Annals of Surgical Oncology

, Volume 20, Issue 5, pp 1494–1499 | Cite as

Predictors for Major Wound Complications Following Preoperative Radiotherapy and Surgery for Soft-Tissue Sarcoma of the Extremities and Trunk: Importance of Tumor Proximity to Skin Surface

  • Elizabeth H. BaldiniEmail author
  • Michelle R. Lapidus
  • Qian Wang
  • Judith Manola
  • Dennis P. Orgill
  • Bohdan Pomahac
  • Karen J. Marcus
  • Monica M. Bertagnolli
  • Phillip M. Devlin
  • Suzanne George
  • John Abraham
  • Marco L. Ferrone
  • John E. Ready
  • Chandrajit P. Raut
Bone and Soft Tissue Sarcomas



Preoperative and postoperative RT for the treatment of high-grade soft-tissue sarcoma result in similar local control and overall survival rates, but morbidities differ. Postoperative RT is associated with a higher rate of long-term fibrosis, edema, and joint stiffness. Preoperative RT is associated with higher rates of wound complications. It is important to identify predictors for major wound complications (MWC) and to develop strategies to minimize this outcome. We reviewed our experience to determine predictors for MWC following preoperative radiotherapy (RT) and surgery for soft-tissue sarcoma.


Between January 2006 and May 2011, 103 patients with soft-tissue sarcoma of the extremities and trunk were treated with preoperative RT followed by surgery. MWCs were defined as those requiring operative or prolonged nonoperative management. Fisher’s exact test was used to compare rates. Logistic regression was used for multivariable analysis of factors potentially associated with MWCs.


Median tumor size was 8.4 cm (range 2–25). All patients had wide or radical resections. Wound closures were primary in 70 %, a vascularized flap in 27 %, and split-thickness skin graft (STSG) in 3 %. There were 36 MWCs (35 %). Significant predictors for MWCs on univariate analysis included diabetes, tumors >10 cm, tumors <3 mm from skin surface, and vascularized flap/STSG closure. The same four variables were significant predictors on multivariable analysis.


MWCs following preoperative RT and surgery were common. Tumor proximity to skin surface <3 mm is a previously unreported independent predictor, and further strategies to minimize wound complications are needed.


Skin Surface Postoperative Radiation Therapy Intensity Modulate Radiation Therapy Free Flap Preoperative Radiation Therapy 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



The authors thank Barbara Silver for her editorial assistance.

Conflict of interest



  1. 1.
    Rosenberg SA, Tepper J, Glatstein E, et al. 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. 1982;196(3):305–15.PubMedCrossRefGoogle Scholar
  2. 2.
    Yang JC, Chang AE, Baker AR, et al. Randomized prospective study of the benefit of adjuvant radiation therapy in the treatment of soft tissue sarcomas of the extremity. J Clin Oncol. 1998;16(1):197–203.PubMedGoogle Scholar
  3. 3.
    Pisters PW, Harrison LB, Leung DH, et al. Long-term results of a prospective randomized trial of adjuvant brachytherapy in soft tissue sarcoma. J Clin Oncol. 1996;14(3):859–68.PubMedGoogle Scholar
  4. 4.
    NCCN. National Comprehensive Cancer Network (NCCN): NCCN clinical practice guidelines in oncology: soft tissue sarcoma. Version 1.2011. Available at:
  5. 5.
    O’Sullivan B, Davis A, Turcotte R, et al. Five-year results of a randomized phase III trial of pre-operative vs post-operative radiotherapy in extremity soft tissue sarcoma. J Clin Oncol. 2004 ASCO Annual Meeting Proceedings 2004;22(14S July 15 Supplement):Abstract 9007.Google Scholar
  6. 6.
    Davis AM, O’Sullivan B, Turcotte R, et al. Late radiation morbidity following randomization to preoperative versus postoperative radiotherapy in extremity soft tissue sarcoma. Radiother Oncol. 2005;75(1):48–53.PubMedCrossRefGoogle Scholar
  7. 7.
    Stinson SF, DeLaney TF, Greenberg J, et al. Acute and long-term effects on limb function of combined modality limb sparing therapy for extremity soft tissue sarcoma. Int J Radiat Oncol Biol Phys. 1991;21(6):1493–9.PubMedCrossRefGoogle Scholar
  8. 8.
    Mundt AJ, Awan A, Sibley GS, et al. Conservative surgery and adjuvant radiation therapy in the management of adult soft tissue sarcoma of the extremities: clinical and radiobiological results. Int J Radiat Oncol Biol Phys. 1995;32(4):977–85.PubMedCrossRefGoogle Scholar
  9. 9.
    Robinson MH, Spruce L, Eeles R, et al. Limb function following conservation treatment of adult soft tissue sarcoma. Eur J Cancer. 1991;27(12):1567–74.PubMedCrossRefGoogle Scholar
  10. 10.
    Karasek K, Constine LS, Rosier R. Sarcoma therapy: functional outcome and relationship to treatment parameters. Int J Radiat Oncol Biol Phys. 1992;24(4):651–6.PubMedCrossRefGoogle Scholar
  11. 11.
    Pollack A, Zagars GK, Goswitz MS, et al. Preoperative vs. postoperative radiotherapy in the treatment of soft tissue sarcomas: a matter of presentation. Int J Radiat Oncol Biol Phys. 1998;42(3):563–72.PubMedCrossRefGoogle Scholar
  12. 12.
    O’Sullivan B, Davis AM, Turcotte R, et al. Preoperative versus postoperative radiotherapy in soft-tissue sarcoma of the limbs: a randomised trial. Lancet. 2002;359(9325):2235–41.PubMedCrossRefGoogle Scholar
  13. 13.
    Bujko K, Suit HD, Springfield DS, et al. Wound healing after preoperative radiation for sarcoma of soft tissues. Surg Gynecol Obstet. 1993;176(2):124–34.PubMedGoogle Scholar
  14. 14.
    Cheng EY, Dusenbery KE, Winters MR, et al. Soft tissue sarcomas: preoperative versus postoperative radiotherapy. J Surg Oncol. 1996;61(2):90–9.PubMedCrossRefGoogle Scholar
  15. 15.
    Korah MP, Deyrup AT, Monson DK, et al. Anatomic tumor location influences the success of contemporary limb-sparing surgery and radiation among adults with soft tissue sarcomas of the extremities. Int J Radiat Oncol Biol Phys. 2012;82(2):933–9.PubMedCrossRefGoogle Scholar
  16. 16.
    Cannon CP, Ballo MT, Zagars GK, et al. Complications of combined modality treatment of primary lower extremity soft-tissue sarcomas. Cancer. 2006;107(10):2455–61.PubMedCrossRefGoogle Scholar
  17. 17.
    Kunisada T, Ngan SY, Powell G, et al. Wound complications following pre-operative radiotherapy for soft tissue sarcoma. Eur J Surg Oncol. 2002;28(1):75–9.PubMedCrossRefGoogle Scholar
  18. 18.
    Tseng JF, Ballo MT, Langstein HN, et al. The effect of preoperative radiotherapy and reconstructive surgery on wound complications after resection of extremity soft-tissue sarcomas. Ann Surg Oncol. 2006;13(9):1209–15.PubMedCrossRefGoogle Scholar
  19. 19.
    Peat BG, Bell RS, Davis A, et al. Wound-healing complications after soft-tissue sarcoma surgery. Plast Reconstr Surg. 1994;93(5):980–7.PubMedGoogle Scholar
  20. 20.
    Kim B, Chen YL, Kirsch DG, et al. An effective preoperative three-dimensional radiotherapy target volume for extremity soft tissue sarcoma and the effect of margin width on local control. Int J Radiat Oncol Biol Phys. 2010;77(3):843–50.PubMedCrossRefGoogle Scholar
  21. 21.
    Kuklo TR, Temple HT, Owens BD, et al. Preoperative versus postoperative radiation therapy for soft-tissue sarcomas. Am J Orthop (Belle Mead NJ). 2005;34(2):75–80.Google Scholar
  22. 22.
    Brant TA, Parsons JT, Marcus RB Jr, et al. Preoperative irradiation for soft tissue sarcomas of the trunk and extremities in adults. Int J Radiat Oncol Biol Phys. 1990;19(4):899–906.PubMedCrossRefGoogle Scholar
  23. 23.
    Mack LA, Crowe PJ, Yang JL, et al. Preoperative chemoradiotherapy (modified Eilber protocol) provides maximum local control and minimal morbidity in patients with soft tissue sarcoma. Ann Surg Oncol. 2005;12(8):646–53.PubMedCrossRefGoogle Scholar
  24. 24.
    Wang D, Zhang Q, Kirsch DG, et al. RTOG phase II trial of preoperative image guided radiotherapy (IG-RT) for primary soft tissue sarcoma of the extremity: acute toxicity report. Int J Radiat Oncol Biol Phys. 2011;81(2):S117.CrossRefGoogle Scholar
  25. 25.
    Cox DR. Analysis of binary data. London: Methuen and Co.; 1970.Google Scholar
  26. 26.
    Hosmer DW. Applied logistic regression. New York: Wiley; 2000.CrossRefGoogle Scholar
  27. 27.
    Kaplan EL, Meier P. Nonparametric estimation from incomplete observations. JASA. 1958;53(282):457–81.CrossRefGoogle Scholar
  28. 28.
    Guo S, Dipietro LA. Factors affecting wound healing. J Dent Res. 2010;89(3):219–29.PubMedCrossRefGoogle Scholar
  29. 29.
    Singer AJ, Clark RA. Cutaneous wound healing. N Engl J Med. 1999;341(10):738–46.PubMedCrossRefGoogle Scholar
  30. 30.
    Dickie CI, Griffin A, Parent A, et al. Phase II study of preoperative intensity modulated radiation therapy for lower limb soft tissue sarcoma. Int J Radiat Oncol Biol Phys. 2010;78(3 Suppl):S84–S85 [abstract #181].Google Scholar
  31. 31.
    Barwick WJ, Goldberg JA, Scully SP, et al. Vascularized tissue transfer for closure of irradiated wounds after soft tissue sarcoma resection. Ann Surg. 1992;216(5):591–5.PubMedCrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2012

Authors and Affiliations

  • Elizabeth H. Baldini
    • 1
    • 5
    Email author
  • Michelle R. Lapidus
    • 2
    • 5
  • Qian Wang
    • 6
  • Judith Manola
    • 7
  • Dennis P. Orgill
    • 3
  • Bohdan Pomahac
    • 3
  • Karen J. Marcus
    • 1
    • 5
  • Monica M. Bertagnolli
    • 2
    • 5
  • Phillip M. Devlin
    • 1
    • 5
  • Suzanne George
    • 5
    • 9
  • John Abraham
    • 8
  • Marco L. Ferrone
    • 4
    • 5
  • John E. Ready
    • 4
    • 5
  • Chandrajit P. Raut
    • 2
    • 5
  1. 1.Department of Radiation OncologyBrigham and Women’s HospitalBostonUSA
  2. 2.Department of SurgeryBrigham and Women’s HospitalBostonUSA
  3. 3.Department of Plastic SurgeryBrigham and Women’s HospitalBostonUSA
  4. 4.Department of Orthopedic SurgeryBrigham and Women’s HospitalBostonUSA
  5. 5.Center for Sarcoma and Bone OncologyDana-Farber Cancer InstituteBostonUSA
  6. 6.Beijing Novartis Pharma Co. Ltd.BeijingChina
  7. 7.Department of Biostatistics and Computational BiologyDana-Farber Cancer InstituteBostonUSA
  8. 8.Department of Orthopedic Surgery, Rothman InstituteThomas Jefferson UniversityPhiladelphiaUSA
  9. 9.Department of Medical OncologyDana-Farber Cancer InstituteBostonUSA

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