SOFT-TISSUE SARCOMA OF THE EXTREMITY - LIMB SALVAGE AFTER FAILURE OF COMBINED CONSERVATIVE THERAPY

Purpose: To assess the results of salvage therapy using surgery alone or surgery and re-irradiation for patients with locally recurrent extr emity soft tissue sarcoma (STS) following conservative surgery and rad iotherapy. Materials and methods: 25 patients with locally recurrent S TS after conservative surgery and irradiation were assessed between 19 90 and 1995. Two patients with concurrent systemic relapse were treate d palliatively. Seven patients were not candidates for conservative re -excision and underwent amputation, 11 patients underwent conservative resection without irradiation. Seven of these patients relapsed, and five went on to receive combined conservative surgery and re-irradiati on. A further five patients initially received combined retreatment, f or a total of ten patients treated with combined conservative surgery and re-irradiation. Six of these ten patients were treated with brachy therapy alone, one with brachytherapy and external beam therapy, and t hree with external beam therapy alone. The median retreatment dose was 49.5 Gy (range 35-65 Gy), and the median cumulative soft tissue dose was 100 Gy (range 93-120 Gy). Results: The median follow-up from the m ost recent treatment is 24 months (range 7-42 months). At the last fol low-up 14 patients are alive and disease free; two are alive with loca l disease and four with systemic disease, and five are dead of disease . Overall local control is 19/23 (91%). The local control for patients treated with conservative excision without irradiation is 4/11 (36%) and for conservative excision with re-irradiation 10/10 (100%). Six (6 0%) of these patients experienced significant post-irradiation wound-h ealing complications, but three have recovered fully. Functional score s for the entire treated group are significantly lower after treatment , as are those for patients undergoing combined surgery and re-irradia tion, but 70% of those treated with conservative surgery and re-irradi ation had a good or excellent post-treatment functional score. Conclus ions: Combined conservative surgery and re-irradiation provided superi or local control to local re-excision alone and a functional outcome s uperior to amputation. Combined treatment with re-irradiation should b e considered the primary salvage therapy for patients who fail combine d therapy and who are suitable for conservative re-excision. Systemic relapse is a significant problem, and optimal therapy should minimize the risk of local relapse after the initial therapy. Eighteen patients (72%) had a history of intralesional excision as their initial interv ention, and suggests that inappropriate initial management is a risk f actor for relapse after combined conservative therapy. Improvements in therapy must include the appropriate education of the primary care ph ysicians.