Local recurrence of soft tissue sarcoma. A Scandinavian Sarcoma Group Project.

Trovik CS

摘要

The aim of this project was to investigate the diagnosis, treatment and consequences of local recurrence of soft tissue sarcoma (STS). It is based on patients reported to the Karolinska Hospital Sarcoma Register and the Scandinavian Sarcoma Group Register. Demographic and treatment data, based on 1613 adult patients reported to the Scandinavian Sarcoma Group Register by sarcoma centers in Norway, Sweden and Finland are presented. They all had STS of the extremities or trunk wall, and were diagnosed between 1986 and 1995. One third of the tumors were subcutaneous and two thirds deep-seated. The median size was 7 (1-35) cm and 75% were high grade. Metastases at presentation were diagnosed in 8% of the patients. Two thirds of the patients were referred to a sarcoma center before surgery. The preoperative morphologic diagnosis was made by fine-needle aspiration cytology in 72%. Among patients with final treatment for primary tumor at a sarcoma center (n = 1331), the surgical margins were wide or better in 76% of subcutaneous lesions, and in 58% of deep-seated lesions. Adjuvant radiotherapy has not generally been considered indicated after wide or compartmental excisions in Scandinavia. Overall, 23% of patients managed by surgery had adjuvant radiotherapy. Among patients with an intralesional or marginal excision, 44% had postoperative radiotherapy. Patients treated outside of sarcoma centers were seldom referred for radiotherapy. The crude local recurrence rate was 225/1331 (17%) among the patients with final treatment for primary tumor at a sarcoma center. The local recurrence rate after local surgery for high-malignant deep-seated STS was 103/391 (26%). The rate was 25/64 (39%) after an intralesional/marginal margin without postoperative radiotherapy versus 28/119 (24%) when radiotherapy was given. Fine-needle aspiration cytology (FNAC) was used to diagnose suspected local recurrences. 95 FNAC were performed in 86 patients from Karolinska Hospital. There were 47 local recurrences, of which 44 were diagnosed correctly by FNAC; one biopsy was inconclusive, and two lesions were incorrectly assessed as benign. 39 patients proved to have benign lesions in the scar examined cytologically on 50 occasions. None of the specimens was regarded as malignant, but in 4 cases FNAC was inconclusive. The inconclusive or false cytological diagnoses had no serious clinical consequences. Among 205 patients with local recurrence identified in the SSG Register 1987-1995, 169 patients were surgically treated. An intralesional or marginal margin was achieved in 110 of these patients, 59 of whom were also given radiotherapy. 54 of the 169 patients had a second local recurrence. The second local recurrence rate was 0.50 if the first local recurrence was treated using surgery with a marginal margin alone, compared to 0.28 if treated using either surgery with a marginal margin and radiotherapy, or a wide margin (p = 0.0008). In extremity STS, the amputation rate for local recurrences was 0.22, compared to 0.09 for primary tumors. The overall 5-year MFS was 0.72 (95% CI 0.68-0.76). High histopathological malignancy grade (Relative Risk 3.0; 95% CI 1.5-6.3) and an inadequate surgical margin (2.9; 95% CI 1.8-4.6) were independent risk factors for local recurrence. High histopathological malignancy grade and large tumor size (> 7 cm) were the most important risk factors for metastasis. Local recurrence was associated with an increased risk of metastasis (4.4; 95% CI 2.9-6.8), but an inadequate surgical margin was not a risk factor for metastasis (1.1; 95% CI 0.8-1.7). In conclusion, it is unlikely that local recurrence of STS is a major source of metastases. It nevertheless represents a costly, complicated and emotionally difficult problem. More radical surgical margins would improve the local recurrence rate, but this can hardly be achieved for center-operated patients without increasing the amputation rate. Instead, local control will improve by giving radio

机译：该项目的目的是研究软组织肉瘤（STS）局部复发的诊断，治疗和后果。它基于向Karolinska医院肉瘤注册机构和斯堪的纳维亚肉瘤团体注册机构报告的患者。提供了人口统计和治疗数据，该数据基于在挪威，瑞典和芬兰的肉瘤中心向斯堪的纳维亚肉瘤团体登记处报告的1613名成年患者。他们都患有四肢或躯干壁的STS，并在1986年至1995年之间被诊断出。三分之一的肿瘤是皮下的，三分之二是根深蒂固的。中位尺寸为7（1-35）厘米，高等级占75％。 8％的患者被诊断出出现转移。手术前三分之二的患者被转诊到肉瘤中心。术前形态学诊断通过细针穿刺细胞学检查占72％。在肉瘤中心接受原发性肿瘤最终治疗的患者中（n = 1331），在76％的皮下病变和58％的深部病变中，手术切缘较宽或更好。在斯堪的纳维亚半岛广泛或部分切除后，一般不认为需要进行辅助放疗。总体而言，手术治疗的患者中有23％接受了辅助放疗。在病灶内或边缘切除的患者中，有44％接受了术后放疗。在肉瘤中心以外接受治疗的患者很少接受放射治疗。在肉瘤中心接受原发性肿瘤最终治疗的患者中，粗略的局部复发率为225/1331（17％）。高恶性深部STS局部手术后的局部复发率为103/391（26％）。不进行术后放疗的病灶/边缘边缘发生率为25/64（39％），而接受放疗时为28/119（24％）。细针穿刺细胞学检查（FNAC）用于诊断可疑的局部复发。 Karolinska医院对86例患者进行了95次FNAC。局部复发47例，其中FNAC正确诊断出44例。 1例活检尚无定论，2处病灶被错误评估为良性。 39例患者经50次细胞学检查证实在疤痕中有良性病变。没有一个标本被认为是恶性的，但是在4例FNAC中没有结论。不确定的或错误的细胞学诊断没有严重的临床后果。在1987-1995年SSG登记簿中确定的205例局部复发患者中，有169例接受了手术治疗。其中110例患者达到了病灶内或边缘切缘，其中59例也接受了放疗。 169例患者中有54例第二次局部复发。如果仅使用边缘切缘术治疗第一次局部复发，则第二个局部复发率为0.50，相比之下，如果使用边缘切缘和放疗或宽切缘术治疗，则第二个局部复发率为0.28。（p = 0.0008）。在四肢STS中，局部复发的截肢率为0.22，而原发肿瘤为0.09。总体5年MFS为0.72（95％CI 0.68-0.76）。高组织病理学恶性等级（相对危险度3.0; 95％CI 1.5-6.3）和手术切缘不足（2.9; 95％CI 1.8-4.6）是局部复发的独立危险因素。较高的组织病理学恶性等级和较大的肿瘤大小（> 7 cm）是转移的最重要危险因素。局部复发与转移风险增加有关（4.4; 95％CI 2.9-6.8），但手术切缘不足不是转移的危险因素（1.1; 95％CI 0.8-1.7）。总之，STS的局部复发不太可能是转移的主要来源。但是，它代表了一个代价高昂，复杂且在情感上困难的问题。更大幅度的手术切缘将提高局部复发率，但是如果不增加截肢率，中心手术患者很难达到这一目标。取而代之的是，通过广播

Local recurrence of soft tissue sarcoma. A Scandinavian Sarcoma Group Project.

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