive therapeutic protocol, and the expertise gained by dedicated subspecialists improves clinical outcomes.
LOCALLY RECURRENT DISEASE
Approximately 10 to 15 percent of patients with extremity STS who are treated with complete resection and adjunctive radiation therapy (RT) will develop a local tumor failure, the majority within the first two years [1-4]. A local recurrence is associated with a significant worsening of prognosis, although whether the local relapse is causative or simply a marker of worse tumor biology is debated [5-12]. At least in theory, the two mechanisms might coexist and possibly interact, with both contributing to outcomes. On the other hand, if local control can be regained after aggressive management of a local recurrence and there are no metastases, prognosis may not necessarily be adversely impacted.
The approach to the patient with an isolated local recurrence is similar to that for primary disease, with some modification depending on whether the patient has received previous RT.
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- IMPORTANCE OF MULTIDISCIPLINARY EVALUATION AND MANAGEMENT
- LOCALLY RECURRENT DISEASE
- Overview of the therapeutic approach
- Adjunctive treatment
- - Patients without prior radiation therapy
- Radiation therapy
- Preoperative chemoradiotherapy
- - Previously irradiated patients
- Regional chemotherapy approaches
- Chemotherapy with regional hyperthermia
- - Postoperative chemotherapy
- UNRESECTABLE LOCALLY ADVANCED DISEASE
- Overview of the therapeutic approach
- Radiation therapy and chemoradiotherapy
- Regional chemotherapy
- - Isolated limb perfusion
- - Isolated limb infusion
- Systemic chemotherapy with and without regional hyperthermia
- Palliative chemotherapy
- Guidelines from expert groups
- POSTTREATMENT SURVEILLANCE
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS
- Local recurrence
- Unresectable locally advanced