Nghiên cứu kết quả điều trị bảo tồn chi ung thư phần mềm giai đoạn t2n0m0 tt tiếng anh

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INTRODUCTION
Soft tisue sarcoma is a rare malignancy that arises from connective tissue
outside the bone and peripheral nervous system. It can locate anywhere on the body,
but are common in the lower limbs especially. Soft tissue sarcoma is a rare disease
that accounts for about 1% of all malignant lesions in adults and about 21% of
malignant lesions in children. Diseases diversified in location, diverse in
histopathological type. According to the World Health Organization (WHO)
classification, the subgroup of soft tissue sarcoma includes more than 50 different
histologic categories, based on the origin of the tissue.
The most common clinical manifestations are tumor appearance, the tumor
gets bigger in size, the initial tumor is usually less painful, when the large tumor
compresses nearby tissue causing pain symptoms, the tumor may be located
superficial that easy to detect, or may be located deep within the muscle bundles that
when tumor bigger in size that can be detectted. Enlarged tumors can break the skin,
ulcers, bleed. Among the diagnostic methods, MRI scan plays an important role in
diagnosing tumor size, its association with muscle, nerve and blood vessels. Tumor
biopsy by open biopsy or needle biopsy of histopathological diagnosis is a method
with definite diagnostic value.
Aims of limb sparing treatment of soft tissue sarcoma are to increase the
survival rate, avoid local complications, maintain maximum function of the limb. The
principle of surgery is wide local resection, achieving negative microscopic margin.
However, the major challenge in surgery is that large tumors located close to the
vascular, nerve, or bone bundles are difficult to perform wide local resection. For
these, it is possible to resect marginal, however, it must be ensured that the
microscopic section does not have cancer cells, then combined with radiation therapy
to reduce local recurrence.
Adjuvant radiotherapy plays a role in reducing local recurrence, but does not
improve the survival rate, the average radiation dose (50-60Gy) can effectively
eliminate microscopic lesions around the tumor, achieved when compared to

amputation. In the 1970s, more than half of patients with extremity soft tissue
sarcoma had amputation. With the advancement of surgical methods, especially
plastic surgery, microsurgery combined with adjuvant radiotherapy, the rate of
amputation is reduced to about 1% without changing the survival rate. Role of
chemotherapy, immunotherapy and targeted treatment are still limited.
Currently in Vietnam, there is no meticulous research on multi-modal
coordination in limb sparing treatment. Therefore, I perform research “research the
results of limb sparing treatment of extremity soft tissue sarcoma with stage
T2N0M0” with two objectives
1. Assessing some clinical and paraclinical characteristics of extremity soft
tissue sarcoma T2N0M0
2. Evaluation of limb sparing surgery results and adjuvant radiotherapy.


2

NEW CONTRIBUTION OF THESIS
1. This is the first study in Vietnam with a sample size large enough to reach the most
complete results on the effectiveness of limb sparing surgery combined with adjuvant
radiotherapy in extremity soft tissue sarcoma.
2. The results from the study show that:
The most common tumor location in the thigh is 59,2%. The surperficial
tumors accounted for 27,5%, deep lesions were 72,5%. 84.5% of tumors had
heterogeneous signal intensity on MRI. 71,1% tumors had irregular border.
Undifferentiated pleomorphic sarcoma were 21,2%. Grade 3 was highest with 52,1%.
Tumor resection was 85,2%. Wide tumor resection with margin over 1cm was
52,8%. The incidence of lymphoedema following adjuvant radiotherapy was 23,2%.
Acute radiation skin toxicities were mostly mild (grade 1) accounted for 59,2%. Late
radiation skin toxicities were 45,1% with mostly grade 1 37,4%. Joint stiffness were
rare by 7,8%. Extremity edema met 18,1%.

Five year overall survival rates were 63,2%. Five-year disease free survival
rates were 54,5%. Five-year recurrent rates were 28,8%. Factors affecting five year
overall survival rates were tumor size, tumor depth and histologic grade. Tumor size,
tumor depth, histologic grade and surgical procedures that affect the five-year
recurrent rates
STRUCTURE OF THESIS
The thesis includes136 pages and consist of: Introduction (2 pages), Chapter
1: Overview (35 pages), Chapter 2: Subjectsand methods (18 pages), Chapter 3:
Results (34 pages), Chapter 4: Discussion (42pages), Conclusion (2 pages),
Recommendation(1 page). In this thesis, there are 41 tables, 14 graphs and 9 figure.
References contain 136 documents (13 in Vietnamese and 223 in English). The
appendix includes patient list, illustration pictures, study parameters and standards,
case report form, questionaire, letters and informed consent of patients.
CHAPTER 1: OVERVIEW
1.1.
Epidemiology and pathogenesis
1.2.
Diagnotic
- Tumor: usually a little pain, gradually enlarged. Tumor that suspect malignancy
when: size > 5cm, pain, increasing in size, deeply tumor and recurrence after surgery.
- MRI scan: valuable diagnostic and stage evaluation, accurate assessment of
anatomical location, related to nerves, blood vessels, invasion of the tumor into one
or more muscle bundles. Suspected malignancy when larger than 5cm, heterogeneous
and irregular boder.
- Tumor biopsy for histopathological diagnosis may involve needle biopsy or open
biopsy. Histopathological classification according to WHO 2013 and histologic
classification according to the French Federation of Cancer Prevention (FNCLCC).
1.3. Treatment
- Limb sparing surgery: tumor resection (wide local resection without cutting into the
tumor cutting the healthy tissue surrounding the tumor, preserving nerve structure,

blood vessels, bones) is the most important step in treatment of extremity soft tissue
sarcoma. The purpose of surgery is to resect the tumor wide with a negative


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microscopic margin. Nerves, large blood vessels are often preserved during surgery if
the tumor is carefully dissected, peeled of the sheath of nerves because the tumor
rarely invades the nerves or blood vessels. If microscopic margin is positive (except
for bone, neural, and large blood vessels) resection should be performed to obtain a
microscopic section without cancer cells. Large tumors located close to the vascular
bundles, nerves can be resectted marginal in order to achieve negative microscopic
margin but still preserve these important structures.
- Radiotherapy: radiotherapy reduce local recurrence. The average radiation dose (5060Gy) can effectively remove microscopic lesions around the tumor, providing good
results when comparing amputation with radical surgery. Reports of local control
rates of 85-90% for extremity soft tissue sarcoma and 95-100% for low-grade
extremity soft tisue sarcoma depending on tumor size. Radiotherapy techniques such
as 3D-CRT (three-dimensional conformal radiotherapy), intensity-modulated
radiotherapy (IMRT), proton beam therapy provide high efficiency. Currently at K
hospital, most of them apply 3D-CRT, the radiation field covers an average distance
of 5-20cm from the outside of the tumor. Field diameter depend on tumor size and
tumor conservation surgery surgical area of limb sparing operation. Filed of radiation
will be narrowed to 1-2cm in length. Dose of 1.8 - 2 Gy / day x 5 days / week.
Duration of 5- 6 weeks.
- Other treatment procedures. The role of chemotherapy for soft tissue sarcoma is still
controversial. Valuable evidence from meta-analyzes and randomized clinical trials
suggests that postoperative epirubicin and ifosfamide chemicals improve nonrecurrent survival (RFS) in patients with extremity soft tisue sarcoma. However, the
data related to overall survival is controversial. Targeted therapy has shown promise
in some advanced or metastatic soft tissue sarcoma.
CHAPTER 2. PARTICIPANT AND STUDY METHOD

2.1. Study participant
This study included 142 extremity soft tissue sarcoma patients treated with
limb sparing surgery and adjuvant radiotherapy Vietnam National Cancer Hospital
from January 1st 2013 to November 31st 2018.
* The eligibility criteria included:
- Extremity soft tissue sarcoma (upper and lower limb)
Stage
T2N0M0
according
to
AJCC
2010
classification.
- Tumors have not invaded nerves, large blood vessels, and have not lost limb
function.
- Pathology is soft tissue sarcoma. Histopathology grade classification according to
FNCLCC. Patients were done Immunohistochemistry.
- Patients were performed limb sparing surgery and treated adjuvant radiotherapy.
- Patients and families voluntarily participated in the study.
- There is information about the post-treatment condition through follow-up
examination and / or information from the reply sent to the patient and family or
phone.
* Exclusion criteria
- Non-extremity soft tissue sarcoma.


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- Histopathology is not soft tissue sarcoma
- The tumor is not in the pT2N0M0 stage

- Tumors invaded nerve, large blood vessels, causing loss of limb function.
- Amputation of disarticulation.
- Abandoning treatment, not completed treatment course
- Patients had other serious illnesses that at risk of death.
2.2. Study methods
2.2.1. Study design: this was a retrospectively and prospectivelydescriptive study
with longitudinal follow-up
2.2.2. Sample size of study
The formula to calculate the sample
size:
p (1-p)
n=
Z21-/2
2
n: is the sample size of the study
p: 5-year survival rate of the domestic study is 0.6 (1-p = 0.4)
: absolute tolerance allowed. The error estimate is 10% (absolute tolerance
allowed. The error estimate is 10% (=0,1)
Z21-/2: 5% confidence limit coefficient, look up tables (= 1.96).
Applying the above formula, sample size is 92
In this study, we included 142 patients.
2.2.3. Study process
- Enroll eligiblepatients. Information was collected based on a consensus medical
record sample. All patients participating in this study were treated with limb sparing
surgery with negative microscopic margin and adjuvant radiotherapy. Data were
collected at the
following moments: starting point of treatment, during
treatment,ending of treatment and ending of follow-up (time of death or whenfinal
information was collected or whenfollow-up was ended (November 31st 2018)).
- Assessment of several characteristics of study patients: age, gender, tumor

clinical symptoms, tumor location, tumor size, tumor depth (superficial, deep tumor),
tumor characteristics on MRI (tumor margin, signal intensity), histopathology and
grade.
- Evaluation of treatment results including evaluation of surgical characteristics,
surgical methods, early postoperative complications. Features of adjuvant radiation
therapy, lymphatic edema complications, acute skin complications due to radiation,
radiation-induced wound complications, late skin complications, stiffness, radiation
edema . Overall 5-year survival, disease-free 5 year survival, 5 year recurrent rate.
- Evaluate several factors affecting overall 5-year survival, 5 year recurrent rate:
age, gender, tumor location, tumor size, depth of tumor, histology, methods of
surgery, radiation dose. Factors related to multivariate analysis.
2.3. Data analysis
Information was collected based on designed case report forms. Data collection
methods: clinical examination, laboratory test, follow-up examination, prescription,
call or write letter to the patients to record treatment efficacy. Data were processed
and analyzed on SPSS 16.0 software with statistical algorithms. Survival was
pn = Z21 - /2
p (1 - p)

n  Z (21   / 2 )

2 p



2

.p

5

estimated by the Kaplan- Meier method. The univariate analysis: use log-rank test
when comparing survival curves among groups. The multivariate analysis: use Cox
proportional hazards models with 95% confidence interval (p=0.05).

CHAPTER 3.RESULTS
3.1. CHARACTERISTICS OF PATIENTS
Table 3.1. Characteristicsof patients
Characteristics
N
%
Characteristics
Male
76 53,5
arm
Gender
Forearm
and
Female
66 46,5
hand
location
50.4
Mean age
thig
±16.7
<3 months
23 16,2
Led and foot

5-<10cm
42 29,6
Time
of 3-<6 months
disease
10-<15cm
6-≤12months
50 35,1
Tumor
progression
size
15-<20cm
>12 moths
27 19,1
Tumor
symtoms

Skin
tumor

Movable
tumor

mass

131 92.3

pain

37

26.1

Tumor bleeding

6

4.2

Normal

112 79.2

cover infitration

19

12.9

Break the skin
easy

11

7.9

44

31,2

limit

82

57.1

fix

16

Weight loss
Body
fever
Undifferentiated
Histopathology pleomorphic
sarcoma

3.6

3

2.1

21,1

%
15,5

12

8,4

84

59,2

25
87

16,9
61,3

27

19,1

15

10,5

13

9,1

Homorogeneous 22
MRI
signal
Heterogeneous 120
intensity
Regular

41
Tumor
boder
Irregular
101
Tumor
necrosis

11,7

5

30

≥ 20cm

N
22

Tumor
depth

Tumor
grade

15,5
84,5
28,9
71,1

None

43

30,2

< 50%

58

40,9

≥ 50%

41

28,9

Surpificial

39

27,5

Deep tumor

103 72,5

grade 1

22

15,5

grade 2

46

32,4


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liposarcoma

22

15,5

Fibrous sarcoma

27

19,0

Synovial sarcoma

21

14,9

nerve 19

13,4

Malignant
peripheral
sheath tumor
Smooth
sarcoma

muscle

11

7,7

rhabdomyosarcoma 5

3,5

Others

4,9

7

grade 3

74

52,1

Comments: Average age 50.4 ± 16.7,
mass 92.3%, limited movable tumor
57.1%. Undifferentiated pleomorphic
sarcoma 21.1%. The position of the
tumor in the thigh was 59.2%. The
signal intensity was non heterogenous
on MRI of 84.5% and 71.1% by
irregular tumor. Deep tumor 72.5%.
The grade 3 accounts for the majority
of 52.1%

Table 3.2. Relationship between tumor depth and tumor size
Tumor size Tumor depth
Total
Surperficial Deep tumor
5-<10cm
33 (86,4%) 55 (52,9%) 88(62.0%)
10-<15cm 2 (5,3%)
25 (24,1%) 27 (19.0%)
15-<20cm 2 (5,3%)
12 (11,5%) 14 (9.9%)
≥ 20cm
1 (2,6%)
12 (11,5%) 13 (9.2%)
38 (100%)
104 (100%) 142 (100.0%)
Total

P=0,002
Comments: Deep tumors tend to have a larger proportion of tumor size than
superficial tumors, the difference is statistically significant with p = 0.002,
Table 3.3. Relationship between tumor grade and tumor size
Tumor grade Tumor size
Total
5-<10cm
≥ 10cm
Grade 1
20 (22,7%) 2 (3,7%)
22 (15,5%)
Grade 2
28 (31,8%) 18 (33,4%) 46 (32,4%)
Grade 3
40 (45,5%) 34 (62,9%) 74 (52,1%)
88 (100%) 54 (100%) 142 (100.0%)
Total
P=0,007
Comments: Grade 3 accounts for a high proportion in the group of patients with
tumor size ≥ 10cm (62.9%), grade 1 in the group of patients with ≥ 10cm accounts
for the lowest rate (3.7%). significant with P = 0.007.


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3.2. CHARACTERISTICS OF TREATMENT
Table 3.4. Characteristics of surgery
Characteristics
N
%

Characteristics of surgery
Tumor resection
121 85,2%
Tumor resection and plastic surgery
19 13,4
Tumor resection with microscopic surgery 2

1,4

Procedures of surgery
Wide local resection with margin ≥ 1cm
75 52,8
Tumor resection with margin <1cm
67 47,2
Enucleation
0
0
Radical resection
0
0
Postoperation complication
Infection of incision
8
5,6
Long healing incision (>14days)
16 11,2
Posoperative fever
3
2,1
Wound exudation

12 8,5
Postoperative bleeding
4
2,8
Comments: Tumor resection 85,2%. Wide local resection with margin ≥ 1cm 52,8%,
Tumor resection with margin <1cm 47,2%. Long healing incision accounted for the
highest 11.2%.
Table 3.5. Relationship between surgical method with tumor size and tumor depth
Surgical procedure

Tumor size
> 5 – 10cm

Wide local resection with margin ≥
51 (58,6%)
1cm
Tumor resection with margin <1cm 36 (41,4%)
Total
87 (100%)
χ2=11,482
P=0,036
Tumor depth
Surgical procedure
Superficial
tumors
Wide local resection with margin ≥
29(74,4%)
1cm
Tumor resection with margin <1cm 10 (25,6%)
Total

39 (100%)

Total
> 10cm
24 (43,6%)
31 (56,4%)
55(100%)

75 (52,8%)
67 (47,2%)
142
(100%)
Total

Deeply
tumors
46 (44,7%)

75 (52,8%)

57 (55,3%)

67 (47,2%)
142
(100%)

103 (100%)

P = 0,002

Comments: In group of tumor size > 5 – 10cm, the incidence of wide local resection
with margin ≥ 1cm accounts for a high rate of 58.6%, in group of tumor size > 10cm,


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tumor resection with margin <1cm high, 56.4%, the difference is significant. with p =
0.036. In group of the superficial tumor, wide local resection with margin ≥ 1cm was
high, accounting for 74.4% high, tumor resection with margin <1cm was low, 25.6%.
In contrast, the deeply tumor, rate of tumor resection with margin <1cm accounted
for 55.3% higher than the width wide local resection with margin ≥ 1cm 44.7%,
significant difference p = 0.002.
Table 3.6. Characteristics of adjuvant radiotherapy
Characteristics
N
3D-CRT accelerated radiation
142
Radiation fields
1 field
19
2 fields
123
Radiation dose
50 Gy
89
60 Gy
53
Complications of lymphedema after radiation therapy
None
109

Mild lymphedema
24
Moderate lymphedema
7
Severe lymphedema
2
Very severe lymphedema
0
Acute skin complications due to adjuvant radiotherapy
Grade 0 (no change in skin color)
Grade 1 (blurred erythema, alopecia, dry desquamation, decreased
perspiration)
Grade 2 (Clear red rash, scattered wet skin, moderate edema)
Grade 3 (Exfoliating wet, edema into cavities)
Grade 4 (Ulcers, bleeding, necrosis)
Complications of incision due to radiation therapy
Openly incision
Infection of the incision
Long healing incision
Wound exudation
Late complications of radiotherapy
Skin
Grade 1 (slight atrophy, change in pigmentation, low hair loss)
Grade 2 (Atrophy, moderate vasodilation, hair loss)
Grade 3 (Significant atrophy, severe vasodilation)
Grade 4 (Ulcers)
Joint
Grade 1 (Mild stiffness, loss of light motor amplitude)
Grade 2 (moderate stiffness, pain, loss of amplitude of motion)
Dollars 3 (Severe stiffness, pain, loss of movement amplitude)

%
100,0
13,4
86,6
62,7
37,3
76,8
16,9
4,9
1,4
0,0
10

7,1

84

59,2

38
9
1

26,7
6,3
0,7

9
6

7
8

6.3
4.2
4,9
5,6

64/142
53
7
3
1
11/142
9
2
0

45,1
37,4
4,9
2,1
0,7
7,8
6,4
1,4
0


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Grade 4 (Necrosis, complete fixation
0
0
Extremity edema
26/142 18,3
Grade 1 (Mild, but clear, swollen)
24
16,9
Grade 1 (Mild, but clear, swollen)
2
1,4
Grade 3 (Significant severe swelling)
0
0
Grade 4 (Very heavy, shiny skin, hard cracked skin or not)
0
0
Comments: 100% of 3D-CRT accelerated radiation treatment, 86.6% of 2-fields of
radiation, dose of 50Gy 62.7%. Lymphedema 23.2%, the majority mild 16.9%. Acute
skin complication most met minor (grade 1) 59.2%. Late complications limiting joint
movement and limb edema are rare. Late complications on the skin 45.1%, the
majority encountered mild (grade 1) 37.4%.
Table 3.7. Relationship between radiation dose and some factors
Factors
Radiation dose
Total
50 Gy
60 Gy
Tumor size < 10cm 66 (75,9%) 21 (24,1%) 87

≥ 10cm 23 (41,8%) 32 (58,2%) 55
χ2=6,264 89
53
142 (P=0.0141)
Tumor depth U nông 33 (84,6%) 6 (15,4%) 39
U sâu
56 (54,4%) 47 (45,6%) 103
142
=
χ2=4,642 89
53
0.032)
- Comment: The tumor group <10cm radiation dose 50Gy accounts for high
percentage of 75.7%, the tumor group ≥ 10cm radiation dose 60Gy makes up the high
rate of 58.2%, significant difference p = 0.0141. The group of superficial tumors with
the dose of 50Gy accounts for the majority of 84.6%, the group of deeply tumors with
the dose of 60Gy has the higher rate than the group of superficial tumors 45.6%
compared to 15.4%, the difference is significant p = 0.032.
3.3. RESULTS OF TREATMENT
3.3.1. Survival and recurrence
Table 3.8. Overall survival
Overall survival

2 years 3 years 5 years

Accumulated number of deaths
Cumulative survival rate (%)

26
32

35
73,2 % 65,7 % 63,2%

Average survival time ± standard deviation (months) 68,7 ± 4,4
-Comments: Average survival time 68.7 ± 4.4 months. The overall survival rate after
2 years, 3 years and 5 years was 73.2% respectively; 65.7% and 63.2%.


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Table 3.9. Sống thêm không bệnh
Disease-free survival

2 years 3 years 5 years

Number of cumulative recurrence, metastases
35
43
47
Cumulative survival rate (%)
68,3 % 57,2 % 54,7 %
Average survival time ± standard deviation (months) 57,5 ± 4,3
Comments: The average disease-free survival was 57.5 ± 4.3 months. The diseasefree survival rate after 2 years, 3 years and 5 years is 68.3%; 57.2% and 54.7%.

Figure
3.1.
Overall
survival
Table 3.10. 5 years recurrent rate
Recurrence

and

disease-free

survival

time

2 years 3 years 5 years

Accumulated number of recurrences 19

23

26

21,7 % 23,3 % 28,8 %
Cumulative recurrence rate (%)
Comment: The recurrence rate after 2 years, 3 years and 5 years is 21.7%; 23.3%
and 28.8%.

Biểu đồ 3.2. recurrence rate


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3.2. Factors affecting treatment results
3.3.1. Factors influencing treatment results of univariate analysis
Table 3.11. The influencing factors of overall survival when univariate analysis

Factors
N
OS
Number
of %
P
deaths
≤ 50
63 15
66,9 0,646
Age
> 50
79 20
59,4
Male
76 19
62,9 0,537
Gender
Female
66 16
64,2
34 8
68,8 0,977
Tumor location Upper limb
Lower limb
108 27
63,0
5-<10cm
87 13
73,8 0,016

Tumor size
10-<15cm
27 10
55,9
≥ 15cm
28 12
39.7
Superficial
39 4
87,4 0,019
Tumor depth
Deep
103 31
52,3
22 2
94,1 0,0092
Histologic grade Grade 1
Grade 2
46 10
72,8
Gade 3
74 23
44,1
Wide local resection with 67 21
55,5 0,154
Surgical
margin ≥ 1cm
procedures
Wide local resection with 75 14
67

margin <1cm
50 Gy
89 23
61,1 0,418
Radiation dose
60 Gy
53 12
65,0
Comment: Factors affecting the overall 5-year survival rate are tumor size, tumor
depth and histology
Table 3.12. Factors affecting recurrence when univariate analysis
Factors
N
5-years recurrence
Number
of %
P
recurrences
≤ 50
63 14
31,4 0,817
Age
> 50
79 12
27,5
Male
76 15
30,2 0,613
Gender
Female

66 11
26,9
34 7
32,7 0,306
Tumor location Upper limb
Lower limb
108 19
23,1
5-<10cm
87 10
17,2 0,013
10-<15cm
27 7
39,1
≥ 15cm
28 9
47,8
Superficial
39 3
12,4 0,039
Tumor depth
Deep
103 23
32,2


12

Grade 1
22

Grade 2
46
Gade 3
74
Wide local resection with 67
margin ≥ 1cm
Wide local resection with 75
margin <1cm
50 Gy
89
60 Gy
53

Histologic
grade
Surgical
procedures

Radiation dose

2
6
18
17

7,7 0,022
15,4
38,8
40,9 0,003

9

18,4

17
9

29,2 0,362
26,4

Comments: Factors affecting recurrence rate are tumor size, tumor depth, histologic
grade and surgical methods.
3.3.2. Affectting factors of multivariate analysis
Table 3.13. Variables with predictor of mortality risk
Factors

Coefficient
B

Standard
error

P

Age

0.312

0.363

0.672

Tumor location

- 0.468

0.384

0.173

Tumor size

1,643

0,841

0,002

Tumor depth

0,531

0,252

0,016

Histologic grade

0,912

0,431

0,009

Surgical procedures

-2.036

0.946

0.073

0.481

0.131

Radiation
dose
0.413
(50Gy and 60 Gy)

Reliability
(95%CI)
0.6771.953
0,2411,352
1,1131,521
1,1221,923
1,2135,691
0.2671.025
0.6323.274

Rate
difference
1.241
0,642
1,265
1,471
1,265
0.547
1.712

Comment: multivariate analysis, factors of size u, depth of tumor, histology are
independent prognostic
factors affecting survival time (p <0.05).
- Tumor Size groups with risk ratio of 1,265; 95% confidence interval is 1,113-1,521;
p = 0.002.
- The group of the depth of the tumor has a risk ratio of 1,471; confidence interval
1,122-1,923; p = 0.016.
- Groups of differentiated histology have a risk ratio of 2,613; 95% confidence
interval is 1,213-5,691; p = 0.009.


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Table 3.14. Variables have a risk of relapse
Factors

Coefficient
B

Standard
error

P

Reliability
(95%CI)

Rate
difference

0.5270,952
1.842
0,496Tumor location
- 0.745
0.271
0.367
0,962
1,742
1,815Tumor size
0,973
0,792
2,524
0,0078
2,962
1,328Tumor depth
0,627
0,543
1,721
0,0231

2,435
1,768Histologic grade
1,842
0,947
3,146
0,0026
4,941
Surgical
1,2481,214
0.504
1,863
0,0013
procedures
2,583
Radiation
dose
0.3920.614
0.521
0.082
1.431
(50Gy and 60 Gy)
2.164
Comment: The factors of tumor size, tumor depth, histology, surgical methods are
independent prognostic factors affecting the risk of recurrence (p <0.05).
- The tumor size group has risk ratio 2,524; 95% confidence interval is 1,8152,962; p = 0.0078.
- The group of the depth of the tumors has a risk ratio of 1,721; 95%
confidence interval is 1,328-2,435; p = 0.0231.
- Groups of patients with differentiated histologic grade have a risk ratio of
3,146; 95% confidence interval is 1,768-4,941; p = 0.0026.
- The group of patients with wide local resection and marginal resection has

risk ratio of 1,863; 95% confidence interval is 1,248-2,583; 0.0013.
Age

- 1,362

0.531

0.962

CHAPTER 4. DISCUSSION
4.1. CHARACTERISTICS OF PATIENTS
4.1.1. Some clinical and subclinical characteristics
- The study was conducted on 142 patients, with characteristics of age, gender,
duration of disease, tumor symptoms, skin on tumor and tumor mobility similar to
domestic studies and a number of other authors in the world.
- Tumor location: the research results showed that the tumor met the majority of the
position in the thigh 59.2%, other positions were less common. Roi Dagan (2012) on
317 patients, the thigh area tumor has 222 patients accounting for 70%, the tumor in
the arm position has 51 patients accounting for 16.1%, the tumor in the forearm has


14

18 patients accounting for 5.7 patients % and tumor in the foot have 26 patients
accounting for 8.2%. Jeffrey S. Kneisl (2017) on 162 patients, 37 patients on the
upper limb accounted for 22.8%, while the lower limb had 125 patients accounting
for 77.2%.
- Tumor size: 5- <10cm accounts for 61.3%, tumor size 10- <15cm accounts for
19.1%, tumors size 15- <20cm account for 10.5%, tumor size ≥ 20cm accounts for 9,
first%. A. Gronchi (2011) in 911 patients showed that patients with hospital size on

average were 6cm, tumor size was a prognostic factor to live after treatment.
- Heterogeneous tumor signal intensity is one of suspected malignant characteristics,
in the study, 84.5% of patients had heterogeneous signal strength. The study of Jong
Woong Park et al about tumor border characteristics on MRI film in 144 patients
showed that the tumor had irregular edges on MRI film accounted for 71.8%.
- Clinical form of tumor: deep tumors account for the majority of 72.5%. One of the
characteristics of suspected malignant tumors is that the tumor is deep compared to
the superficial fascia. Studies of other authors also show that the majority of deep
tumors, Joeke M (2013) study on 118 patients, 79 patients of the deep tumors
accounting for 66.9%, the study also shows tumor depth is an important prognostic
factor.
- Histopathology: research results show that tumors are diverse in histopathology,
undifferentiated pleomorphic sarcoma accounts for the highest proportion of 21.1%.
Researches by other domestic and foreign authors show a variety of histopathological
differences.
. – Histologic grade: grade 3 accounts for the highest 52.1%, grade 1 accounts for
15.5%, grade 2 accounts for 32.4%. Studies of other authors also showed that gr 3
accounted for the highest, A. Gronchi (2011) of 1094 patients, showing that grade III
accounted for the highest proportion of 49.6% (543 patients), continued grade 2
accounted for 27.5% (301 patients) and grade 1 accounted for the lowest rate of
22.9% (250 patients). Thereby showing that soft tissue sarcoma is highly malignant,
rapidly progressing.
4.1.2. Some related factors
- Relationship between tumor depth and tumor size: Deep tumors tend to have higher
a proportion of larger tumor than superficial tumors, the difference is statistically
significant with p = 0.002. These are prognostic factors related to each other,
affecting the outcome of treatment, postoperative survival and recurrent rate. Deep
tumors are often harder to detect than superficial tumors, many are deep in skeletal

15

muscle masses and vascular bundles, with no symptoms that the patient may not
show any sign and symptom, when detected. so the tumor has been large.
- The relationship between tumor size and histologic grade: grade 3 accounts for a
high proportion in the group of patients with tumor size ≥ 10cm (62.9%), grade 1 in
the group of patients with tumor size ≥ 10cm has the lowest rate (3 , 7%), the
difference is significant with P = 0.007. Tumors with a high histologic grade (grade
3) are highly malignant, the cells multiply strongly so that the tumors grow faster,
their size increases quickly, so these tumors are high or encountered in larger size
tumors. Fang Zhao (2014), 95 patients, showed that for tumors ≥ 5cm, grade 3 also
accounts for a high proportion of 37/80 patients (52.8%), grade 1 accounts for a low
rate of 7/80 diseases. In the group of tumor size <5cm, the proportion of histologic
grade was similar, the difference in size and histologic grade significance was
statistically significant with P = 0.004.
4.2. Characteristics of treatment
4.2.1. Surgical Characteristics
- Surgical characteristics: The majority of patients had tumor resection alone 85.2%,
local muscle skin flap 13.4%, microsurgical flap transferred 1.4%. Most patients have
wide local resection with healthy tissue surrounding, ensuring that the negative
microscopic margin then closed with a simple surgical procedure without using
plastic surgery. Some patients after wide tumor resection with large defects, those
cases are combined with rotating skin flap or micro surgical flap covering the flaw,
making the recovery process after surgery faster, shorten the treatment time, in recent
years, we often perform surgeries in collaboration with plastic surgeons to increase
the effectiveness of surgery and improve the quality of life for patients.
- Surgical method: the proportion of wide local resection with margin ≥1cm
accounted for 52.8%, tumor resection with margin <1cm accounted for 47.2%. The
most important principle of soft tissue sarcoma surgery is to cut the tumor wide to
ensure a negative microscopic margin. In clinical practice, large, deep tumors, located

near important components of the limbs (nerve, blood vessels), surgery is difficult to
achieve margin > 1cm from the tumor, sometimes the tumor is close to the vascular
bundles, The nerve then accepts marginal resection to achieve a negative microscopic
margin. Postoperative complications: limb sparing surgery is usually safe and few
complications, these other complications are usually mild and fully recovered after
the time of incision care.


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- Relationship between surgical method with tumor size and depth tumor: the
research results show that the larger the tumor size, the lower the rate of wide local
resection (p <0.05), the deeper tumors the lower the rate of wide local resection is
lower than superficial tumos(p<0.05). Research by Rima Ahmad (2016) on 235
patients, showed the relationship between the average tumor size and the width of the
resection, with the margin ≤ 1mm the size of the tumor is 10cm average, with the
margin > 1mm - ≤ 5mm average tumor size is 8cm and with margin > 5mm, the
average u size is 5cm difference is statistically significant with p = 0.0049. Deep
tumors are usually larger in size, often located near large vascular bundles, nerves,
and sometimes tumors invade those components, making it possible to cut the tumor
at a wide distance from the tumor. difficult to achieve, superficial tumors are usually
in a favorable position to be able to resect the wide tumor resection with the distal
margin.
4.2.2. Characteristics of adjuvant radiotherapy
- All patients received accelerated radiation with 3D-CRT technology. The majority
of patients (86.6%) were irradiated with 2 radiation fields, only 13.4% of the patients
were irradiated with 1 radiation that were superficial tumors on the surface of the
limbs. The percentage of patients who received postoperative adjuvant radiotherapy
with the dose of 50Gy accounted for a high rate of 62.7%, the dose of 60Gy
accounted for 37.3%. Normally, dose of postoperative adjuvant radiotherapy is 50Gy,

large tumors resected not wide enough can raise the dose to 60Gy.
- Complications of lymphedema: most had mild degree, degree 0 accounted for
76.8%, degree 1 (mild lymphedema) accounted for 16.9%, level 2 (average lymphatic
edema) accounted for 4.9% , grade 3 (severe lymphedema) accounted for 1.4% and
grade 4 (very severe lymphedema) without severe patients. Other studies also show
that the majority experience mildness, Daniel Friedmann et al (2011) in 288 patients,
the incidence of lymphedema is 28.8%, of which the first degree is 20.1%, the second
degree is 7 , 6%, degree 3 is 1.1%. Joeke M (2013) in 118 patients with 27% of
lymphatic edema.
- Acute skin complications due to radiation: based on RTOG standards, the results
show that the majority of acute skin complications due to radiation are mild, of which
grade 1 (59.2%), grade 2 (26.1%), rare severe skin complications of grade 3 (6.4%)
and grade 4 (0.7%). Nowadays, with the development of accelerated radiation,
significant reduction of radiation complications, acute complications are usually mild,
do not affect function and cause symptoms. discomfort for patients. Ru-Ping Zhao


17

(2016) on 220 patients, the rate of acute skin complications ≥ 2 accounted for 3.3%.
Yosuke Takakusagi et al (2017) at Gunma University showed that the majority had
acute level complications (71%).
- Complications from incision due to radiation therapy: rare, low proportion, 6.3%
incision, wound infection accounted for 4.2%, long healing incision accounted for
4.9% and wound exudation accounted for 5.6%. %, or mild severities, often take care
of local wounds with antibiotics, and these complications can go away without
surgical intervention.
- Late complications due to radiation: late complications on the skin accounted for
45.1%, of which 37.4%, level 2 accounted for 4.9%, level 3 accounted for 2.1% and
level 4 (ulcers) accounted for 0.7% rate. Complications limiting joint movement

accounted for 7.8% of which first degree accounted for 6.3%, second degree
accounted for 1.4%, there were no patients with joint stiffness of grade 3 and level 4.
Complications of edema accounted for 18, 3% in which level 1 accounted for 16.9%,
level 2 accounted for 1.4%, no patients had edema grade 3 and 4. Thus late
complications due to radiation was relatively rare and most met mild. Joeke M.
Felderhof (2013) in 118 patients showed that complications on the skin accounted for
42.4%, degree 1 40.7%, level 2 1.7%, complications limiting joint mobility, the rate
of limiting joint mobility accounted for 22.9% in which level 1 accounted for 18.6%,
level 2 accounted for 1.7% and level 3 accounted for 2.5%, complications of edema
accounted for 25.4%, of which level 1 was 25.4% not met. complications of limb
edema degree 2, degree 3 and degree 4.
- Relationship between radiation dose and tumor size and tumor depth: tumors
<10cm, radiation dose 50Gy accounted for 75.7% with high proportion, tumor ≥
10cm radiation dose 60Gy was high proportion 58,2%, significant difference means p
= 0.0141. The group of superficial tumors with the dose of 50Gy accounted for the
majority of 84.6%, the group of deep tumors with the dose of 60Gy has the higher
rate than the group of superficial tumors 45.6% compared to 15.4%, the difference is
significant p = 0.032. Postoperative adjuvant radiation plays an important role in
local control, reducing the rate of local recurrence after surgery. Usually, the adjuvant
radiation dose is 50Gy for wide local resection. The radiation dose is increased to
60Gy for large tumors, when it is difficult to ensure safe surgical margin or margin is
less than 1cm from the edge of the tumor.


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4.3. Treatment results
4.3.1. Results of survival and recurrence
- Overall survival and disease-free survival: 63.2% 5 year overall survival (OS), with
an average OS time of 68.7 ± 4.4 months, 5 year disease-free survival (DFS) was

57.4% with an DFS time average 57.5 ± 4.3 months. The majority of patients died
and relapsed in the first 2 years. Compared with some other domestic studies, Nguyen
Dai Binh (2003) of 111 patients showed that relapse failure, distant metastasis and
death occurred mainly in the first year after surgery. 3-year OS was 61.7%. The
survival rate for non-recurrent metastases was 54%. Ngo Truong Son (2007) of 95
patients with soft tissue sarcoma of trunk showed that the 5-year OS rate was 60.1%,
the 5-year DFS rate was 55.2%. Compared to the previous studies, the survival rate
according to our research has improved because in the last few years we have had
improved surgical technique. For large tumors after surgery, after resectting the
tumor leaving a large flaw, in combination with plastic surgeons to perform on-site
transfer or micro-surgery to cover flawed areas, if these areas were previously long
after taking a long time to take care of the place, combined with diet support the area
of new defects to fill up and heal wounds, prolonging the time patients wait for
postoperative radiation to affect treatment results. Compared to a number of studies
in the world, Joke M. Felderhof (2013) on 118 patients, 5 year OS was 69%, a 5-year
DFS was 64%. Dagan R et al (2012) on 317 patients, the average duration of followup for 4.7 years showed that the 5-year OS rate was 62% and the 5 year DFS was
59%. Jeffrey S. Kneis (2016) of 162 patients, the mean follow-up time of 5.1 years
showed that the 5-year OS rate was 76% and 5 year DFS rate was 64%.
- 5 year recurrence rate: our study showed that the recurrence rate after 2 years, 3
years and 5 years was 21.7%, 23.3% and 28.8%, respectively. One of the important
features of soft tissue sarcoma is frequent recurrent after treatment, there were
patients who relapse many times after treatment despite extensive surgery and
adjuvant treatment. Tang YW et al (2012) on 73 patients, the 5-year relapse rate was
24.6%. Harati K et al (2017) on 643 patients, the 5-year relapse rate was 34.7%.
Thus, compared with other authors in the world, our study results have the same
recurrence rate, there are patients with one recurrence, but there are patients with
multiple recurrences. In clinical practice, we have seen patients relapse 7 times after
initial treatment.

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4.2. Factors affecting treatment results
4.2.1. Factors influencing treatment results of univariate analysis
* Factors affecting overall survival
- Some factors do not affect the OS such as age, gender, tumor location (p> 0.05).
Gronchi, P.G (2005) of 911 patients, 5-year OS rate of group ≤ 50 were 67.4% of the
age group> 50 was 71.3%, p = 0.713. Jeffrey S. Kneisl et al (2017) on 120 patients
with high grade, 5-year OS between 2 age groups ≤ 50 (44BN) and > 50 (76BN)
showed no difference between the 2 age groups with p> 0, 05, the 5-year OS rate
between male and female according to univariate analysis was not statistically
significant with P = 0.168, cumulative risk index HR = 0.442. There was no
difference in 5 year OS rate with the upper tumor group (29 patients) and the lower
tumor group (91 patients) with p = 0.585, cumulative risk index HR = 1,244. These
are independent factors that OS unaffected by age, gender and location.
- Tumor size: 5 year OS of the group u 5- <10cm, 10- <15cm and ≥ 15cm
respectively 73.8%, 55.9% and 39.7%, the difference is statistical significance with p
= 0.016. Other studies have shown similar results, Jurgen Weitz et al (2003) on 1261
patients, 5 year DFS of tumor group size <5cm, 5-10cm and> 10cm respectively
75%, 62% and 51%, p <0.0001. Andrew J. Jacobs et al (2015) of 5203 patients, 5
year OS with tumor group ≤ 5cm was 75%, of tumor group> 5cm was 58%, p <0.05.
Thus, all studies have shown that tumor size is a prognostic factor, the higher the risk
of a metastasis, Moreover, with large tumors, the possibility of surgical removal of
the tumor to achieve a safe margin is also more limited
- Depth of the tumor: the study showed that the 5-year OS rate of superficial tumor
was 87.4%, the deep tumor was 52.3%, p = 0.0019. Deep tumors are often found with
a larger size, located near the vascular bundles, nerves when surgery the ability to cut
tumors more limited. Gronchi, P.G (2005) on 911 patients, 5 year OS of the group of
superficial tumors and deep tumors were statistically significant with p <0.001, with
risk index HR = 3.4. Harati K et al (2017) on 643 patients, 5 year OS of superficial

tumor group was 78.2%, of deep tumor group was 62.3%, p = 0.008.
- Histologic grade: the 5-year OS rates of gade I, II, and III were 91.4%, 72.8% and
44.1% respectively, p = 0.0092. Other studies have also shown that histologic grade
is a prognostic factor, Nguyen Dai Binh 3 year OS rate of 85.0%, grade 2 (73.2%)
and grade 3 (35.1%). ), (p <0.0001). Andrew J. Jacobs et al (2015) Patient, OS
according to histologic grade I, II, II, IV respectively 89%, 80% 57% and 48% p
<0.0001.


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- Surgical method: 5 year OS of wide local resection width ≥ 1cm and tumor
resection with margin <1cm was 67% and 55.5%, p = 0.154. Patients in our study
were all negative microscopic margin. Vraa S et al. (2001) of 152 patients, 5 year OS
of wide local resection and marginal resection were 59% and 60%, no differences.
Rima Ahmad et al (2016) of 382 patients, 5 year OS for the negative and positive
margin were 82% and 69% respectively, the difference was significant at p = 0.009.
For patients with negative margin, the author divided the width of margin by less than
1mm,> 1mm and ≤ 5mm,> 5mm, OS were 81%, 68% and 100% respectively, no
significant difference p = 0.064. Thus the most important is surgery to achieve a
negative margin.
- Radiation dose: 5 year OS of radiation dose of 50Gy and 60Gy were 61.1% and
65.0%, p = 0.418. Lzlem Yetmen Dogan et al (2018) on 114 patients, 5 year OS of
<60Gy and ≥ 60Gy were 76.9% and 75.3%, p = 0.8. Radiation therapy plays a role in
reducing local recurrences but does not improve survival.
* Factors affecting recurrence rate
- Some factors such as age, gender, tumor location: research results show that these
factors do not affect the 5-year relapse rate (p> 0.05). Joeke M. Felderhof et al (2013)
in 118 patients, the recurrence rate in the group> 50 years old and ≤ 50 years old was
8.7% and 12.2% respectively, p = 0.68. Harati K et al (2017) on 643 patients, the 5year recurrence rate of the group> 50 years old and ≤ 50 years old were 32.4% and

22.7% p = 0.093 respectively, the recurrence rate of the tumor group The upper and
lower limbs are 39.4% and 32% respectively, p = 0.096.
- Tumor size: the 5-year recurrence rate of tumor size 5- <10cm, 10- <15cm and ≥
15cm were 17.2%, 39.1% and 47.8%, significant for p = 0.013. Other authors also
noted that tumor size was a factor affecting recurrence, Jurgen Weitz et al (2003) in
1261 patients, the 5-year relapse rate of tumor <5cm, 5-10cm and> 10cm were 18%,
23% and 28%, p = 0.05. Harati K et al (2017) on 643 patients, the 5-year relapse rate
of tumors ≤ 5cm and> 5cm were 16.2% and 32.4%, respectively, significant
difference with p = 0.003.
- Depth of tumor: the recurrence rate of superficial tumors and deep tumors were
12.4% and 32.2% respectively, the difference was statistically significant with p =
0.039. The deeper the tumor is located near the critical structures, the more limited
the ability to be resectalbe, so the rate of recurrence is higher. Kenneth R. Gundle
(2018) on 2217 patients, the 5-year recurrence rate of the superficial and deep tumor


21

group was different with p = 0.030, the HR ratio was 1.5 with 95% confidence from
1.1 to 2. Masaya Sekimizu (2019) on 2827 patients, the recurrence rates of superficial
tumors and deep tumors had differences with P <0.05, HR ratio 2.16 with 95%
confidence interval was 1.52-3, 06.
- Histologic grade: the 5-year recurrence rate of histology 1 was 7.7%, gade 2 was
15.4% and grade 3 was 38.8%, the difference was statistically significant with p =
0.022. Several other studies also show that histologic grade is a prognostic factor
affecting recurrence rates. Kenneth R. Gundle (2018) on 2217 patients, the 5-year
recurrence rate of grade 1 compared with grade 3 had a significant difference with p
= 0.02, HR ratio = 2.0 with confidence interval. 95% confidence from 1.1 to 3.6.
Lzlem Yetmen Dogan (2019) on 114 patients, the 5-year recrrence rate of grade 1
was 19.5%, grade 2 was 24.9% and grade 3 was 36.1%, the difference statistical

significance with p <0.05.
- Surgical method: the study showed that the 5-year recurrence rate of wide local
resection with margin ≥ 1cm and tumor resection with margin less than 1cm was
respectively 18.4% and 40.9%, the difference was statistical significance with p =
0.003. Tang YW et al (2012) on 73 patients with UTPM surgery from 1995 to 2010
showed that the 5-year relapse rate was 24.6%. The recurrence rate of wide tumor
resection and marginal resection were 11.6% and 45.5%, the difference was
significant with p <0.05. Kainhofer V et al (2016) showed that the 5-year recurrence
rates of margin of R0 and R1 were 9.5% and 36.7% respectively, the difference was
significant with p <0.05. A study by Gundle KR and CS (2018) showed that 5-year
recurrence rates with margin R0, R1 and R2 were 6%, 17% and 38%, respectively.
Characteristics of soft tissue sarcoma are often recurrent after surgery. The recurrence
rate depends on the width of the surgical margin.
- Radiation dose: The study results showed that the recurrence rates of the radiation
dose of 50Gy and 60Gy were 29.2% and 26.4% respectively, the difference was not
significant with p = 0362. In our study, all patients received adjuvant radiotherapy.
Other studies have shown that adjuvant radiation reduces relapse compared to those
without adjuvant radiotherapy. A. Gronchi et al. 2011 on 1094 patients, the nonrecurrent survival rate of tumors with adjuvant and non-adjuvant radiation was
different from p = 0.0201, odds ratio 0.68 and confidence interval 0.49-0.94. Jeffrey


22

S. Kneisl (2017) in 120 patients, the recurrence rate of the 2 groups with radiation
and non-radiation were different with p = 0.0201, risk ratio of 0.68 and confidence
interval of 0.49 -0.94. Kamran Harati et al (2017) above 783, 5-year non-recurrence
survival of adjuvant and non-adjuvant radiation were 61.3% and 70.5%, significant
difference. with p = 0.002.
4.2.2. Factors influencing treatment results of multivariate analysis
- Variables with predictive risk of death: Cox regression analysis showed that tumor

size factors, histological differentiation and depth tumor were independent predictors
(p <0.05). Similarly to the study of A. Gronchi et al (2011) on 911 patients with limb
software, multivariate analysis showed tumor size (risk ratio 1.9; confidence interval
1.4-2.5 (p <0.001)), depth of tumor (risk ratio 3.4; confidence interval 2.0 -5.7 (p
<0.001)), histologic grade (risk ratio 3.3; approx. Confidence of 1.9-5.6 (p <0.001))
are prognostic factors affecting OS. Roi Dagan et al (2013) on 317 patients,
multilateral analysis showed that histology, tumor size were independent prognostic
factors affecting OS p <0.05. Kamran Harati et al (2017) on 783 patients, showed
tumor size (risk ratio 1.23; confidence interval 1 , 12-2.20 (p = 0.00254)), histologic
grade (risk ratio 3.33; confidence interval 1.06-5.46 (p = 0.001)), depth of tumor
(billion probability risk 2.30; confidence interval 1.20-4.12 (p = 0.010)) and section
(risk ratio 2.85; confidence interval 1.45-5.61 (p = 0.002) ) are independent
quantitative factors related to survival time p <0.05.
- Variables with predictive risk of recurrence: analysis by Cox regression method, the
factors of tumor size, histologic grade, depth of tumor and surgery method affect the
relapse rate (p <0.05). Gronchi, PG (2005) at Milan Hospital, Italy, on 911 patients
showing the depth of the tumor (risk ratio 1.60; confidence interval 1.05-2.60 (p =
0.0467)), margin (risk ratio 1.94; confidence interval 1.37-2.73 (p = 0.0002)),
adjuvant radiation (risk ratio 0, 68; confidence interval 0.49-0.94 (p = 0.0201)) are
independent prognostic factors affecting non-recurrent survival. Masaya Sekimizu et
al (2019) on 2827 patients showed tumor size (risk ratio 1.95; confidence interval
1.31-2.92 (p = 0.001)), histopathologic grade (risk ratio 2.43; confidence interval
1.48-3.99 (p <0.001)) and margin (risk ratio 3.12; confidence interval 2.22-4) , 37 (p
<0.001)) are independent quantitative factors related to DFS p <0.05.


23

CONCLUSION
Through a study of 142 patients with extremity soft tisue sarcoma with a size

of ≥ 5cm, treated with conservative surgery and combined with adjuvant radiotherapy
at K hospital from January 2014 to August 2018, we have come to the conclusion:
1. Clinical and subclinical characteristics
- Mean age 50.37 ± 16.68. Male / female ratio 1.15.
- The most common clinical symptom is palpable mass 92.3%, limited movable
tumor 57.1%
- The most common tumor position in the thigh 59.2%
- Tumor size 5- <10cm accounts for the highest 61.3%
- 84.5% of tumors had heterogeneous signal intensity on MRI, 71.1% had irregular
tumor edges.
- Superficial tumor and deep tumor account for 27.5% and 72.5%.
- Undifferentiated pleomorphic sarcoma accounts for the highest rate of 21.1%.
- Grade 3 accounted for the highest 52.1%
- Deep tumors tend to have a proportion of tumors that are larger than superficial
tumors, grade 3 is more significant in tumors size ≥ 10cm (p <0.05).
2. Treatment results
- Surgery for tumor resection alone accounted for 85.2%.
- Wide local resection with margin ≥ 1cm accounting for 52.8%, tumor resection with
margin <1cm 47.2%
- The method of resection was related to size and the depth tumor (p <0.005).
- Complications of lymphatic edema accounted for 23.2%, the majority of mild cases
accounted for 16.9%.
- Acute skin complications most mild (grade 1) accounted for 59.2%.
- Late toxicities on the skin accounted for 45.1%, the majority met mildly (grade 1) 37.4%.
Limitation of joint movement was rare by 7.8%. Edema accounted for 18.1%.
- 5 year OS was 63.2%. 5 year DFS was 54.7%. 5-year recurrence rate was 28.8%.
- 5-year OS rate was entirely related to tumor size, tumor depth and histologic grade (p <0.05).
- The 5-year relapse rate was related to tumor size, tumor depth, histologic grade and
surgical methods.
- The 5-year OS survival rate was independently related to tumor size, histology and

depth of tumor according to multivariate analysis.
- The 5-year recurrence rate was independently related to tumor size, histology,
tumor depth and surgical method.


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RECOMMENDATION
In this study, we saw that chi-conserving surgery combined with adjuvant
radiation therapy offers encouraging effects, a high rate and survival time, and a
reduction in recurrence rates, which confirms the role of limb sparing surgery and
adjuvant radiation treatment for tumors ≥ 5cm in size. Through research we
recommend
Extremity soft tissue sarcoma with not metastasis, not invading the nerves,
large blood vessels, acceptable limb fuction should perform limb sparing treatment
brings good results in terms of oncology as well as functional.