Outcome Following Limb Salvage
Surgery and External Beam
Radiotherapy for High Grade Soft
Tissue Sarcomas of the Groin and Axilla
Rapin Phimolsarnti M.D.
Anthony M. Griffin MSc
Peter C. Ferguson MD FRCSC
Charles N. Catton MD FRCPC
Peter W. Chung, MD FRCSC
Robert S. Bell MD FRCSC
Jay S. Wunder MD FRCSC
Brian O’Sullivan MD FRCPC
Musculoskeletal Oncology Unit,
Mount Sinai Hospital, University of Toronto.
Introduction
• High grade sarcoma usually treated with
combination of limb salvage surgery and
radiation ± chemotherapy.
• Low rates of local recurrence
• Impact on overall survival?
Introduction
• Previous study: soft tissue sarcoma
located in the central area which included
axilla and groin tumors had less
favorable local control compared to more
distal anatomic sites when treated with
surgery and adjuvant brachytherapy.
• External beam radiation therapy ?
Alektiar Ann Surg Oncol 2002
Purpose of the study
• To determine the outcome in terms of local
control and complications in the area of
the central flexor fossa (groin and axilla) in
our institution treated with external beam
radiation therapy and limb sparing surgery.
Materials and Methods
• Review of prospectively collected
database
• Surgery between 1989-2002
• Surgery- Mount Sinai Hospital.
• Radiation Therapy- Princess Margaret
Hospital.
Materials and Methods
• Inclusion criteria:
– Intermediate to high grade soft-tissue
sarcoma of the extremity
– Treated with limb sparing surgery
– Pre- or post operative radiation therapy
Materials and Methods
• Exclusion criteria.
– Metastasis at presentation
– Prior radiotherapy
– Adjuvant chemotherapy
Materials and Methods
• Surgical aspect
– 3 musculoskeletal oncologists (RSB, JSW,
PCF) all performed at MSH
– Surgical resections were attempted to
achieved 2cm margins
– Exception
• Natural boundary to tumor invasion (fascia,
periosteam)
• Close to but not fixed to the tumor mass
Materials and Methods
• Radiation Therapy
– 3 radiation oncologist (CNC, PWC and BOS)
– All performed at Princess Margaret Hospital
• Pre-op or Post-op
– Radiation dose
• 50 Gy for pre-op RT
• 60-66 Gy for post-op RT
Materials and Methods
• Follow up: Calculated from the time of
definite surgery to last follow up
• Local recurrence
– Physical Exam, MRI
• Distant Metastasis
– Chest x-ray, CT scan
• Complications
– Wound complications, infection, fracture
Material and Methods
• Statistical Analysis
– Survival rate: Kaplan-Meier
– Survival curve comparison: Log-rank test
– Association between variables: Chi-square
method
– Independent prognostic factors: Coxmultivariate analysis
Results
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•
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560 adult patients who met the criteria
418 lower, 142 upper
Median F/U 52 months
28 cases of tumor located in groin area
16 cases of tumor located in the axilla
area
Results
• There was no difference regarding to the
distribution of depth, grade, gender, prior
surgery, surgical margin, type of
radiotherapy between the central group
(axilla and groin) and the more distal
group
Results
• 5 years local recurrence free survival of
the entire group = 90.9%
• 5 years local recurrence free survival of
the groin and the axilla group = 90.6%
• There were no significant difference
between two groups (p>0.05)
Results
• Cox-multivariate analysis
– Margin, depth, prior “unplanned” excision and
anatomical site.
– Only a positive surgical margin is a significant
factor for the local recurrence
• 5 yr LR-free survival with
– Negative margin = 93.8%
– Positive margin = 78.2% (p<0.00001)
Complications
• 22 (50%) patients in the central location
group had complications (wound 15,
infection 4, fracture 1)
• 149 (28%) from 516 patients in the noncentral group had complications (wound
108, infection 17, fracture 12)
Discussion
• Eilber FC et al (Surg Oncol 1999)
– 1974-1998 UCLA medical center
– 68 patients with high grade soft-tissue
sarcoma of flexor fossae (popliteal, groin,
cubital, axilla)
– Pre-op chemotherapy (Adriamycin,
Ifosfamide) and radiation therapy
– Achieved local control in 89%
Discussion
• Alektiar et al (Ann Surg Oncol 2002):
– Memorial Sloan Kettering 1982-1997
– 202 patients (25 in the central area)
– High grade soft-tissue tumor
– Surgical excision with adjuvant brachytherapy
– 5-yr Local control rate in the central area was
lower than other sites (57% versus 88%)
Discussion
• Alektiar et al: 5-yr local control rate in the
central area is lower than other sites
• Current study- no difference in local
control rate between the central area and
more distal sites (90.6% versus 90.9%)
• However, the complications are higher in
the groin and axilla group (p=0.003)
Conclusion
• An axillary or groin location of an intermediate
and high grade sarcoma didn’t confer any
greater risk for local recurrence as compared to
more distal lesions.
• However, there are greater risk of complication
associate with external beam radiation in the
groin or axillary area compare to more distal
lesion
• Positive margin remains the major risk factor for
Local recurrence rate.
Thank you for your attention