SURGICAL CULTURE, TECHNIQUES OR ADJUVANT THERAPIES: WHAT IS RELEVANT IN LIMB SAVING FOR SOFT TISSUE SARCOMA.

Azzarelli A., Casali P, Gronchi A., Bertulli R., Fissi S., Rasponi A. Unit of Musculo-Skeletal Surgery - Istituto Nazionale Tumori, Milano - 20133 ITALIA.

Amputations for soft tissue sarcoma (STS) dramatically decreased in the recent decades, and multimodal treatment policies (perioperative radiation therapy, adjuvant chemotherapy, isolated limb perfusion, and combinations) are usually conceived to be responsible for this improving in limb salvage surgery, but their role was never proved. The number of amputations for patients with STS significantly dropped from 40/60% to 5/20% in the last 20 years, and this is an impressive gap if compared with the survival rate which in the same period had a minimal improvement. In order to find out the reason of this observation, we reviewed 1319 patients with extremity STS operated in our Institute in the period 1965-1998, examining the relationship between the limb-salvage rate and the employment of preoperative adjuvant procedures or special surgical techniques. The amputation rate stratified by years was respectively: 1965-’75=71% (37/52 pts), 1976-`85=16% (46/287), 1986-`95=8% (61/764), 1996-`98=3% (6/216). RT is the main adjuvant tool for improving local control, but its rationale, even if more standardized in the recent period, did not change grossly by years, and usually indicates RT postoperatively with a poor role on the surgical choice between conservative versus ablative operation. Preoperative CT was employed in 143 cases (111 with intra-arterial delivery of Adriamycin): shrinkage of the lesion was documented in about 40% of cases, but the split from amputation versus conservative operation was estimated around 4%. More recently hyperthermic isolated limb perfusion (HILP) chemotherapy seems to improve these conservative possibilities. We perfused 70 patients, mainly in the last five years: only two (3%) amputations out of 68 post HILP operations and their final role in local control is still under evaluation, however not responsible of the important improvement reported between the `70ties and the `80ties. Surgical reconstructive methodologies and vascular prosthesis were employed in less than 10% (128/1319) of our operations and changed the surgical indication in favor of limb sparing surgery in less than 3%. By their own any single procedure helped local control and conservative operations but do not provide explanation for the dramatic drop of amputations. This event, that is the only significant favorable result achieved in the treatment of STS and confirmed in different experiences, is thought to be due mainly to improved anatomo-surgical knowledge and practice.