Forty-six consecutive patients with nonmetastatic, large, high-grade soft tissue sarcomas were treated with surgical resection and radiation therapy but no adjuvant chemotherapy. Clinical and radiographic followup ranged from 36 to 90 months (mean, 50 months). One patient died of unrelated causes 10 months after the completion of radiation and surgery, leaving the oncologic outcome of 45 patients to be evaluated. Twenty-seven of 45 patients (60%) survived with an average followup of 50 months. The limb salvage rate was 91% and local control was obtained in 43 of 45 patients (96%). During the time of the study, 73% of patients could have been offered chemotherapy. However, only 53% of patients who died of their disease would have been candidates for chemotherapy trials because of medical comorbidities. More importantly, patients with a Karnofsky performance score of 80 or more had a significantly better survival rate than patients with a Karnofsky performance score less than 80 without the use of chemotherapy. Current chemotherapy trials that exclude patients because of medical comorbidities are introducing bias toward improved survival that may not be attributable to the chemotherapy. If a real survival benefit of adjuvant chemotherapy exists, it would be most evident in the largest (> 15 cm) high-grade tumors. Aggressive metastasectomy seems to be most beneficial for patients with isolated nodules.

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