Figure 1. Actuarial overall survival in 110 patients.
Figure 2. Actuarial local control rate in 107 patients with complete tumour excision
Cancer Therapy Vol 3, 31-40, 2005
Quality of surgery in soft tissue sarcoma: a single centre
experience with the French Sarcoma Group (FSG) surgical system
Eberhard Stoeckle1*, Jean-Michel Coindre2, Guy
Kantor3,
Laurence Thomas3, Antoine Avril1, Philippe Lagarde3,
Michle Kind4,
Binh Nguyen Bui5
1Department of Surgery,
2Department of Pathology,
3Department of Radiotherapy,
4Department of Radiology,
5Department of Medicine,
Institut Bergoni, Regional Cancer Centre, 33076 Bordeaux Cedex, France
__________________________________________________________________________________
*Correspondence: Dr. E.
Stoeckle, Department of Surgery, Institut Bergoni, Regional Cancer Centre, 229
cours de lÕArgonne,
33076 Bordeaux Cedex, France; Phone: (33) 5 56 33 33 33; Fax: (33) 5 56 33 33
87; E-mail: stoeckle@bergonie.org
Key words: Soft
tissue sarcoma, Local recurrence, Quality of surgery, French Sarcoma Group
(FSG), FSG surgical system, Resection type, UICC,
Abbreviations:
co-operative group of surgical oncology, (CAO); External beam radiotherapy,
(EBRT); French Federation of Cancer Centres, (FNCLCC); French Sarcoma Group,
(FSG); local recurrence, (LR); patients, (pts.); soft tissue sarcoma, (STS)
Summary
The UICC
recommends to report results of surgery in soft tissue sarcoma (STS) according
resection type (R), but does not indicate how to determine (R). For this
purpose, the French Sarcoma Group (FSG) developed a surgical system, based on a
collective determination of (R), evaluated here in a single institution. One
hundred ten patients (pts.) with primary trunk wall and extremity STS operated
consecutively at Institut Bergoni from 1996 to 1999 were prospectively
allocated to resection types (R) by FSG criteria. Evaluation of the FSG system
was based on repartition of resection types (R) and on local recurrence rates
according to resection types (R). There were 75 (68%) resections R0, 32 (29%)
resections R1 and 3 (3%) resections R2. Repartition of resection type (R)
depended on tumour invasion. At a median follow-up of 70 months (range: 43 -
106 months) for surviving pts., local recurrence (LR) occurred in 10/107 pts
(9%) with initial gross excisions, giving an actuarial local control rate of
91% at 5 years. LR was 4% (3/75 pts.) after resection R0 and 22% (7/32 pts.)
after resection R1 (p< 0,01). By this system, patients R0 can be foreseen not
to recur locally in 96% of cases, whereas patients R1 harbour a 22% risk of LR.
The FSG surgical system combines simplicity and accuracy in determining quality
of surgery. Highly predictive of local outcome, it may be useful in decision
making concerning multidisciplinary treatment and help to improve local outcome
of STS.
Reporting quality of surgery in soft tissue sarcoma
(STS) should be done according resection - type (R) as recommended by the UICC
(Union Internationale Contre le Cancer), meaning resection R0 = in sano,
resection R1 = microscopic residual disease, resection R2 = macroscopic
residual disease (Hermanek et al, 1992). However, the UICC does not give
instructions, how to determine resection type (R)! Therefore, quality of surgery
in STS is often determined individually by either surgeons or pathologists.
Surgeons mostly transpose EnnekingÕs classification (Enneking et al, 1980) to
the R- classification, meaning wide margins = R0, close margins = R1 and
intra-lesional excision = R2. However, surgeons tend to overestimate quality of
surgery. This fact has been demonstrated in an overview of practice within the
German co-operative group of surgical oncology (CAO) by Junginger, et al
(2001), where resection rates R0 are reported in up to 82% of assessable
extremity sarcoma and in 64% of retroperitoneal sarcoma, a rate hardly
achievable in this localisation (Stoeckle et al, 2001).
Pathologists, on the other hand, do not see the
ongoing of excision, but a post-operative specimen. Analysis of margins can be
erroneous, especially after shrinkage of the specimen, giving falsely view to
the tumour capsule, due to the retraction of muscles initially covering the
tumour surface. Currently however, in about half of cases of re-excisions recommended
for contaminated margins, no residual tumour is found in the re-excision
specimen. Hence, at a period where soft tissue sarcoma are treated
conservatively by a multidisciplinary approach (Rosenberg et al, 1982; Brennan
et al, 1987; Sarcoma Meta-Analysis, 1997; Yang et al, 1998), an inexact
appreciation of quality of surgery, either by over- or underestimation, leads
to inadequate treatment, concluding either to over- or undertreatment. The
consequences are excessive sequels or high local recurrence rates. Moreover,
the results of the different series are to be considered with caution as the
initial definitions may differ.
In order to clarify reporting of surgical results in soft tissue sarcoma, the French Sarcoma Group (FSG) decided to elaborate a surgical system deemed to be easily reproducible. A first step consisted in 1995 to review retrospectively ten operation forms of sarcoma patients in each of the eight participating centres in order to gather pertinent information about surgery. As a result, technique of surgery was well described, but information concerning the tumour (size, localisation, depth) was sparse and moreover, quality of surgery mostly could not be determined correctly. A check-list of surgery reporting was therefore established (Table 1). Importance was given to descriptive items, asking the surgeon to describe excision, but not to interpret it. Essential terms for this purpose were the notions whether the tumour was seen, whether there was rupture of tumour and how theses critical margins were managed. Good acceptance of this check-list was confirmed after a multicentric survey by questionnaire. It confirmed reliability to pathological findings especially in primary operations, whereas more difficulties were seen in re-excisions (Stoeckle et al, 1997). A third step consisted to establish recommendations for pathological reporting in soft tissue sarcoma (Ghnassia et al, 1998) (Table 2). Finally, the FSG recommended to determine quality of surgery collegially according resection type R, by confronting surgical and pathological reports, at a regular common staff meeting.
This procedure was aimed to
gain more objectivity in defining quality of surgery by confronting purely
descriptive reports from each, surgeon and pathologist, allocating surgery to
resection type (R) as a result of a consensual decision. At Institut Bergoni,
one of the participating centres to FSG, this procedure was introduced in 1996.
The objective of the present study is to report the prospective experience with
the FSG surgical system in this single centre. Endpoints considered for
validation of the procedure were distribution of resection types (R) and local
recurrence (LR) rates, reflecting finally optimal adequacy between result of
surgery and complementary treatment. To obtain sufficient follow-up data, the
four-year period from 1996 to 1999 was considered for analysis. The final
follow-up date was December 2004.
Table 1. FSG check-list for surgery reporting in soft tissue
sarcoma
|
The
operative form is established according to the surgeonÕs own practice. For
soft tissue sarcoma, the following informations should figure systematically: 1. Title of operation 2. Clinical presentation Ξ
tumour size Ξ
tumour depth/fascia 3. What has been done? Ξ
excised structures (muscles, nerves, vessels, organs). Ξ
tumour bed marked Ξ
description of tumour (if seen): pseudcapsula, focality, site 4. Conclusion: what remains? Ξ excision complete? yes/no Ξ tumour seen? yes/no?
site? re-excision? Ξ rupture of tumour? yes/no? site? re-excision? Ξ margins? site?
quality? distance (mm)? |
Table 2. FSG recommendations for pathology reporting in soft
tissue sarcoma (from (Ghnassia et al, 1998),
modified)
|
1. Presentation of operative specimen Ξ fresh,
unprepared specimen (avoid picric acid) Ξ presentation
following previous agreement with surgeon Ξ do
not change afterwards 2. Pathological report Ξ Macroscopy –
tumour size – depth/fascia Ξ Microscopy – confirmation of malignancy – histological type – histological grade – local extension: focality, neurovascular
involvement, tumour emboli Ξ Status of margins – localisation of nearest margin – description of margins: distance (in mm),
quality (fascia) – status of complementary margins 3. Conclusion (descriptive, do not interpret quality of surgery!) Ξ Definition of tumour type and grade Ξ Description of margins (distance in mm,
quality) |
From January 1996 to December
1999, all consecutive patients undergoing resection of primary STS at Institut
Bergoni, a regional cancer centre in south west of France, were prospectively
included in the study. For the present analysis, only primary STS of the
extremities and trunk wall, operated first at the centre, or re-operated after
referral, were considered. This excluded patients operated elsewhere and having
subsequent, non surgical treatment at our Institut, patients with other
locations of STS, or not true soft tissue sarcoma, e.g. fibromatosis, and
patients with recurrent STS. One hundred and ten patients fulfilled the
inclusion criteria and are analysed here.
There were 54 females and 56 males. Median age was 60 years (range: 15-84 years). Median tumour size was 10 cm (range: 2-30 cm). Malignant fibrous histiocytoma, liposarcoma and leiomyosarcoma predominated among a wide variety of histopathologic subtypes. Most tumours were high grade and deep. Locally advanced disease, as defined by neurovascular or bone involvement, multifocal spread or both, was present in 37% of patients. Four patients had sarcoma located within radiation fields. Table 3 details tumour characteristics. Sixty one patients were re-operated after referral from another institute. Forty nine patients had their first operation at Institut Bergoni, preceded by biopsy in 46 cases (16 core needle biopsies, 30 surgical biopsies).
Function-sparing conservative
surgery was the goal in all patients. In 21 patients with high grade, locally
advanced tumours not suitable directly to conservative surgery, tumour
reductive first-line chemotherapy was performed. In 18 patients with a close
dissection between the tumour and a functional structure, intra-operative
brachytherapy was performed in order to allow a conservative resection. With
this multidisciplinary approach, satisfactory conservative surgery could be
performed in 106 patients. One patient with a sarcoma of the hand underwent a
finger amputation. Three patients experienced primary treatment failure: (1)
one patient with an extensive, rapidly growing, inoperable radiation-induced
sarcoma of the thoracic wall had primary excisional biopsy only and progressed
under chemotherapy; (2) one patient with an advanced angiosarcoma of the
forearm refused amputation and underwent incomplete, conservative surgery; (3)
one patient with an advanced liposarcoma of the groin involving the femoral
bifurcation underwent two successive incomplete surgeries and refused proposed
amputation.
Post-operative radiotherapy
was indicated after resection of deep tumours (stages T1b and T2b). Twelve
patients with deep tumours did not undergo irradiation because of previous
radiotherapy in 4 cases, post-operative complications in 4 cases, palliative
treatment in three cases, refusal in one case. Eighty seven patients (79%)
underwent post-operative radiotherapy. The treatment volume included the tumour
compartment when present, comprising the tendons and insertions of the muscles
involved, but sparing a strip of unirradiated tissue in the extremities.
External beam radiotherapy (EBRT) was delivered by high energy photons from a
linear accelerator in accordance with a technique described elsewhere (Lagarde
et al, 1990). Treatment recommendations at our Institut required a dose of
50 Gy after resections R0, whereas a complementary boost was indicated
after resections R1, either by post-operative radiotherapy, delivering 10 Gy to
a reduced volume in the tumour bed, or by afterloading brachytherapy delivering
15 Gy according to a technique described elsewhere (Thomas et al, 1994). In
cases of previous brachytherapy, the dose of post-operative radiotherapy was
lowered to 45 Gy. Twenty seven patients received a radiation boost, 15 in
patients R1, 12 in patients R0. The total delivered radiation dose was 52 Gy
(range: 44-65 Gy).
Apart from
the indication as first-line treatment in patients with locally advanced
tumours, complementary chemotherapy was usually recommended for criteria other
than quality of surgery (e.g. metastatic presentation, high tumour grade,
high-risk pathology). During the study period, an anthracyclin-based
chemotherapy was used, mostly by combination chemotherapy with the MAID regimen
(Mesna, Doxorubicin 60 mg/m2, Ifosfamide 7.5 mg/m2,
Dacarbazine 900 mg/m2; days 1-3), exceptionally with Doxorubicin
alone.
Table
3. Characteristics of
tumours in 110 operated patients
|
Tumour
characteristics |
N |
(%) |
|
|
|
|
|
Median tumour size (range) |
10 cm |
(2-30 cm) |
|
|
|
|
|
Location |
|
|
|
Upper
extremity |
(15) |
(14) |
|
Shoulder
girdle (shoulder, axilla) |
(12) |
(11) |
|
Trunk
wall |
(18) |
(16) |
|
Pelvic
girdle (buttock, groin) |
(8) |
(7) |
|
Lower
extremity |
(57) |
(52) |
|
|
|
|
|
Major tissue invasion |
(41) |
(37) |
|
(multifocal: 24 pts;
neurovascular/bone involvement: 23 pts; both: 6 pts) |
||
|
T T1a |
(9) |
(8) |
|
T1b |
(22) |
(20) |
|
T2a |
(2) |
(2) |
|
T2b |
(77) |
(70) |
|
|
|
|
|
N1 or M1 |
(9) |
(8) |
|
(N1:
4 pts; M1: 7 pts; both: 2 pts) |
||
|
|
|
|
|
Histological subtypes |
|
|
|
Malignant
fibrous histiocytoma |
(30) |
(27) |
|
Liposarcoma |
(22) |
(20) |
|
Leiomyosarcoma |
(16) |
(14) |
|
Synovial
sarcoma |
(9) |
(8) |
|
Clear
cell sarcoma |
(5) |
(5) |
|
Extraskeletal
osteosarcoma |
(5) |
(5) |
|
Rhabdomyosarcoma |
(3) |
(3) |
|
MPNST |
(3) |
(3) |
|
Angiosarcoma |
(3) |
(3) |
|
Others |
(7) |
(6) |
|
Undifferentiated,
unclassified sarcoma |
(7) |
(6) |
|
|
|
|
|
Grade G1 |
(21) |
(19) |
|
G2 |
(19) |
(17) |
|
G3 |
(70) |
(64) |
Six cycles of treatment were usually delivered According to former experience with concomitant
radio- and chemotherapy (Lagarde et al, 1998) showing no supplementary toxicity
despite the use of anthracyclins, post-operative chemotherapy was usually
associated with post-operative radiotherapy. Sixty-six patients (60%) underwent
chemotherapy.
D. Determination of resection quality
Surgery was prospectively
encoded in accordance with the FSG checklist for surgery (Table 1).
Pathological work-up was done
in accordance with the recommendations from the pathologists of the FSG
(Ghnassia et al, 1998) (Table 2).
Histological subtype was established according to WHO recommendations (Weiss et
al, 1994). Grading was done in accordance with the French Federation of Cancer
Centres (FNCLCC) classification (Trojani et al, 1984).
As recommended by the FSG, resection type was determined collegially at a weekly group meeting. After confrontation between the surgical and pathological reports, type of resection was then expressed according to UICC R criteria.
Information on patientsÕ charts comprised patient identification, tumour specification, treatment and follow-up data. Final follow-up date was December 2004. The interval of follow-up was calculated for surviving patients from date of surgery to date of last follow-up. For deceased patients, the intervals between first surgery and death were calculated. Comparisons between frequencies were obtained using the Chi-square test. Actuarial local recurrence-free estimations were made with the Kaplan-Meier method.
F. Outcome of patients
At update
on December 31, 2004, seventy eight patients were alive and 32 patients were
dead, twenty four of whom have died from cancer and two from treatment
complications. Median interval to death was 19 months. Median follow-up of
living patients was 70 months (range 43 – 106 months). Ninety six percent
of patients (75/78 patients) were followed-up over four years and seventy seven
percent (60/78 patients) over five years. Actuarial overall survival at 5 years
was 75% (Figure 1).
Figure 1. Actuarial overall survival in 110 patients.
Figure 2. Actuarial local control rate in 107 patients with complete tumour excision
G.
Validation criteria
The
reliability of the FSG surgical system was measured on (1) the repartition of
resection types, and (2) local recurrence rates.
A. Repartition of resection types
In order to achieve a satisfactory resection, 52 of 61
referred patients were re-operated once, six patients two times and three
patients three times. Residual tumour was found in 31 patients (51%). Final
distribution of resection types in referred patients was resections R0 in 45
patients (74%), R1 in 14 patients (23%), R2 in 2 patients (3%).
In 49 patients operated directly at Institut Bergoni, re-operations for insufficiency of surgery were performed in six patients. Distribution of resection type was resections R0 in 30 patients (61%), R1 in 18 patients (37%) and R2 in 1 patient (2%).
In 69 patients with limited disease there were 61
resections R0 (88%) and 8 resections R1 (12%). In 41 patients with locally
advanced disease (multifocality or neurvascular or bone involvement) there were
14 resections R0 (34%), 24 resections R1 (59%) and three resections R2 (7%).
The difference in resection rates R0 between limited disease (61/69 patients)
and locally advanced disease (14/41 patients) was significant (p < 0.001).
B. Local recurrence
LR was considered in 107 patients with complete tumour
excision (R0 + R1). Ten patients recurred locally giving a crude LR rate of 9%.
Actuarial local recurrence-free rate at 5 years was 91% (Figure 2). Median interval to LR was 12 months (range: 5-70
months). Nine of ten LRÕs occurred within 33 months. The incidence of LR
differed significantly between patients of groups R0 and R1 with respectively
3/75 (4%) and 7/32 (22%) LRÕs (p < 0.01). Therefore, in the current series,
the prevalence of LR is 9% (9/107 patients), the positive predictive value
(risk for patients R1 having LR) is 22% (7/32 patients) and the negative
predictive value (probability of patients R0 not having LR) is 96% (72/75
patients).
There was a difference in LR within 32 patients R1 whether or not a radiation boost was delivered. In 15 patients with a boost, one LR occurred (7%), whereas in 17 patient with no boost, six LR occurred (35%). This difference is significant (p < 0.05).
We report a continuous series of patients operated at
our centre for primary STS of the extremities and trunk wall, for whom quality
of surgery was determined prospectively in accordance to the surgical system of
FSG.
Determination of type of resection
at a weekly staff meeting rapidly proved to be consensual. Decisions for
re-excision or complementary treatment were made collegially. The reliability
of the system showed to be good.
The current series reports a
resection rate R0 of 68% and an actuarial local recurrence rate at five years
of 9%. At a median follow-up of 70 months, the risk of LR is 4% in patients R0,
22% in patients R1, reaching 35% in patients R1 lacking a radiation boost.
The rate of resections R0 in the current monocentric
series (68%) is lower than that reported by Junginger (Junginger et al, 2001)
in their multicentric survey (82%), notwithstanding the fact that monocentric
studies usually show superior results when compared to multicentric studies. In
the current patient group, 37% of patients had locally advanced disease with
vasculonervous – or bone invasion, or multifocal spread. Vasculonervous
or bone invasion has shown to be an independent, negative prognostic factor for
resectability of STS (Sastre et al, 1997). The difficulty to obtain satisfactory
resection in this patient subgroup with locally advanced disease is underlined
in the current study by a significant lower resection rate R0 in this subgroup
when compared to the subgroup of patients with limited disease. In our mind, a
rate of 68% of resections R0 is a rate closer to what really can be done by
surgery in a continuous series of patients with soft tissue sarcoma. Without
doubt, the collegial determination of resection type R gives a more objective
appreciation of quality of surgery as if it was determined by the sole surgeon.
Local recurrence rates beneath 10% are usually
reported only in series of selected patients, like limited tumours selected for
surgery alone (Rydholm et al, 1991; Baldini et al, 1999), superficial tumours
(Gibbs et al, 1997) or in patients responding to neoadjuvant therapy (Eilber et
al, 2001) or selected for pre-operative radiotherapy excluding patients already
operated (Sadoski et al, 1993). In unselected series, local recurrence rates
rank from 10 to 30% (Le Vay et al, 1993; Coindre et al, 1996; Lewis et al,
1997; Karakousis et al, 1999; Fleming et al, 1999; Pitcher et al, 2000; Trovik
et al, 2000; Zagars et al, 2003: pp 2530 - 2543). We think that the better
local results observed in the current series, are mostly due to the better
appreciation of quality of surgery, allowing therefore to adapt best treatment
strategy. That includes re-excision, which surely allows to obtain more
resections R0, as shown in patients re-operated after prior surgery elsewhere
with higher resection rates R0 (74% vs. 61%) than in patients operated directly
at our centre who underwent mostly one single operation. The same findings have
been made by others (Zagars et al, 2003: pp 2544- 2553). Furthermore, knowing
best quality of surgery, complementary treatment can be better adapted. In our
patient subgroup R1, LR is only 7% when a radiation boost is added to external
beam radiotherapy as recommended, but attains 35% when the boost is omitted. On
the contrary, given the 96% probability of absence of local recurrence in
patients defined R0 by the FSG system, complementary radiotherapy could
probably be withdrawn in a selected subgroup of these patients. Before testing
this hypothesis, the results of an ongoing multicentric evaluation of the FSG
system are awaited in order to confirm the multicentric reproducibility of the
system.
Meanwhile, results of the current
study (e.g. lack of radiation boost
in 17 patients R1, excessive boost in 12 patients R0) have already permitted to
improve treatment strategy for soft tissue sarcoma at Institut Bergoni,
helping to elaborate the current algorithm for local treatment as shown Figure 3.
The cornerstone of the FSG surgical system is the collegial determination of quality of surgery. In groups with a similar, collective approach defining surgery, equal low rates of local recurrences are reported (Gerrand et al, 2003). In this Canadian series, local recurrences are 10% in 480 consecutive patients with extremity soft tissue sarcoma. Whatever the system which has been elaborated, it seems that a collective determination of quality of surgery shows to be superior, more precise, than an individual approach, either by the surgeon or the pathologist. The advantage of the FSG system is its simplicity, with easily reproducible items (tumour seen or ruptured) and the descriptive approach, allowing rapid consensus within the participants.
Special thanks to Vronique Picot for statistical
analysis and to Dorothe Quincy for assistance in preparing the manuscript.
Figure 3. Algorithm for local treatment strategy at Institut Bergoni according
to resection type (R).
Baldini EH, Goldberg J,
Jenner C, Manola JB, Demetri GD, Fletcher CD, Singer S (1999) Long-term outcomes after function-sparing surgery without
radiotherapy for soft tissue sarcoma of the extremities and trunk. J Clin Oncol 17, 3252-3259.
Brennan MF,
Hilaris B, Shiu MH, Lane J, Magill G, Friedrich C, Hajdu SI (1987) Local recurrence in adult soft
tissue sarcoma. A randomized trial of brachytherapy. Arch Surg 122,
1289-1293.
Coindre JM,
Terrier P, Bui NB, Bonichon F, Collin F, Le Doussal V, Mandard AM, Vilain MO,
Jacquemier J, Duplay H, Sastre X, Barlier C, Henry-Amar M, Mace-Lesech J,
Contesso G (1996) Prognostic factors in adult patients with locally controlled
soft tissue sarcoma. A study on 546 patients from the French Federation of
Cancer Centers sarcoma group. J Clin
Oncol 14, 869-877.
Eilber FC,
Rosen G, Eckardt J, Forscher C, Nelson SD, Selch M, Dorey F, Eilber FR (2001) Treatment-induced pathologic
necrosis: a predictor of local recurrence and survival in patients receiving
neoadjuvant therapy for high-grade extremity soft tissue sarcomas. J Clin Oncol 19, 3203-3209.
Enneking WF,
Spanier SS, Godman MD (1980) A
system for the surgical staging of musculoskeletal sarcoma. Clin. Orthoped. 153, 106-120.
Fleming JB, Berman RS, Cheng
SC, Chen NP, Hunt KK, Feig BW, Respondek PM, Yasko AW, Pollack A, Patel SR,
Burgess MA, Papadopoulos NE, Plager C, Zagars G, Benjamin RS, Pollock RE,
Pisters PW (1999) Long-term outcome of patients with American Joint Committee
on Cancer stage IIB extremity soft tissue sarcomas. J Clin Oncol 17, 2772-2780.
Gerrand CH,
Bell RS, Wunder JS, Kandel RA, OÕSullivan B, Catton CN, Griffin AM, Davis AM (2003) The influence of anatomic
location on outcome in patients with soft tissue sarcoma of the extremity. Cancer 97, 485-492.
Ghnassia JP,
Vilain MO, Coindre JM, Bertrand G, Chteau MC, Collin F, Depardieu C, Fiche M,
Guillou L, Jacquemier J, Larsimont D, Le Doussal V, Leroux-Broussier A, Mandard
AM, Marques B, Ranchre D, Sastre X, Terrier P, Trassard M (1998) Recommandations
pour la prise en charge anatomo-pathologique des sarcomes des tissus mous de
lÕadulte. Ann Pathol 18, 505-511.
Gibbs CP,
Peabody TD, Mundt AJ, Montag AG, Simon MA (1997)
Oncological outcomes of operative treatment of subcutaneous soft-tissue
sarcomas of the extremities. J Bone
Joint Surg 6, 888-897.
Gustafson P,
Dreinhofer KE, Rydholm A (1994) Soft
tissue sarcoma should be treated at a tumor center. A comparison of quality of
surgery in 375 patients. Acta Orthop
Scand 65, 47-50.
Hermanek P, Sobin
LH (1992) TNM classification of
malignant tumours. Fifth edition, second revision, Springer, Berlin.
Junginger TH,
Kettelhack C, Schnfelder M, Saeger HD, Rieske H, Krummenauer F, Hermanek P (2001)
Therapeutische Strategien bei malignen Weichteiltumoren. Ergebnisse der
Weichteiltumor-Registrierstudie der CAO. Chirurg
72, 138-148.
Karakousis CP,
Driscoll DL (1999) Treatment and
local control of primary extremity soft tissue sarcoma. J Surg Oncol 71, 155-161.
Lagarde P,
Kantor G, Bussires E, Stckle E, Coindre JM, Tramond P, Avril A, Bui NB, Mare D (1990) Radiothrapie
post-opratoire des sarcomes des parties molles des membres. Analyse des
volumes et des doses dÕirradiation sur une srie de 31 cas. Bull Cancer Radiother 77, 101-109.
Lagarde P,
Kantor G, Tawfiq N, Salem N, Thomas L, Stckle E, Bui NB (1998) Chimiothrapie
des sarcomes des tissus mous de lÕadulte. Cancer
Radiother 2, 747-751.
LeVay J,
OÕSullivan B, Catton C, Bell R, Fornasier V, Cummings B, Hao Y, Warr D, Quirt I
(1993) Outcome and prognostic
factors in soft tissue sarcoma in the adult. Int J Radiat Oncol Biol Phys
27, 1091-1099.
Lewis JL,
Leung D, Heslin M, Woodruff JM, Brennan MF (1997) Association of local recurrence with subsequent survival in
extremity soft tissue sarcoma. J Clin
Oncol 15, 646-652.
Pitcher ME,
Ramathan RC, Fish S, AÕHern A, Thomas JM (2000)
Outcome of treatment for limb and limb girdle sarcomas at the Royal Marsden
Hospital. Eur J Surg Oncol 26, 548-551.
Rosenberg SA,
Tepper J, Glatstein E, Costa J, Baker A, Brennan M, DeMoss EV, Seipp C,
Sindelar WF, Sugarbaker P, Wesley R (1982) The treatment of soft-tissue
sarcomas of the extremities. Prospective randomized evaluations of (1)
limb-sparing surgery plus radiation therapy compared with amputation and (2)
the role of adjuvant chemotherapy. Ann
Surg 196, 305-315.
Rydholm A,
Gustafson P, Roser B, Willen H, Akerman M, Herrlin K (1991) Limb-sparing surgery without radiotherapy based on anatomic
location of soft tissue sarcoma. J Clin
Oncol 9, 1757-1765.
Sadoski C,
Suit HD, Rosenberg A, Mankin H, Efird J (1993)
Preoperative radiation, surgical margins, and local control of extremity
sarcomas of soft tissues. J Surg Oncol 52, 223-230.
Sarcoma
meta-analysis collaboration (1997)
Adjuvant chemotherapy for localised resectable soft-tissue sarcoma of adults:
meta-analysis of individual data. Lancet
350, 1647-1654.
Sastre-Garau
X, Coindre JM, Leroyer A, Terrier P, Ollivier L, Stoeckle E, Bonichon F, Collin
F, Le Doussal V, Contesso G, Vilain MO, Jacquemier J, Bui BN (1997) Predictive factors for complete
removal in soft tissue sarcomas: a retrospective analysis in a series of 592
cases. J Surg Oncol 65, 175-182.
Stoeckle E,
Coindre JM, Bonvalot S, Kantor G, Terrier P, Bonichon F, Bui BN (2001) Prognostic factors in
retroperitoneal sarcoma. A multivariate analysis of a series of 165 patients of
the French Cancer Federation Sarcoma Group. Cancer 92: 359-368.
Stoeckle E (1997) Nouvelles techniques
chirurgicales des sarcomes des tissus mous. Cancer Radiother 1, 453-456.
Thomas L,
Delannes M, Stoeckle E, Martel P, Bui BN, Daly-Schveitzer N, Pigneux J,
Chevreau C, Kantor G (1994)
Intra-operative interstitial Iridium brachytherapy in the management of soft
tissue sarcomas : preliminary results of a feasibility phase II study. Radiother Oncol 33, 99-105.
Trojani M,
Contesso G, Coindre JM, Rouss J, Bui NB, de Mascarel A, Goussot JF, David M,
Bonichon F, Lagarde C (1984)
Soft-tissue sarcoma of adults; study of pathological prognostic variables and
definition of a histopathological grading system. Int J Cancer 33, 37-42.
Trovik CS,
Bauer HC, Alvegard TA, Anderson H, Blomqvist C, Berlin O, Gustafson P, Saeter
G, Walloe A (2000) Surgical margins,
local recurrence and metastasis in soft tissue sarcoma: 559 surgically-treated
patients from the Scandinavian Sarcoma Group Register. Eur J Cancer 36,
710-716.
Weiss SW,
Sobin LH (1994) Histological typing
of soft tissue tumors. WHO International Classification of Tumours. 2nd
ed. Berlin: Springer Verlag.
Yang JC, Chang
AE, Baker AR, Sindelar WF, Danforth DN, Topalian SL, DeLaney T, Glatstein E,
Steinberg SM, Merino MJ, Rosenberg SA (1998)
Randomized prospective study of the benefit of adjuvant radiation therapy in
the treatment of soft tissue sarcomas of the extremity. J Clin Oncol 16, 197-203.
Zagars GK, Ballo MT, Pisters
PW, Pollock RE, Patel SR, Benjamin RS, Evans HL (2003) Prognostic factors for patients with localized soft-tissue
sarcoma treated with conservation surgery and radiation therapy: an analysis of
225 patients. Cancer 97, 2530-2543.
Zagars GK,
Ballo MT, Pisters PW, Pollock RE,Patel SR, Beamin RS (2003) Surgical margins and resection in the management of patients
with soft tissue sarcoma using conservative surgery and radiation therapy. Cancer 97, 2544-2553.
Eberhard
Stoeckle