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Connective Tissue Oncology Society |
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| 2001 CTOS Annual Meeting Posters— Surgery CLOSE SURGICAL MARGINS
IN SOFT TISSUE SARCOMA RESECTION DO NOT PREDICT LOCAL RECURRENCE
WHEN INDUCTION (NEOADJUVANT) CHEMOTHERAPY IS USED IN THE TREATMENT
OF HIGH GRADE EXTREMITY SOFT TISSUE SARCOMA OBJECTIVE: Surgical resection with "wide" margins, i.e. with a rim of normal of tissue, is the mainstay of local control for high grade soft tissue sarcoma. The objective of this study is to assess whether the presence of close or microscopically positive surgical margins contributes to local recurrence and what role, if any, induction chemotherapy without preoperative radiation plays in prevention of local recurrence after limb-sparing resection of soft tissue sarcomas METHODS: During the period of 1988 to the present, over 100 resections for high-grade soft tissue sarcomas were performed by the same surgical team. Of these, 58 whose tumors were deep, large (more than 5 cm) and high grade were eligible for enrollment into a chemotherapy protocol consisting of neoadjuvant plus adjuvant doxorubucin, intra-arterial cisplatin and, after 1996, ifosfomide. Patients did not undergo preoperative radiation but those with poor chemotherepeutic response and close surgical margins also underwent adjuvant external beam radiotherapy. Twenty nine patients who underwent their first surgery after induction chemotherapy and have follow-up of two years or more form the basis of this report. Pathology reports from 15 of these cases specify a margin depth in centimeters. RESULTS: The overall local recurrence rate was 6.9% (2/29). For the 27 patients without local recurrence, 14 (52%) have pathology reports specifying margin depth. Of these 10/14 (71%) had a minimum distance of less than or equal to 5 mm from the tumor to the inked margin whereas 1/14 (7%) had a "positive" margin, where tumor is focally present at the inked margin. Among the 2 patients with local recurrence, 1 (50%) has a pathology report specifying the margin depth which was less than or equal to 5 mm. Pathology reports not specifying margin depth stated generally that the margins were "free of tumor". Adjuvant radiotherapy was administered to 1 (50%) patient with local recurrence (margin depth not specified) and 3 (11%) patients without local recurrence all of whom had 20% or less tumor necrosis (one margin less than 5 mm, one margin unspecified). The maximum tumor diameter in non-recurring and recurring patients averaged 11.2 cm and 15.8 cm, respectively. CONCLUSION: Even with the use of adjuvant radiotherapy, several recent large reviews have reported 20% - 25% local recurrence rates with the most important risk factor being the surgical margins of the resection specimen. In our series, there was only a 7% local recurrence rate which is even more remarkable when it is noted that, of the patients without local recurrence who had exact margins recorded, nearly 80% had a surgical margin of 5mm or less. Thus the presence of microscopically close or positive resection margins in our series did not correlate with local recurrence. Furthermore, only 4/29 (14%) patients underwent postoperative radiotherapy and no patient underwent preoperative radiotherapy suggesting that radiation did not significantly contribute to this low recurrence rate. While systemic chemotherapy is generally administered in an attempt to improve overall survival, our results imply that the killing of malignant cells in the periphery of tumors with induction chemotherapy can improve local control and postoperative function by allowing for the removal of a minimum amount of normal tissue with an acceptable rate of local recurrence.
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