Rapin Phimolsarnti M.D. Anthony M. Griffin MSc Peter C. Ferguson MD FRCSC

1. Outcome Following Limb Salvage Surgery and External Beam Radiotherapy for High Grade Soft Tissue Sarcomas of the Groin and Axilla Rapin Phimolsarnti M.D. Anthony M. Griffin MSc Peter C. Ferguson MD FRCSC Charles N. Catton MD FRCPC Peter W. Chung, MD FRCSC Robert S. Bell MD FRCSC Jay S. Wunder MD FRCSC Brian O’Sullivan MD FRCPC Musculoskeletal Oncology Unit, Mount Sinai Hospital, University of Toronto.

2. Introduction • High grade sarcoma usually treated with combination of limb salvage surgery and radiation ± chemotherapy. • Low rates of local recurrence • Impact on overall survival?

3. Introduction • Previous study: soft tissue sarcoma located in the central area which included axilla and groin tumors had less favorable local control compared to more distal anatomic sites when treated with surgery and adjuvant brachytherapy. • External beam radiation therapy ? Alektiar Ann Surg Oncol 2002

4. Purpose of the study • To determine the outcome in terms of local control and complications in the area of the central flexor fossa (groin and axilla) in our institution treated with external beam radiation therapy and limb sparing surgery.

5. Materials and Methods • Review of prospectively collected database • Surgery between 1989-2002 • Surgery- Mount Sinai Hospital. • Radiation Therapy- Princess Margaret Hospital.

6. Materials and Methods • Inclusion criteria: • Intermediate to high grade soft-tissue sarcoma of the extremity • Treated with limb sparing surgery • Pre- or post operative radiation therapy

7. Materials and Methods • Exclusion criteria. • Metastasis at presentation • Prior radiotherapy • Adjuvant chemotherapy

8. Materials and Methods • Surgical aspect • 3 musculoskeletal oncologists (RSB, JSW, PCF) all performed at MSH • Surgical resections were attempted to achieved 2cm margins • Exception • Natural boundary to tumor invasion (fascia, periosteam) • Close to but not fixed to the tumor mass

9. Materials and Methods • Radiation Therapy • 3 radiation oncologist (CNC, PWC and BOS) • All performed at Princess Margaret Hospital • Pre-op or Post-op • Radiation dose • 50 Gy for pre-op RT • 60-66 Gy for post-op RT

10. Materials and Methods • Follow up: Calculated from the time of definite surgery to last follow up • Local recurrence • Physical Exam, MRI • Distant Metastasis • Chest x-ray, CT scan • Complications • Wound complications, infection, fracture

11. Material and Methods • Statistical Analysis • Survival rate: Kaplan-Meier • Survival curve comparison: Log-rank test • Association between variables: Chi-square method • Independent prognostic factors: Cox-multivariate analysis

12. Results • 560 adult patients who met the criteria • 418 lower, 142 upper • Median F/U 52 months • 28 cases of tumor located in groin area • 16 cases of tumor located in the axilla area

13. Results • There was no difference regarding to the distribution of depth, grade, gender, prior surgery, surgical margin, type of radiotherapy between the central group (axilla and groin) and the more distal group

14. Results • 5 years local recurrence free survival of the entire group = 90.9% • 5 years local recurrence free survival of the groin and the axilla group = 90.6% • There were no significant difference between two groups (p>0.05)

19. Results • Cox-multivariate analysis • Margin, depth, prior “unplanned” excision and anatomical site. • Only a positive surgical margin is a significant factor for the local recurrence • 5 yr LR-free survival with • Negative margin = 93.8% • Positive margin = 78.2% (p<0.00001)

21. Complications • 22 (50%) patients in the central location group had complications (wound 15, infection 4, fracture 1) • 149 (28%) from 516 patients in the non-central group had complications (wound 108, infection 17, fracture 12)

22. Discussion • Eilber FC et al (Surg Oncol 1999) • 1974-1998 UCLA medical center • 68 patients with high grade soft-tissue sarcoma of flexor fossae (popliteal, groin, cubital, axilla) • Pre-op chemotherapy (Adriamycin, Ifosfamide) and radiation therapy • Achieved local control in 89%

23. Discussion • Alektiar et al (Ann Surg Oncol 2002): • Memorial Sloan Kettering 1982-1997 • 202 patients (25 in the central area) • High grade soft-tissue tumor • Surgical excision with adjuvant brachytherapy • 5-yr Local control rate in the central area was lower than other sites (57% versus 88%)

24. Discussion • Alektiar et al: 5-yr local control rate in the central area is lower than other sites • Current study- no difference in local control rate between the central area and more distal sites (90.6% versus 90.9%) • However, the complications are higher in the groin and axilla group (p=0.003)

25. Conclusion • An axillary or groin location of an intermediate and high grade sarcoma didn’t confer any greater risk for local recurrence as compared to more distal lesions. • However, there are greater risk of complication associate with external beam radiation in the groin or axillary area compare to more distal lesion • Positive margin remains the major risk factor for Local recurrence rate.

26. Thank you for your attention