Management of Small Soft-Tissue Sarcoma of the

Extremity in Adults

Richard J. Geer, MD; James Woodruff, MD;

significance of small (\m=le\5cm in diamsarcoma of the extremity, 174 adult patients soft-tissue eter) were identified from information that had been entered prospectively into a database of 1742 patients between July 1982 and December 1990. Median follow-up was 48 months. The majority of tumors were high grade (n=114; 66%). Local recurrence (n=17) was seen in patients with both high-grade (11 %) and low-grade tumors (7%). Distant metastases were seen in 7% of high-grade tumors and in no low-grade tumors. The overall 5-year survival rate was 94% for all patients. Grade, depth, location, type of operation, and sex did not affect 5-year survival or local recurrence\x=req-\ free survival. Neither postoperative adjuvant chemotherapy nor radiation therapy resulted in superior 5-year survival or local recurrence-free survival when compared with no postoperative treatment. The prognosis of these lesions is favorable, and no additional prognostic factors were identified. Inclusion of these patients into adjuvant therapy trials examining survival is inappropriate. \s=b\

To determine the

(Arch Surg. 1992;127:1285-1289)

treatment of soft-tissue sarcoma of the continues to evolve and be defined. recurrence and survival have

Multidisciplinary extremity factors for local

Prognostic

been identified in an attempt to define a population for which adjuvant therapy is necessary.1 In the staging system used by the American Joint Committee on Cancer (AJCC), the primary determination of stage includes the designation of tumor grade and the presence or absence of distant metastasis (Table 1). Although tumor size is con¬ sidered within stage categories, its value has received lit¬ tle emphasis. A sarcoma smaller than 5 cm in diameter may be classified by grade as either stage I, II, or III. Each stage has considerable prognostic significance for survival, with patients with stage III lesions having an approximate 30%o 5-year survival.2 Poor survival in patients with stage III sarcoma emphasizes that the small lesion that a patient

Accepted for publication July 9,

1992.

Departments of Surgery (Drs Geer and Brennan), Pathology (Dr Woodruff), and Medicine (Dr Casper), Memorial Sloan-Kettering Cancer Center, New York, NY. Presented at the 45th Annual Cancer Symposium of the Society of Surgical Oncology, New York, NY, March 16, 1992. Reprint requests to 1275 York Ave, New York, NY 10021 (Dr From the

Brennan).

Ephraim S. Casper, MD; Murray F.

Brennan, MD

perceives as a relatively minor problem is considered life

threatening by the physician. Alternative

for soft-tissue sarcoma in¬ factors that include tumor grade and size, with the addition of tumor depth in relation to the superficial fascia, have been proposed. In the system used at our institution as proposed by Hajdu,3 the importance of tumor size has received greater emphasis than is given in the AJCC staging system (Table 2). Tumors are graded as either high or low; no intermediate grade is recognized. For the small soft-tissue sarcoma (5 cm or less in diam¬ eter), controversy arises as to the extent of resection and the need for adjuvant therapy. These lesions are often misdiagnosed and their significance underappreciated. In an ef¬ fort to clarify the significance of such small lesions, we conducted the present analysis using a prospective data¬ base of all patients who underwent treatment at a single institution. Our objective was to determine if these small lesions have a sufficiently poor prognosis for local recur¬ rence and survival to justify their inclusion in trials that examine adjuvant benefits of local and systemic therapy.

staging systems

volving prognostic

PATIENTS AND METHODS From July 1982 to December 1990, 1747 patients older than 16 years with primary or recurrent soft-tissue sarcoma were admit¬

ted to Memorial Sloan-Kettering Cancer Center (New York, NY); their records were entered prospectively into a sarcoma database. Two hundred fourteen of these patients were diagnosed as hav¬ ing localized extremity lesions 5 cm or less in diameter. Of these patients, 40 (19%) had recurrent disease at initial presentation at our institution and 174 (81 % ) presented for primary management. These latter patients form the basis of this study. The following data were analyzed: demographics, including age and sex; tumor characteristics (ie, size, site, grade, histologie type, and depth); treatment (ie, biopsy technique, type of opera¬ tion, surgical margins, and adjuvant therapy); and outcome (ie, site and date of recurrence and follow-up). Tumor size, determined after careful review of the initial clin¬ ical description, imaging studies, and/or pathology report, re¬ flects the maximum diameter of the tumor. Discrepancies often arose between the pathologic size and the clinical size. The size of the tumor was determined from gross pathologic description, if available; if not, size was based on initial clinical description. Tumors located above the superficial fascia were considered su¬ perficial, and those located below the superficial fascia were con¬ sidered deep. Tumors located above the elbow or knee were con¬ sidered proximal, and those distal to these structures were considered distal. Tissue structure of the tumor and grade were

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Table 1.—Clinical Cancer

Staging System for

Tumor

Grade

Stage

Sarcoma Used

l(A), IB

Size,

by the American Joint Committee on Cancer Regional Lymph Nodes

cm

5

ll(A), MB lll(A), NIB lll(C)

Negative Negative Negative

None

Positive

None

Any Any

None