Do surgical margin and local recurrence influence survival in soft tissue sarcomas?

Abstract

Background: Established prognostic factors influencing survival in soft tissue sarcomas include tumor stage, histopathologic grade, size, depth, and anatomic site. The presence of tumor near or at the margin of resection increases the risk of local recurrence but whether a positive surgical margin or local recurrence affect overall survival is controversial.

Questions/purposes: We explored the impact of microscopic margin on local recurrence, metastasis, and overall survival in patients with intermediate- to high-grade soft tissue sarcomas of the extremities. We then determined whether local recurrence decreases overall survival.

Methods: We retrospectively reviewed the medical records of 248 patients who had soft tissue sarcomas of the extremities treated surgically from 1995 to 2008. We estimated survival, local recurrence, and distant metastasis and examined factors potentially influencing these outcomes. The minimum followup was 0.4 years (median, 4.4 years; range, 0.4-13 years).

Results: The 5-year cumulative incidence of local recurrence was 4.1%. Patients who presented with positive margins or a margin of 2 mm or less had a worse survival than patients who had margins of greater than 2 mm and wide margins (5-year survival, 47% versus 70% and 72%). In addition to surgical margin, developing metastasis, tumor response of less than 90% necrosis, high histopathologic grade, high AJCC stage (Stage III), increasing age, and male gender were associated with decreased overall survival. Local recurrence independently predicted decreased overall survival.

Conclusions: Microscopic surgical margin and local recurrence after surgical treatment should be included as risk factors predicting decreased overall survival for intermediate- to high-grade soft tissue sarcomas of the extremities.

Fig. 1

A Kaplan-Meier survivorship curve shows overall survival rates with 95% CIs at 2, 5, and 10 years postsurgery. The Kaplan-Meier 5-year estimated rate of survival for the entire cohort was 65.1% (95% CI, 58.1%–72.9%).

Fig. 2

A Kaplan-Meier survivorship curve illustrates the effect of microscopic surgical margin on overall survival. The 5-year estimated rate of overall survival was lower (p = 0.005) for patients with an inadequate margin (46.6%, 95% CI, 32.1%–67.5%) compared to those with a margin between 2 mm and 1.9 cm (69.7%, 95% CI, 61.5%–78.9%) and with a wide margin (72.3%, 95% CI, 55.3%–94.4%).

Fig. 3

A Kaplan–Meier survivorship curve shows overall survival using a 12-month landmark. Patients were grouped into those who had local recurrence within the first year and those who were free of local recurrence at 12 months. Patients who had local recurrence within the first 12 months had worse survival than those who did not.