Management of soft tissue sarcomas in first isolated local recurrence: a retrospective study of 83 cases

Purpose/Objective: To analyse the management and clinical outcome of patients treated for a first isolated local recurrence of STS (trunk or extremities) and to identify prognosis factors. Materials/Methods: Between 1980 and 1999, 83 adult patients presenting an isolated local recurrence of a STS after a first conservative treatment were treated by surgery. Patients with prior or simultaneous distant or node recurrence were excluded. Mean age was 61 years. Recurrence occured in a mean delay of 37 months, in the same location for 63% patients. 78 recurrences were diagnosed clinically, and 5 by radiological investigations. Mean tumor size was 6 cm. Most recurrent sarcomas were located in extremities (n=74), were deep (n=60), and were proximal (n=53); 30 involved nerves or vessels. Histological subtypes were mainly grade 2 (42%) or 3 (36%) histiocytofibrosarcomas (50%) and liposarcomas (42%). Surgical treatment of recurrences consisted in wide excisions (29 cases), marginal resections (43 cases), but 5 patients required amputation. Final resection results was R0 (n=33), R1 (n=47) or R2 (n=3). Besides surgery, 6 patients received neoadjuvant and 6 others adjuvant chemotherapy. 24 patients received postoperative external beam radiation therapy (EBRT) (mean dose 55 Gy +/- 19 Gy) and 27 interstitial 192Ir low dose rate brachytherapy (Bcy) (mean dose 45 Gy for Bcy alone, 22 Gy when associated with EBRT), 18 patients being re-irradiated. Results: The mean follow-up at analysis was 13 years. Thirty-seven (45%) patients relapsed locally, and 62% of those with another local recurrence. Only 19 patients developed distant metastases. Multivariate analysis showed only tumor depth (p=0.05) and two-time surgery for primary R1 resection (p=0.018) being independent prognosis factors for global tumor control. After univariate analysis, post-operative radiation (EBRT and/or Bcy) significantly increased local control (p=0.05) but not overall survival (p=0.07). The overall survival rate of this series was 73% at 3 years, 54% at 5 years, and 47% at 10 years. Multivariate analysis showed trunk (p<0.0001) or inferior extremity location (p=0.023), symptomatic (p=0.001), high grade (p=0.01), deep(p=0.01) tumors, and occurence of a further local failure (p=0.004) as unfavorable characteristics for overall survival. Disease-free survival was 51%, 39% and 27% at 3, 5 and 10 years, respectively. Two independant factors decreased disease-free survival: trunk location (p=0.002) and grade 3 sarcomas (p=0.009). However, a two time surgery for primary R1 resection increased independently the disease-free survival (p=0.017). Metastasis-free survival was 66%, 51%, and 43% at 3, 5, 10 years, respectively. Occurence of a second local failure (p=0.0001), staging > IIb (p=0.001), compressive (p=0.002) or symptomatic tumors (p=0.003), and trunk sarcomas (p=0.06) were independently associated with a worse prognosis for metastasis-free survival. Forty patients presented acute complications, and 9 (11%) needed surgical repair, without any amputation. 41 patients developed chronic G3 or 4 (49%) complications and 3 died of treatment related toxicity. Conclusions: The prognosis of a first isolated local recurrence is correlated with the occurence of a further relapse: this emphasizes the absolute need for an optimal local therapeutic strategy. Surgery is the prior treatment and should be a complete surgical resection, performed in centers that have expertise in the management of STS. EBRT or Bcy significantly increase local control and should be overtaken whenever as possible. Late delay of first local relapse and worse prognosis of large size and symptomatic tumors, lead us to recommend regular and longer follow-up.