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Oncological Outcomes of Operative Treatment of Subcutaneous Soft-Tissue Sarcomas of the Extremities*

C. PARKER GIBBS, M.D., TERRANCE D. PEABODY, M.D., ARNO J. MUNDT, M.D., ANTHONY G. MONTAG, M.D. and MICHAEL A. SIMON, M.D., CHICAGO, ILLINOIS

Investigation performed at The University of Chicago Medical Center, Chicago

	Abstract

Top Abstract Introduction Materials and Methods Results Discussion References

 
We reviewed the cases of sixty-two patients who had had a subcutaneous sarcoma to determine the effect of tumor and treatment-related variables on the rates of survival and local recurrence. Fifty-nine (95 per cent) of the patients had had an operation at another hospital before being referred to us. Twenty-nine (47 per cent) of the sixty-two tumors were high-grade, forty-two (68 per cent) were small (five centimeters or less), and thirty (48 per cent) were malignant fibrous histiocytomas. We followed a treatment strategy that consisted of repeat excision with the goal of obtaining wide margins. Excluding thirteen patients who had had a palpable local recurrence at the time of presentation, twenty (49 per cent) of forty-one patients who had had a marginal excision at another hospital had microscopic residual tumor on repeat excision. At a median of fifty-six months after the repeat excision, fifty (81 per cent) of the sixty-two patients had been continuously disease-free, one had no evidence of disease, eight had died of the disease, and three had died of other causes. The five-year rate of disease-free survival was 85 per cent (fifty-three of sixty-two patients). There were three local recurrences, all in patients who had had a marginal resection. No recurrences were noted in patients who had had a wide local excision of the tumor or of the previous operative field. Multivariate analysis revealed that a large tumor (greater than five centimeters), a marginal excision, and adjuvant radiation therapy were associated with a worse prognosis. Excellent rates of survival for patients who have a subcutaneous sarcoma, including those who have a large or high-grade tumor and those who have residual tumor following a previous operation, can be obtained with carefully planned operative treatment alone. We recommend operative excision or repeat excision with wide margins because of the high prevalence of residual tumor. Size is the most important tumor-related factor, and the operative margin is the most important treatment-related factor. The additional value of adjuvant radiation therapy remains unproved.

	Introduction

Top Abstract Introduction Materials and Methods Results Discussion References

 
Soft-tissue sarcomas often are confined to the subcutaneous tissue of an extremity. Rydholm et al. found that 129 (32 per cent) of 404 soft-tissue sarcomas in their population-based study were subcutaneous and were associated with a favorable prognosis²⁸. Almost all subcutaneous soft-tissue lesions are benign or inflammatory^17,25. Patients who have a benign lesion can be managed adequately and effectively in their community by physicians and surgeons who do not have specific training in oncology. It is only after the excision of a subcutaneous lesion that, on histological examination, is found to be a sarcoma that a patient may be referred to a tertiary care center.

In an earlier study of patients who had a soft-tissue sarcoma, we found that most patients whom we had managed for a subcutaneous lesion had had a marginal excision at an outside institution¹⁸. Giuliano and Eilber reported that most patients who had had a repeat excision after an unplanned excision of a sarcoma had residual tumor on either histological or gross examination¹². Those authors recommended repeat excision for all patients.

We undertook this retrospective review to determine the important factors that predicted local recurrence in, and disease-free and cause-specific survival of our patients who had a subcutaneous sarcoma, most of whom had had a previous excision. In addition, we describe the operative technique that we have found to be valuable for the management of these patients, including those who have had a previous excision.

	Materials and Methods

Top Abstract Introduction Materials and Methods Results Discussion References

 
We reviewed the database of The University of Chicago Medical Center and identified sixty-two patients who had been managed for a subcutaneous sarcoma between 1975 and 1993. The database consisted of medical records, operative reports, preoperative and postoperative imaging studies, photographs of operative specimens, paraffin-embedded histological slides with corresponding pathology reports, and information from the hospital-based tumor registry. The demographic data; the history of treatment before referral; and the size, depth, and location of the tumor had been recorded prospectively. The oncological status, including local recurrence, metastasis, and survival, had been determined at the latest follow-up evaluation. Two of us (C. P. G. and T. D. P.) reviewed each imaging study, operative report, pathology report, and photograph of the gross specimen to determine the anatomical location, depth, original size, and stage of the tumor. As most of the patients had had an excision before being referred to us, pathology and operative reports and images from other institutions often were used to determine these parameters. A subcutaneous tumor was defined as one that was within the subcutaneous tissue and had not penetrated the underlying fascia (Fig. 1-A). Patients who had a skin-based lesion, such as Kaposi sarcoma, were excluded from the study; however, involvement of the overlying dermis by a subcutaneous sarcoma was not a reason for exclusion. Each tumor was assigned a stage according to the system of the American Joint Committee on Cancer¹.

View larger version (123K): [in this window] [in a new window]   Figs. 1-A through 1-F: Drawings showing the operative technique for a wide excision of a subcutaneous sarcoma in the mid-lateral aspect of the thigh. Fig. 1-A: Cross section of the thigh; the lesion is completely contained within the subcutaneous tissue and does not involve the underlying fascia.

All patients were managed operatively with a consistent approach of attempted wide resection of the tumor or, for those who had had a previous excision elsewhere, with a wide repeat excision of the tumor bed (Figs. 1-B 1-C 1-D 1-E through 1-F). The terms marginal and wide were used as defined by Enneking et al.⁹. A wide resection is one that leaves a cuff of normal tissue surrounding the tumor. A marginal resection is one in which the plane of dissection passes through the reactive zone or pseudocapsule of the mass, thus potentially leaving microscopic foci of tumor behind. As most patients had had a previous excision, a wide excision was defined as normal tissue (no tumor, cicatrix, or hematoma) at all margins of the specimen obtained at the repeat excision. An excision was defined as marginal when there was histological evidence that it had passed through the reactive zone, with pseudocapsule, cicatrix, or hematoma in some portion of the resection margin.

View larger version (15K): [in this window] [in a new window]   Fig. 1-B The planned margin of resection of the previously biopsied tumor is indicated by the dotted line.

View larger version (46K): [in this window] [in a new window]   Fig. 1-C A sharp dissection is performed through the subcutaneous tissue away from the mass, with use of the underlying fascia as the deep margin.

View larger version (93K): [in this window] [in a new window]   Fig. 1-D The wide margin, including the deep fascia, seen in cross section.

View larger version (29K): [in this window] [in a new window]   Fig. 1-E The vascular muscle bed after resection.

View larger version (31K): [in this window] [in a new window]   Fig. 1-F The defect covered with a split-thickness skin graft.

In patients who had had a previous excision, we resected three centimeters of skin in all directions from palpable tumor or from any previous operative scar, hematoma, or biopsy track, including a cuff of normal subcutaneous fat around the tumor, the underlying fascia, and one centimeter of muscle just deep to the fascia. The peripheral subcutaneous dissection is performed at a 45-degree angle away from the scar or the tumor. The deep dissection crosses muscle parallel to the skin. No effort is made to conserve skin in order to achieve a primary closure. This resection leaves an excellent vascular bed for the placement of a split-thickness skin graft, which often is the only soft-tissue coverage that is needed. In some patients, only marginal margins can be achieved because of the proximity of a subcutaneous sarcoma or a resection scar to major neurovascular or osseous structures.

Whether adjuvant radiation therapy or chemotherapy was given was determined by the surgeon in consultation with medical and radiation oncologists. This decision usually was based on the grade and size of the tumor, the presence or absence of residual tumor in the operative specimen, and the margins that had been obtained at the definitive operative procedure.

The interval between the initial diagnosis and the progression of the disease in the form of local recurrence or metastasis was recorded, as was the duration of survival. Kaplan-Meier survival-estimate curves¹⁴ were generated; the variables that were considered included demographic data, intervention before referral to our center, size and histological grade of the tumor, histological diagnosis, operative margins, and use of adjuvant radiation therapy or chemotherapy. We also evaluated the oncological outcomes relative to the presence of residual tumor for patients who had had a wide repeat excision at the site of a previously excised mass and for those who had had a local recurrence. These outcomes were compared with use of the log-rank test; p values of less than 0.05 were considered significant¹⁹. A stepwise Cox proportional-hazards model was constructed⁸. Variables that were significant on univariate analysis (p < 0.05) were entered into the model.

	Results

Top Abstract Introduction Materials and Methods Results Discussion References

 
The study included sixty-two consecutive patients who had had treatment of a subcutaneous sarcoma of an extremity at our institution between 1975 and 1993. There were thirty-seven male patients (60 per cent) and twenty-five female patients (40 per cent). The median age was forty-seven years (range, three to eighty-nine years). The median duration of follow-up for the surviving patients was fifty-six months (range, twelve to 189 months). The most common histological diagnosis was malignant fibrous histiocytoma (thirty patients; 48 per cent), followed by liposarcoma (eight patients; 13 per cent), leiomyosarcoma (five patients; 8 per cent), fibrosarcoma (five patients; 8 per cent), synovial-cell sarcoma (four patients; 6 per cent), clear-cell sarcoma (two patients; 3 per cent), and malignant tumor of the nerve sheath (two patients; 3 per cent). Six patients (10 per cent) had another type of tumor (angiosarcoma, epithelioid sarcoma, hemangioendothelioma, soft-tissue osteosarcoma, Ewing sarcoma, and myxoid chondrosarcoma).

Each lesion was assigned a stage according to the system of the American Joint Committee on Cancer¹. This system includes three histological grades—low, intermediate, and high—which correspond to stages I, II, and III, respectively. Stage IV represents metastatic disease. In addition, the first three stages are subdivided according to the size of the lesion. The letter A refers to lesions that are five centimeters or less in the greatest diameter, and the letter B refers to those that are larger than five centimeters. There were sixteen (26 per cent) low-grade, seventeen (27 per cent) intermediate-grade, and twenty-nine (47 per cent) high-grade sarcomas. Of the sixty-two lesions, eleven (18 per cent) were stage IA; twelve (19 per cent), stage IIA; nineteen (31 per cent), stage IIIA; five (8 per cent), stage IB; five (8 per cent), stage IIB; and ten (16 per cent), stage IIIB. No patient had metastasis at the time of diagnosis. Forty-two patients (68 per cent) had a lesion that was five centimeters or less in the greatest dimension, whereas twenty (32 per cent) had a lesion that was larger than five centimeters.

The operative treatment of our patients had been somewhat complicated (Fig. 2). Only three patients who were referred to our institution had not had a previous operation. One of these three had a primary wide excision, and the other two had a primary marginal excision. The remaining fifty-nine patients (95 per cent) had been referred after some form of operative intervention. Thirteen patients had had a palpable local recurrence after an excision at another hospital, forty-three had had a previous excisional biopsy, and three had had an incisional biopsy. Of the thirteen who had had a palpable local recurrence, seven had a wide repeat excision and two had a marginal repeat excision. The remaining four patients had a wide amputation because the anatomical location of the recurrent tumor precluded salvage of the limb; two of these four recurrent tumors were in the foot, one was in the forearm, and one was in a dysvascular leg. Of the forty-three patients who had had a previous excisional biopsy, forty-one (95 per cent) had an attempted wide repeat excision and two received radiation only, again because of anatomical constraints that precluded repeat excision without amputation. Two of the attempted wide repeat excisions resulted in marginal margins. Specimens from twenty (49 per cent) of the forty-one repeat excisions demonstrated residual foci of tumor.

View larger version (30K): [in this window] [in a new window]   Fig. 2 Chart showing the operative treatment of the sixty-two patients. An asterisk indicates that one of the patients who had the indicated treatment subsequently had a local recurrence, and RT = radiation therapy.

All adjuvant treatment was directed by the surgeon in consultation with medical and radiation oncologists. The use of adjuvant treatment evolved over time, but it was based on the operative margins, the presence of residual tumor, and the size and histological grade of the tumor. Thirty-five (56 per cent) of the sixty-two patients had operative treatment only, twenty-five (40 per cent) had adjuvant radiation therapy after operative treatment, and two received radiation only as the initial therapy at our institution. No patient had preoperative radiation therapy. Four patients received chemotherapy without radiation. Six of the ten patients who had a stage-IIIB tumor were managed with radiation therapy, and one was managed with chemotherapy, in addition to the operative treatment. For patients who were managed with skin-grafting and postoperative external-beam radiation, a four to six-week interval was allowed between the operation and the initiation of irradiation to allow time for consolidation of the graft. Although desquamation was noted in a few patients, no patient needed repeat skin-grafting.

Three patients had a local recurrence after treatment at our institution. All three had received radiation therapy. One of these patients, who had a pleomorphic liposarcoma in the posterior aspect of the shoulder, was managed initially with a marginal resection followed by irradiation. The lesion recurred at thirty months, and a forequarter amputation was performed. The patient subsequently died of disseminated disease at 100 months. Another patient had been referred to us after an incidental marginal excision of a synovial sarcoma during an ulnar-nerve transposition. She was managed initially with irradiation alone, but she had a recurrence at thirty-four months and a transhumeral amputation was performed. At the time of writing, she had no evidence of disease. The third patient who had a local recurrence had had a marginal excision of a malignant fibrous histiocytoma of the forearm with postoperative irradiation before referral. He had a marginal repeat excision of the tumor with use of a split-thickness skin graft. He then had a recurrence outside of the field of radiation and was managed with a wide excision and brachytherapy. Distant metastases later developed, and the patient died fifteen months after presentation. All three locally recurrent tumors were high-grade, and two were more than five centimeters in diameter. No patient had a local recurrence after operative treatment with wide margins.

Nine patients had a marginal excision as the definitive operative procedure; seven had this procedure at our institution, and two had it elsewhere. Of these nine patients, five had postoperative radiation therapy and three of them had a local recurrence. The remaining four patients did not have postoperative irradiation, and none had a local recurrence. Of the fifty-three patients (85 per cent) who had a wide excision, twenty (38 per cent) had postoperative irradiation; the tumor did not recur either in these patients or in the remaining thirty-three patients who had no radiation therapy.

Of the eight patients who died of the disease, two had had a local recurrence. Of the nine patients who had had a marginal excision, three had a local recurrence. For these analyses, the two patients who had been managed with radiation therapy only at our institution were included in the group that had had a marginal excision, because the only operative procedure had been a marginal excision that had been performed elsewhere.

The over-all five-year rates of cause-specific survival and disease-free survival were 87 per cent (fifty-four of sixty-two patients) and 85 per cent (fifty-three of sixty-two patients), respectively (Fig. 3). At the time of the latest follow-up evaluation, fifty patients (81 per cent) had been continuously disease-free, one had no evidence of disease, eight had died of the disease, and three had died of other causes. The median duration of survival for the patients who died of the disease was twenty-nine months (range, nine to 186 months). Of these eight patients, five had had a stage-IIIB lesion and one each had had a stage-IIB, IIA, and IA lesion¹. Seven of the eight patients had received radiation therapy.

View larger version (15K): [in this window] [in a new window]   Figs. 3 through 6: Kaplan-Meier survivorship curves. Fig. 3: Over-all disease-free survival.

View larger version (16K): [in this window] [in a new window]   Fig. 4 Disease-free survival according to tumor size. Open circles = five centimeters or less, and closed circles = more than five centimeters (p = 0.009).

The significance of the size of the tumor as compared with the grade of the tumor can be demonstrated by comparing the outcomes for stage-IIIA lesions with those for stage-IIIB lesions, thus controlling for grade. Patients who had a stage-IIIB tumor fared worse than those who had a stage-IIIA tumor with regard to both disease-free survival (p = 0.002) and cause-specific survival (p = 0.009).

Although only nine patients had had a marginal resection, univariate analysis revealed that all three outcomes—local recurrence (p < 0.0001), disease-free survival (p = 0.0001), and cause-specific survival (p = 0.02)—were distinctly poorer for these patients (Table I and Fig. 5 ). Three of the nine patients had a local recurrence, and four eventually died of the disease. We thought that the worse rate of survival for the patients who had had a marginal resection might be attributable to a disproportionate number of large or high-grade tumors; however, chi-square analysis revealed no bias toward large (p = 0.31) or high-grade (p = 0.88) tumors in these patients.

View larger version (17K): [in this window] [in a new window]   Fig. 5 Disease-free survival according to operative margins. Open circles = wide resection, and closed circles = marginal resection (p = 0.0001).

View larger version (16K): [in this window] [in a new window]   Fig. 6 Disease-free survival with and without adjuvant radiation therapy. Open circles = operative treatment only, and closed circles = operative treatment and subsequent in radiation (p = 0.01).

	Discussion

Top Abstract Introduction Materials and Methods Results Discussion References

 
Subcutaneous sarcomas have been reported to account for approximately 30 per cent of all soft-tissue sarcomas^18,28. Although much has been written regarding the local treatment of soft-tissue sarcomas in general, no study of which we are aware has been devoted to the treatment of subcutaneous soft-tissue sarcomas in particular. We reviewed our experience with the treatment of subcutaneous sarcomas to determine the oncological outcomes associated with a specific operative strategy and to identify significant factors related to survival and local recurrence.

Over the last half century, the treatment of soft-tissue sarcomas has evolved from simple excision to wide en bloc resection² to planned compartment resection³⁰ to more conservative operative treatment combined with other modalities such as radiation therapy and chemotherapy^{4,21,23,31,32}. Recently, it has been suggested that subcutaneous sarcomas often can be treated with operative intervention alone, with good results^18,28,29. We managed sixty-two patients with attempted wide excision or repeat excision, when possible, followed by liberal use of grafts for coverage. The use of adjuvant therapy was determined for each patient on the basis of perceived risk of a poor outcome.

Fifty-nine (95 per cent) of the sixty-two patients were referred to us after having had some form of operative intervention, most commonly a marginal excision of an unsuspected sarcoma, elsewhere. Giuliano and Eilber demonstrated residual tumor foci in forty-four (49 per cent) of ninety patients who had had excision of a malignant lesion that had not been suspected preoperatively¹². They concluded that these patients should have had a wide repeat excision of the tumor bed in order to decrease the probability of local recurrence and subsequent distant metastasis. Ideally, all patients who have a malignant subcutaneous lesion would be referred to a tumor center preoperatively. However, it is probably unrealistic to expect the referral of all patients who have a small superficial lesion before operative intervention because there is no reliable method other than a biopsy for determining whether a lesion is malignant. In addition, most small superficial lesions (less than five-centimeters) are benign^17,25. Fortunately, the rates of survival of and local recurrence in our patients were excellent despite previous operative intervention.

Several groups of investigators have shown a relationship between adequate operative margins and better rates of survival of patients who have a soft-tissue sarcoma^3,6,22-24. Others have thought that adequate margins are associated with lower rates of local recurrence but not with better rates of survival^13,32. Of the variables related to treatment that were evaluated in the current study, the attainment of wide operative margins was the most significant prognostic indicator for survival. This significance was maintained on multivariate analysis. A marginal margin was significant in predicting increased local recurrence on univariate analysis, but the significance was lost on multivariate analysis. This was probably because of the small number of patients (three) who had a locally recurrent lesion in our study. However, it should be noted that no tumor recurred locally in a patient who had had wide operative margins.

Radiation therapy was an independent prognostic variable that was associated with a shorter duration of cause-specific survival. We attempted, with chi-square analysis, to determine a difference between the patients who received adjuvant radiation therapy and those who were managed with operative treatment only, in order to account for the difference in the oncological outcome. The only significant difference was that the patients who were managed with radiation therapy were more likely to have had a high-grade tumor. The number of patients who had a large tumor and the number who had marginal margins were not significantly different between the two groups. Our findings are in agreement with those of Heslin et al. who recently reported that postoperative irradiation did not increase the survival of patients who had a deep high-grade sarcoma¹³.

Twenty-nine (47 per cent) of the patients in the current study had a high-grade lesion. Ten of these lesions were large and nineteen were small. Unlike other investigators^{16,20,26,27,31}, we could not demonstrate a significant association between a high-grade tumor and a poor oncological outcome. Selection bias in the form of a relative paucity of low-grade lesions (sixteen) probably accounts for this lack of significance. There were no consistent factors, such as an increased tumor size or marginal margins, to account for this finding. Although five of the eight patients who died of the disease had a high-grade lesion, the grade approached significance for local recurrence only and not for cause-specific or disease-free survival. The tumors in these five patients were large. It is of interest that no patient who had a small high-grade lesion died of the disease.

Two other factors proved not to have prognostic significance: the presence of residual disease on repeat excision, and local recurrence at the time of referral. It might be assumed that, given the time required for local recurrence after an excision, the likelihood of distant failure would increase. In addition, the patients who had residual disease did not, by definition, have wide operative margins initially. These patients presumably had disruption of the tumor and therefore might have been at higher risk for disseminated disease²⁶. These developments were not observed.

Size was the most significant tumor-related variable on both univariate and multivariate analysis. Two-thirds (forty-two) of the lesions were five centimeters or less in their greatest dimension. Tumor size has consistently been reported to be an important prognostic variable for patients who have a soft-tissue sarcoma^{6,7,10,11,15,18,27,31}. The good prognosis associated with subcutaneous sarcomas has been attributed in large part to their relatively small size¹⁸. It is likely that their small size is a function of their superficial location. These lesions may be discovered earlier and treated sooner than their deep counterparts, thus decreasing the time available for production of a sufficient number of cells capable of invasion or metastasis. In contrast to our finding of metastasis at presentation in a substantial proportion of patients who had a deep soft-tissue sarcoma in an earlier study¹⁸, none of the patients in the current study had metastatic disease at the time of presentation.

Technically, most subcutaneous sarcomas are distinctly easier to treat than are deep lesions. The tumors usually are small and, by definition, superficial. Thus, the surgeon generally is not forced to contend with deep vital structures, which, by virtue of their proximity, often limit the margins obtainable. The underlying fascia provides an excellent deep barrier to tumor spread^29,30. Loss of function usually is not substantial even after the resection of a large subcutaneous lesion. If the sarcoma is adjacent to a superficial bone, such as the tibia or the ulna, only marginal margins can be achieved unless the surgeon is willing to sacrifice major functional structures and to perform a complex reconstruction.

The operative treatment of a large (more than five-centimeter), undiagnosed subcutaneous lesion closely approximates that of a deep soft-tissue mass. We believe that a magnetic resonance image should be made preoperatively to determine the nature of the lesion. If the mass has signal characteristics of fat, a marginal excision with primary closure is the treatment of choice. If the findings on magnetic resonance imaging are not consistent with a diagnosis of lipoma, an open or needle biopsy should be performed. Benign tumors then should be treated with a marginal excision, whereas malignant tumors should be widely excised. The widely excised specimen should include the biopsy track, the deep fascia, and a generous cuff of normal fat surrounding the lesion. The resultant defect usually can be covered with a split-thickness skin graft. Skin-grafting should not be avoided in favor of primary closure because this might unintentionally compromise the surgeon's ability to obtain wide margins. All biopsy and resection incisions should be oriented longitudinally to facilitate reoperation, should one be necessary.

Ideally, small subcutaneous tumors should be managed treated in the same fashion. However, it is unnecessary to make a magnetic resonance image for every small subcutaneous lesion because almost all of these lesions are benign. Also, when the mass is small it is technically difficult to perform a biopsy that is not essentially a marginal excision. Therefore, most small subcutaneous tumors are treated with a marginal excision and the patient is referred to a tumor center if the lesion subsequently is found to be malignant. We performed a marginal excision in two of the three patients who were referred to us without having had previous operative intervention. The results of the current study indicate that planned repeat excision of these lesions is associated with a favorable prognosis; however, we believe that a marginal excision should be performed with use of a longitudinal incision, in an operating room, with good hemostasis and that the anesthesia should not be local. In addition, care should be taken not to violate the underlying fascia because we believe that it is a barrier to spread of the tumor and the hematoma and because performance of the repeat excision on the deep surface improves the quality of the operative margins. No comment can be made as to whether removing additional muscle decreases the potential for local recurrence; however, removal of this amount of muscle does not have any impact functionally and is recommended.

Patients who have had a biopsy or a marginal excision elsewhere can be managed similarly, with a wide repeat excision; however, the region that needs to be excised usually is larger. Every effort should be made to determine the extent of the previous operation. If the deep fascia was not violated, it is a natural barrier to tumor spread. The extent of contaminating hematoma often can be determined by physical examination and postoperative magnetic resonance imaging. The operative and pathology reports should be reviewed to determine the extent of tumor contamination, if any. We recommend that the pathology slides obtained from the referring physician be meticulously reviewed, not only to confirm the diagnosis but also, as far as possible, to determine the size of the tumor, the presence or absence of muscle or fascia, and the quality of the initial margins of resection. The entire operative field should be treated as if it were tumor-laden. To perform a wide repeat excision, the surgeon must excise the previous operative field en bloc, including the deep fascia, the area of hematoma, and the overlying skin. Split-thickness skin-grafting usually is necessary.

The choice of whether soft-tissue coverage should consist of skin-grafting, primary closure, or use of a myocutaneous flap was based on the individual characteristics of the defect that remained after excision. Most defects were easily covered with a split-thickness skin graft. In some patients who were managed early in the study and had had a more extensive resection, an excess of subcutaneous fat and skin remained, allowing primary closure over drains. In others, resection left exposed tendon or periosteum, necessitating use of a myocutaneous or a muscle rotation flap with an overlying split-thickness skin graft. This was especially common in patients who had had a resection about the knee. There were no major postoperative complications, and no patient needed a reoperation because of complications related to wound-healing.

The present study demonstrates that excellent rates of survival and low rates of local recurrence can be obtained with use of a carefully planned wide excision alone in patients who have a subcutaneous sarcoma. The quality of the operation and the size of the lesion are the most important prognostic factors. Wide repeat excision after marginal excision of an unsuspected sarcoma is recommended. The additional value of adjuvant radiation therapy has not been proved. Randomized prospective studies are necessary so that the efficacy of radiation therapy can be adequately assessed.

	Footnotes

 
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

Section of Orthopaedic Surgery and Rehabilitation Medicine, Department of Surgery (C. P. G., T. D. P., and M. A. S.), Department of Radiation and Cellular Oncology (A. J. M.), and Laboratory of Surgical Pathology, Department of Pathology (A. G. M.), The University of Chicago Medical Center, 5841 South Maryland Avenue, MC3079, Chicago, Illinois 60637.

	References

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