Primary multidisciplinary management of extremity soft tissue sarcomas

Opinion statement

Soft tissue sarcomas (STS) are a rare and heterogeneous group of malignancies that most commonly present as large painless masses deep in the muscular compartments of the extremities. Investigation and treatment of these patients must be undertaken at a tertiary referral unit. Staging studies must include a high-quality magnetic resonance imaging (MRI) scan of the local site and a computed tomography (CT) scan of the chest to investigate for possible metastatic disease. Review of biopsy material must be undertaken by an experienced musculoskeletal pathologist. Currently, histologic diagnosis and grade are assigned to the tumor, but in tumors such as synovial sarcoma and Ewing’s family of tumors, molecular evaluation is becoming crucial for diagnostic, prognostic, and therapeutic reasons. Surgical resection of sarcomas with negative surgical margins remains the mainstay of treatment. Surgical treatment alone is indicated for small superficial masses that are not adjacent to bone or neurovascular structures. However, in large deep masses where surgical margins are likely to be close in order to preserve important neurovascular structures and bone, combined treatment using surgical resection and radiation results in acceptable local control rates and reasonable patient function. It is incumbent on the management team to decide on timing of radiotherapy as a practice. This decision is based on several factors but potential complications must be taken into account. In this regard the long-term effects on normal tissues must be considered. Functional outcome has become an essential consideration when recommending treatment. If promising techniques become available to reduce the incidence of wound complications or to decrease the dose of radiation to normal tissue, preoperative radiation should be considered in light of its lower incidence of long-term effects that result in reduction in patient function.