(P 282) FUNGATING SOFT TISSUE SARCOMA: A COMPLEX TREATMENT DILEMMA

Objective: Soft tissue sarcomas (STS) are a diverse subset of malignant tumors, 43-75% of which occur in the extremities. Though they account for < 1% of all cancers, more than 5000 deaths resulting from STS are projected for the year 2022 in the United States alone. Treatment for extremity STS has evolved from amputation to wide local excision paired with adjuvant radiotherapy (XRT), which has been correlated with decreased local recurrence (LR) and increased overall survival (OS).
Fungating STS, accounting for between 3.2-3.7% of STS cases, ulcerate or protrude directly from the skin, and have been shown to carry a poor prognosis. Patients with such tumors are more prone to infection in both pre and postoperative stages of treatment, complicating treatment modality and timing. These patients are more susceptible to bleeding from the tumor site which exacerbates infection potential and can lead to anemia. Increased bleeding potential, wound site pain, and unsightly appearance all exacerbate patient discomfort, especially in tumors arising on weight bearing or dynamic locations of the extremities. These unique traits of fungating STS suggest that management can be especially challenging. Considering this, it is plausible that fungating extremity tumors may warrant an individualized treatment approach that differs from standard treatment for non-fungating STS.

Through a review of current literature, our aim is to understand past treatment and outcome trends for fungating STS in order to guide future treatment from time of initial presentation. Specifically, trends in relevant metrics including likelihood of requiring amputation, LR and OS, and incidence of metastasis at initial presentation were assessed. We herein explore relevant considerations regarding the type and expediency of surgical intervention, relevance of and timing of radiotherapy when indicated, and the management of patients presenting with metastatic disease.

Methods: A comprehensive literature review of the PubMed database was performed, using keywords to identify studies focused on fungating STS. Inclusion criteria included human studies, adult population, extremity tumors, and fungating tumors. Exclusion criteria included studies published prior to 1982. 1515 articles were identified and screened for relevance, 10 articles met all criteria.
Primary outcomes were literature trends in primary treatment measures (amputation versus limb salvage), LR rates, 5-year OS, and incidence of metastasis on presentation for patients with fungating STS. Secondary outcomes were effects that fungation had on timing of radiotherapy, likelihood of requiring plastic surgery in those receiving limb sparing surgery, mean time to death, and likelihood of wound complications in the postoperative setting.

Results: Primary Outcomes
Primary outcomes from major contributing studies are summarized in Table 2.
Secondary Outcomes
One study reported a significant decrease in XRT use in fungating STS (39% vs 68%, p=0.02). Two studies suggest that plastic surgical intervention following limb salvage surgery (LSS) was increased compared to non-fungating tumors (47.5-65% vs 25%). Pts with fungating STS have significantly shorter mean time to death compared to their non-fungating counterparts (13.8-16.2 vs 29.0-30.4 months). Postoperative complications rates for fungating tumors are as high as 43% with LSS, with 17% requiring reoperation. Of all complications following amputation, 66% occur in patients with fungating tumors, though both STS and carcinomas were included in those findings.

Conclusion: Given the unique aspects of fungating STS and overall poor prognosis, these tumors may warrant individualized treatment that differs from the standard approach to non-fungating STS. Expedient primary surgical treatment may be appropriate given the higher metastatic potential and increased rate of complications associated with fungating STS. LSS is appropriate for primary, non-metastatic surgical treatment, though fungating tumors are treated with primary amputation more often than non-fungating STS, which may reduce postoperative complications in high-risk patients. Timing of XRT should be carefully considered, as neoadjuvant XRT coupled with a fungating tumor may result in a higher incidence of pre and postoperative complications and increased need for plastic surgical closure techniques. For tumors in close proximity of critical neurovascular structures, primary amputation should be more strongly considered given higher LR coupled with increased complication risk associated with delayed surgery and neoadjuvant XRT. Adjuvant XRT is appropriate and should continue to be used in most non-metastatic cases. In patients who can tolerate it, the use of chemotherapy should be more heavily considered in non-metastatic cases of fungating STS given the greatly increased metastatic potential, especially in high grade chemosensitive tumor subtypes.

STS PAPER_TABLE 2_PRIMARY TRENDS.docx