Algorithm for management of soft tissue sarcomas of the limbs

Abstract

Soft tissue sarcoma (STS) represents a heterogeneous group of malignancies. Any patient with a soft tissue mass that is increasing in size, has a size >5cm or is deep to the deep fascia, whether or not it is painful , should be referred to a diagnostic centre with a formally constituted Sarcoma multidisciplinary team (MDT). Appropriate treatment begins with appropriate staging studies followed by a carefully planned and well executed biopsy. Magnetic resonance imaging (MRI) and core needle biopsy are recommended prior to definitive surgery. Imaging of the thorax by CT scan for lung metastases should be done prior to radical treatment. Treatment plans should be made in a multidisciplinary setting involving input from the surgeon, medical oncologist, radiation oncologist, radiologist and pathologist. Limb salvage surgery is the standard of care; however, there are circumstances in which amputation is necessary or preferred. Surgery is the standard treatment for all patients with localised STS For those patients with resectable disease, a wide excision is the standard surgical procedure. Where a wide excision is not possible due to anatomical constraints, a planned marginal excision plus radiotherapy may be an appropriate means of achieving tumour control while maintaining function. Radiation therapy in combination with surgical resection is highly effective at achieving local control. The use of chemotherapy is evolving but currently is not well-defined. Patients should be monitored closely after resection of their disease for local recurrence and metastatic spread. For patients with borderline resectable tumors, preoperative treatment with chemotherapy or radiotherapy should be considered dependant on individual histology. Post-operative radiotherapy is recommended following surgical resection of the primary tumor for the majority of patients with high-grade tumors, and for selected patients with large or marginally excised, low-grade tumors.The recommended dose for postoperative radiotherapy is 60–66 Gray (Gy); in 2Gy per fraction. Pre-operative radiotherapy is advantageous in terms of long-term functional outcome with equivalent rates of disease control when compared with postoperative radiotherapy. The recommended dose for pre-operative radiotherapy is 50Gy; in 2Gy per fraction. Adjuvant chemotherapy is not routinely recommended but could be considered in situations where it may contribute to local disease control.