Surgery in soft tissue sarcoma: more conservative in extremities, more extended in the retroperitoneum

Extremity soft-tissue sarcomas (ESTS) account for approximately 50% and retroperitoneal soft-tissue sarcomas (RSTS) for approximately15% of all soft-tissue sarcomas. Surgery remains the main treatment modality for all soft-tissue sarcomas. Neoadjuvant and/or adjuvant chemo-and radiation-therapy are also often used to improve the treatment outcomes. In ESTS, surgery had originally been mutilating. The introduction of principles of surgical adequacy and of complementary treatments, especially radiotherapy, led to a reduction in the amputation rate in favor of conservative treatments. The implementation of plastic, vascular and nerve reconstructions allowed for further increase in conservative procedures, with better functional and cosmetic results. Moreover, recent reports have demonstrated how preoperative treatments can offset the negative prognostic impact of marginal resection on local outcome and survival, extending the limit of limb and function preservation. In RSTS, surgery had consisted of simple excision, while the resection of surrounding organs/viscera had been considered only in cases of direct involvement/infiltration. This strategy was associated with a high rate of local recurrence, which in many cases it was the driving cause of death. In order to improve local control and subsequent overall survival, some authors have recently advocated a policy of extended surgery including surrounding organs/viscera en bloc with the tumor. In this review, the authors discuss the standard world wide accepted surgical treatment for ESTS and the new surgical approach for RSTS.