Review Question - QID 213031

The patient has an undifferentiated pleomorphic soft-tissue sarcoma, which should be treated with wide resection and radiation.

Undifferentiated pleomorphic soft-tissue sarcomas present as painless enlarging lesions, typically in the lower extremity. Treatment includes wide excision and radiation to prevent local recurrence. The standard dose of radiation is 50-60 Gy and may be given pre- or postoperatively. Preoperative radiation is associated with a 30% risk for wound complications, while post-operative radiation is associated with greater radiation-induced morbidity and an increased risk of radiation-induced sarcoma.

Kandel et al. published a review on surgical margins and the handling of soft-tissue sarcoma (STS) in extremities. They found that patients with clear margins have a better prognosis, but no prospective studies have indicated how wide margins should be. They recommend that, in limb-salvage surgery for extremity STS, the procedure should be planned to achieve a clear margin. However, to preserve functionality, surgery may result in a very close (<1 cm) or even microscopically positive margin. In this circumstance, they recommend that the use of preoperative or postoperative radiation should be considered.

Ahmad et al. published a study on the width of the surgical margin and outcomes in patients with extremity and truncal soft tissue sarcoma (STS) treated with radiotherapy (RT). They found that, in patients undergoing RT and limb-sparing surgery for STS, achieving a negative margin is essential for optimizing both local control and survival. However, the absolute quantitative width of the negative margin does not significantly influence outcome, and so attempts at wide margins of resection appear to be unnecessary. They note that their findings should not be applied to those patients undergoing surgery alone as the local treatment of their STS, in which case wider margins of resection may be necessary.

Figures A and B are AP and lateral radiographs of the left thigh demonstrating a large soft tissue density in the medial aspect of the proximal thigh. Figure C is an axial fat-suppression T1-weighted MRI demonstrating a large heterogeneous soft tissue mass. Figure D is a histological image of undifferentiated pleomorphic soft-tissue sarcoma, with spindle cells in the classic storiform pattern and histiocytes with marked pleomorphism and bizarre nuclei.

Incorrect Answers:
Answers 1, 2, 3, and 4: Undifferentiated pleomorphic soft-tissue sarcomas should be treated with wide resection and radiation.