Importance of Surgical Resection in the Successful Management of Soft Tissue Sarcoma

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Abstract
SURVIVAL IS OF paramount importance in the management of soft tissue sarcoma (STS). Disease-free survival is not possible without a local disease-free state. The evolution of various modalities of oncologic treatment, especially chemotherapy, has significantly improved the survival in the management of many malignant neoplasms. Surgery for STS is the only modality that alone can produce a local disease-free state. Local or marginal excision alone leads to unacceptably high local failure rates of 70% to 90%; even radical limb-sparing operations have a 25% recurrence with surgery alone.1 The use of adjuvant radiation therapy has allowed for less radical surgery and thus more functional outcomes even for patients presenting with recurrences.2 Radiation therapy in the treatment of patients with more than small isolated microscopically positive margins or who have had the pseudocapsule violated during surgery is likely to be unsuccessful. The use of adjuvant chemotherapy remains controversial in STS except perhaps for high-risk patients, ie, those with high-grade histological findings and tumor masses greater than 10 cm. Chemotherapy as the sole modality of treatment in a patient with STS serves only a palliative role at best. It is our hypothesis that a systemic disease-free state first necessitates a local disease-free state. A local disease-free state requires an appropriate, aggressive operation, meticulously performed with adequate margins by an experienced oncologic surgeon who understands the biology of STS and is able, by that experience and knowledge, to obtain appropriate curative margins. In some cases, when the lesion is low grade, small, and perhaps superficial, local control can be accomplished with surgery alone. However, due to adjacent microsatellites of tumor, the close or marginal margins needed to maximize function or to preserve major nerves or other vital structures require the use of adjuvant radiation therapy. Different adjuvant protocols have been used, including preoperative intra-arterial local chemotherapy, preoperative and postoperative radiation therapy, and various chemotherapy regimens.1,3-5 Radiation has become the mainstay of adjuvant therapy. Timing of perioperative radiation therapy remains a topic of controversy, but postoperative radiation therapy has been shown to lead to fewer wound complications, and this has been our experience.