Department of Surgery, Istituto Nazionale Tumori, Milan, Italy.
Ann Surg. 2010 Mar;251(3):506-11. doi: 10.1097/SLA.0b013e3181cf87fa.
To improve understanding of what is adequate in local treatment of extremity soft tissue sarcomas (ESTS), to maximize the ratio between local control, limb preservation and prognosis.
Nine hundred ninety-seven consecutive patients affected by primary ESTS were reviewed. Size, depth, histotype and grade of the tumor, margin status (R0, R1, R2) of surgical resection, and adjuvant treatments were analyzed. Univariable and multivariable analysis were carried out. For the subgroup of R1 resection the presence/absence of the tumor at the inked surface and the presence/absence of an anatomic barrier were also considered.
Five- and 10-year mortality estimates (95% confidence interval) were 0.29 (0.20-0.38) and 0.38 (0.28-0.49) in R1 cases, and 0.16 (0.13-0.19) and 0.19 (0.16-0.23) in R0 cases (P = 0.0003). Size, grade, depth, and histologic subtype were also significant predictor of mortality. Significant determinants for local relapse were surgical margins, radiation therapy, and histologic subtype. In the subset of R1 resections trends towards a better local control for R1 negative cases and histology other than myxofibrosarcoma were identified. Significant determinants for distant metastases were size, grade and histologic subtype of the tumor but not surgical margins.
Quality of surgical margins independently predicted local control and survival. The effect on survival was directly mediated by local recurrence to proximal sites invading the abdomen/thorax, and this may indeed be the main way by which quality of surgery directly impacts the final prognosis of ESTS patients.
提高对肢体软组织肉瘤（ESTS）局部治疗充分性的认识，最大限度地提高局部控制、保肢率和预后之间的比例。
回顾了 997 例原发性 ESTS 患者。分析了肿瘤的大小、深度、组织类型和分级、手术切除的切缘状态（R0、R1、R2）以及辅助治疗。进行了单变量和多变量分析。对于 R1 切除亚组，还考虑了肿瘤在墨染表面的存在/缺失以及解剖屏障的存在/缺失。
R1 病例的 5 年和 10 年死亡率估计值（95%置信区间）分别为 0.29（0.20-0.38）和 0.38（0.28-0.49），R0 病例分别为 0.16（0.13-0.19）和 0.19（0.16-0.23）（P=0.0003）。大小、分级、深度和组织学亚型也是死亡率的显著预测因素。局部复发的显著决定因素是手术切缘、放射治疗和组织学亚型。在 R1 切除亚组中，R1 阴性病例和非黏液纤维肉瘤组织学的局部控制趋势更好。远处转移的显著决定因素是肿瘤的大小、分级和组织学亚型，但与手术切缘无关。
手术切缘的质量独立预测局部控制和生存。对生存的影响是通过近端部位侵犯腹部/胸部的局部复发直接介导的，这实际上可能是手术质量直接影响 ESTS 患者最终预后的主要途径。
