Surgical Treatment and Other Localized Therapy For Metastatic Soft Tissue Sarcoma - UpToDate PDF

12/18/2018 Surgical treatment and other localized therapy for metastatic soft tissue sarcoma - UpToDate
Authors: Chandrajit P Raut, MD, MSc, FACS, Suzanne George, MD, George D Demetri, MD
Section Editors: Robert Maki, MD, PhD, Russell S Berman, MD, Raphael E Pollock, MD
Deputy Editors: Diane MF Savarese, MD, Kathryn A Collins, MD, PhD, FACS
Contributor Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Nov 2018. | This topic last updated: Feb 05, 2018.
INTRODUCTION — Soft tissue sarcomas are a heterogeneous group of uncommon tumors arising from
mesenchymal cells at all body sites. The malignant precursor cell(s) differentiate along one or several lineages,
such as muscle, adipose, fibrous, cartilage, nerve, or vascular tissue. These tumors arise most often in the
limbs (particularly the lower extremity), followed in order of frequency by the abdominal cavity/retroperitoneum,
trunk/thoracic region, and the head and neck. (See "Clinical presentation, histopathology, diagnostic evaluation,
and staging of soft tissue sarcoma", section on 'Clinical presentation' and "Clinical presentation, histopathology,
diagnostic evaluation, and staging of soft tissue sarcoma", section on 'Introduction'.)
While local complications from primary or recurrent sarcomas can cause significant morbidity and occasional
mortality, the most life-threatening aspect of sarcomas is their propensity for hematogenous dissemination. The
pattern of tumor spread varies according to tumor type:
● For most sarcomas of the extremity, chest wall, and head or neck, the primary metastatic site is the lung
[1]. However, there are exceptions. Extrapulmonary metastases to the retroperitoneum, spine, and
paraspinous soft tissues predominate with myxoid/round cell liposarcomas, although lung metastases
develop eventually in almost all [2]. (See "Clinical presentation, histopathology, diagnostic evaluation, and
staging of soft tissue sarcoma", section on 'Pattern of spread'.)
● The primary site of failure is locoregional for retroperitoneal and visceral sarcomas; less commonly, these
tumors spread hematogenously to the liver and also the lungs [3].
● Spread to locoregional lymph nodes is rare (≤5 percent), with the exception of clear cell and epithelioid
sarcomas, angiosarcomas, and rhabdomyosarcomas [4].
The majority of patients who develop metastatic soft tissue sarcoma are incurable, and palliative systemic
treatment is the most appropriate therapy. Judicious use of systemic therapy provides symptom palliation,
prevents rapid disease progression, and may, in some cases, prolong survival. (See "Systemic treatment of
metastatic soft tissue sarcoma".)
However, for selected patients, surgical resection of metastatic disease can provide long-term relapse-free
survival and potential cure. The majority of these patients have isolated oligometastatic disease in the lungs.
The role of surgery in the treatment of common adult-type metastatic soft tissue sarcomas will be reviewed
here. Surgical management of localized primary soft tissue sarcomas of the extremity, trunk, or
retroperitoneum; the approach to locally recurrent extremity and retroperitoneal soft tissue sarcomas; surgical
management of specific types of soft tissue sarcoma, including gastrointestinal stromal tumors,
rhabdomyosarcoma, uterine sarcomas, desmoids, dermatofibrosarcoma protuberans, and Kaposi sarcoma;
and the general principles of surgical management of pulmonary metastases are discussed elsewhere. (See
appropriate topic reviews.)
PULMONARY METASTASES — Complete pulmonary metastasectomy is feasible in approximately one-third of

patients presenting with isolated oligometastatic disease from soft tissue sarcoma [5].
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Criteria for resection — No single criterion can be reliably used to exclude patients from surgery because of a
predictably low likelihood of cure. In general, the inability to achieve a complete resection, a large number of
pulmonary nodules, and a short interval between surgical resection of the primary tumor and the development
of metastases (less than 12 to 18 months) are adverse prognostic factors for survival [5-7]. The most important
of these is the ability to completely resect all disease [5,6]. In the setting of asymptomatic disease, surgery in
the chest should not be undertaken unless all known deposits of disease are being treated.
The following criteria for pulmonary metastasectomy are generally agreed upon [8-10]:
● No extrathoracic disease (although this is being challenged [11]), pleural effusion, or radiographically
suspicious hilar/mediastinal adenopathy
● The primary tumor is controlled or controllable
● The patient is a medically appropriate candidate for intervention and pulmonary resection
● Complete resection of all disease appears possible
There is no consensus among thoracic surgical oncologists or sarcoma specialists as to what disease burden
represents an insurmountable obstacle. Some experts consider resection of more than eight pulmonary
nodules to be a futile exercise, whereas other highly experienced referral centers will not uncommonly resect as
many lesions as surgically feasible (eg, >50 nodules) in a young, otherwise healthy individual with no evidence
of disease elsewhere. It is not clear that such an extensive surgical approach provides long-term benefit to
patients, and in our view, resection should be limited to patients with a small number of lesions.
Preoperative staging — The most reliable method for assessing metastatic spread is not settled. The majority
of pulmonary metastases are detected through helical computed tomography (CT) imaging.
Increasingly, integrated fluorodeoxyglucose-positron emission tomography (FDG-PET)/CT is being used for this
purpose, particularly to search for otherwise occult extrathoracic involvement. However, the value over helical
CT alone is debated [12]. There are several different histologic subtypes of soft tissue sarcoma, many of which
are not associated with uptake of the FDG tracer. Furthermore, in general, extrathoracic metastases are rare for
most subtypes (although there are exceptions, see below). Guidelines from the National Comprehensive
Cancer Network (NCCN) do not recommend a PET scan in this setting [13]. At least some data suggest that
PET adds little to diagnostic-quality CT scanning in soft tissue sarcomas of the non-Ewing, non-
rhabdomyosarcoma type [14]. (See "Clinical presentation, histopathology, diagnostic evaluation, and staging of
soft tissue sarcoma", section on 'Evaluation for metastatic disease'.)
However, if a PET scan is performed, suspicious positive areas outside of the thorax should be evaluated prior
to surgery, due to the possibility of false-positive findings. Confirmation of disease outside of the chest
precludes pulmonary metastasectomy, although this tenet is being challenged [11]. This subject is discussed in
detail elsewhere. (See "Surgical resection of pulmonary metastases: Outcomes by histology" and "Surgical
resection of pulmonary metastases: Benefits, indications, preoperative evaluation, and techniques".)
Chest CT alone is considered the standard staging method at many institutions. Thin-section, high-resolution
helical CT is preferred over conventional CT in order to maximize detection of all sites of intrathoracic disease.
The presence of bulky mediastinal or hilar nodal disease on CT (which is a rare finding) is considered by most
to represent a contraindication to attempted resection. (See "Surgical resection of pulmonary metastases:
Outcomes by histology" and "Surgical resection of pulmonary metastases: Benefits, indications, preoperative
evaluation, and techniques".)
In addition to chest CT, abdomen and pelvic CT is often recommended for patients with myxoid/round cell
liposarcoma, epithelioid sarcoma, angiosarcoma, leiomyosarcoma, and sarcomas arising within the abdomen
or retroperitoneum to evaluate for intraabdominal and/or retroperitoneal metastases. Spine magnetic resonance
imaging (MRI) may also be indicated for round cell and myxoid/round cell liposarcomas, which have a
propensity to metastasize to the spine and paraspinous soft tissues.
Intraoperative staging and resection technique — Many thoracic surgeons begin the surgical procedure with
mediastinoscopy despite the low likelihood of nodal metastases with soft tissue sarcomas (10 percent in one
series [15]). Lymph node dissection provides information on staging and prognosis, but there is no evidence
that this has any clinical impact. Although prognosis is worse compared with no lymph node involvement, the
discovery of clinically occult hilar or mediastinal lymph node metastases generally does not change the medical
management of these lesions. (See "Surgical resection of pulmonary metastases: Outcomes by histology" and
"Surgical resection of pulmonary metastases: Benefits, indications, preoperative evaluation, and techniques".)
Thoracotomy with wedge resection is the standard procedure for resection; lobectomy or pneumonectomy is
rarely necessary. Good results have been obtained with less invasive procedures such as video-assisted
thoracoscopy (VATS) [16]. Although the VATS procedure is oncologically safe and associated with shorter
recovery times, one disadvantage is that the surgeon cannot palpate the entire lung in order to discover
radiographically occult ipsilateral metastases (table 1). (See "Surgical resection of pulmonary metastases:
Considering the greater likelihood of leaving behind undetected tumor with VATS as compared with open
thoracotomy, the question of whether VATS should be utilized revolves around the natural history of metastatic
disease not detected by preoperative CT scan. Some consider thoracoscopic resection to be a valid approach
only for patients with a solitary pulmonary nodule because they have a low likelihood of harboring clinically
occult metastases. On the other hand, proponents of VATS argue that initially unresected metastases may be
resected once they become detectable on surveillance CT scans, without adversely impacting survival [16].
(See "Surgical resection of pulmonary metastases: Outcomes by histology" and "Surgical resection of
pulmonary metastases: Benefits, indications, preoperative evaluation, and techniques".)
There are no randomized trials addressing this issue. The available retrospective data suggest that patients do
at least as well after VATS as after thoracotomy and imply that there is little, if any, clinical significance to
skipped nodules. However, because these favorable outcomes from VATS were obtained predominantly in
populations with a limited disease extent, many surgeons restrict VATS to patients with a single or very few
pulmonary metastases in the lung periphery. For patients with a limited number of bilateral peripheral lung
nodules, staged bilateral VATS procedures may be feasible. (See "Surgical resection of pulmonary metastases:
Outcomes — Several reports have summarized the outcomes of soft tissue sarcoma pulmonary
metastasectomy from individual institutions and have defined the relevant prognostic factors [7,11,17-22]. The
following illustrates the range of findings from the largest series:
● In a single-institution series of 539 patients undergoing 760 therapeutic-intent pulmonary

metastasectomies for metastatic soft tissue sarcoma, the median survival was 33 months and the five-year
survival was 34 percent [7]. After an R0 pulmonary resection, 74 percent developed a disease recurrence
at any site, 63 percent experienced a lung recurrence, and 34 percent had a recurrence that was lung
isolated. In multivariate analysis, leiomyosarcoma subtype, primary tumor size ≤10 cm, greater time
between primary resection and development of metastases, solitary lung metastases, and minimally
invasive resection were all associated with a lower risk of death.
● The European Organisation for Research and Treatment of Cancer (EORTC) Soft Tissue and Bone
Sarcoma Group conducted a multi-institutional retrospective study of 255 patients who underwent
pulmonary metastasectomy for soft tissue sarcoma [18]. The three- and five-year overall survival rates
following metastasectomy were 54 and 38 percent, and the corresponding disease-free survival rates were
42 and 35 percent, respectively. Favorable prognostic factors included a disease-free interval greater than
2.5 years, microscopically free resection margins, and histologic grade 1 or 2 primary tumors. (See
"Clinical presentation, histopathology, diagnostic evaluation, and staging of soft tissue sarcoma", section on
'Introduction'.)
● In a review of 274 consecutive patients treated at a single institution, the five-year overall survival following
pulmonary metastasectomy was approximately 40 percent [17]. Three unfavorable risk factors were
identified: metastasis size >2 cm, more than one pulmonary metastasis, and a metastasis-free interval of
18 months or less. Patients with none of these risk factors had a 60 percent five-year survival; the
corresponding rates for those with one, two, or three of these factors were 30, 20, and 0 percent,
respectively.
● Long-term outcomes may be less favorable for patients who present with synchronous pulmonary
metastases [21,23,24].
In the absence of a randomized trial, it is impossible to know whether these results simply reflect careful patient
selection and favorable biology (good performance status and relatively indolent disease progression over time
following the discovery of pulmonary metastases) rather than a specific benefit of surgery. However, most lung
metastases in soft tissue sarcoma derive from high-grade rather than low-grade histologic subtypes, and the
clinical behavior of high-grade sarcomas is generally not indolent. The likelihood of patients with metastatic
high-grade soft tissue sarcoma surviving five years with no specific therapy is exceedingly low (probably less
than 5 percent).
There are no data upon which to base a comparison of outcomes in patients treated with surgery versus
systemic chemotherapy alone. Many of the surgical series were published at a time when chemotherapy for
soft tissue sarcoma was suboptimal [6]. Whether the results are still valid in patients treated with modern,
histology-based chemotherapy is unknown. However, even with the advances in systemic therapy that have
occurred over the last 20 years, the likelihood of five-year survival among patients with metastatic high-grade
soft tissue sarcoma is still exceedingly low, probably less than 5 percent.
Despite these uncertainties, it is unlikely that clinicians or patients would ever consider a randomized
prospective clinical trial (of surgery versus best supportive care or chemotherapy alone) feasible in order to test
these hypotheses. Therefore, despite the lack of randomized controlled trials, the retrospective data represent
the best available evidence supporting the benefit of surgery as a treatment option for patients with isolated or
limited potentially resectable pulmonary metastases.
Adjuvant chemotherapy — Patients with completely resected pulmonary metastases are often referred to
medical oncologists to discuss the risks, potential benefits, and uncertainties of postresection chemotherapy.
The efficacy of postmetastasectomy adjuvant chemotherapy for soft tissue sarcomas is unproven; there are no
randomized controlled trials. Some retrospective reviews suggest a better outcome with postoperative adjuvant
chemotherapy [25], while others do not [6,26]. The biases inherent in such retrospective reports preclude
drawing any definitive conclusions regarding whether there is any benefit from such chemotherapy.
As a result, the benefit of chemotherapy and its use in this setting remain a matter of clinical judgment weighing
a variety of patient-specific variables, such as age, comorbidity, patient preferences, and risk profile, as well as
the specific histopathologic subtype of the sarcoma involved and the expected chemosensitivity of the disease.
As an example, the rare adult who presents with distant metastases from a primary rhabdomyosarcoma may
benefit from postresection combination chemotherapy with or without radiation therapy [27]. (See
"Rhabdomyosarcoma in childhood, adolescence, and adulthood: Treatment".)
On the other hand, for the more common types of adult soft tissue sarcoma, the role of adjuvant chemotherapy
after resection of metastatic disease remains much more uncertain and cannot be routinely recommended.
Guidelines from the NCCN do not make a specific recommendation in this regard but, instead, suggest
resection of pulmonary metastases "with or without chemotherapy" [13]. Of note, the administration of adjuvant
chemotherapy following resection of earlier-stage localized disease is also controversial and is not supported
by high-quality evidence. (See "Adjuvant and neoadjuvant chemotherapy for soft tissue sarcoma of the
extremities".)
Neoadjuvant chemotherapy — There are theoretical advantages to neoadjuvant chemotherapy (ie,

chemotherapy administered prior to surgical resection of pulmonary metastases). While there are no data to
support a survival benefit from induction chemotherapy as compared with surgery alone, one of the benefits of
initial chemotherapy is the ability to assess the efficacy of the specific regimen through evaluation of
posttreatment radiographs and the resection specimen. If administration of chemotherapy resulted in a
significant response with a high level of tumor necrosis, this might prompt consideration of additional courses of
postoperative chemotherapy, if the patient's medical condition can tolerate it. However, there are no data that
provide prospective validation of the selective benefit of postoperative chemotherapy in this setting.
Perhaps more importantly, patients who rapidly develop extrapulmonary metastases or new lesions in other
lung lobes during induction chemotherapy may be spared the morbidity of unnecessary surgery. An alternative
strategy is to withhold chemotherapy and simply delay the surgery for six to eight weeks in order to evaluate the
natural history of untreated disease through repeat radiographic evaluation.
The use of neoadjuvant chemotherapy prior to resection of pulmonary metastases is not a widespread practice,
and the decision to pursue this strategy must be made on a case-by-case basis or in the context of a clinical
trial. For most adult-type soft tissue sarcomas, if there are concerns as to the natural history of newly diagnosed
untreated metastatic disease, an alternative option is radiographic reassessment of disease status after an
interval of six to eight weeks to allow the disease biology to declare itself and to spare patients with aggressive
disease unnecessary surgery. The choice of approach may vary significantly depending upon the histologic
subtype and grade of the sarcoma and the symptomatology and performance status of the patient. (See
"Surgical resection of pulmonary metastases: Outcomes by histology" and "Surgical resection of pulmonary
metastases: Benefits, indications, preoperative evaluation, and techniques".)
Second metastasectomy — Despite a potentially curative operation, the majority of patients undergoing
pulmonary metastasectomy will suffer a disease relapse. A subset of these patients may be considered for
repeat surgical intervention as long as extrathoracic metastatic disease is absent. (See "Surgical resection of
pulmonary metastases: Outcomes by histology" and "Surgical resection of pulmonary metastases: Benefits,
indications, preoperative evaluation, and techniques".)
The success of this approach in metastatic soft tissue sarcoma is illustrated by the following uncontrolled
reports [28-30]:
● In a report of 43 patients treated at the National Cancer Institute, 72 percent could be rendered free of
disease at the second thoracotomy, and the median survival for resectable compared with unresectable
patients was 25 versus 10 months [28]. This type of analysis is prone to several sources of bias since the
patients who had reresection might not have been directly comparable with those who did not in terms of
disease burden or extent, and performance status. Therefore, it cannot be assumed that the resection
procedure itself necessarily improved the outcomes.
● In a series of 86 patients undergoing reoperation for recurrence of pulmonary metastases, the median
disease-specific survival was 43 months and the estimated five-year survival was 36 percent [30].
Prognostic factors for a more favorable outcome included the ability to achieve clear margins, one or two
versus three or more nodules, the largest size of metastases ≤2 cm, and low-grade rather than high-grade
primary tumor histology.
● The relationship between disease extent at the time of recurrence and outcomes was further shown in a
series of 39 patients from MD Anderson Cancer Center who underwent reoperation for a second
pulmonary metastasis after an initial successful metastasectomy [29]. The median survival for the 19
patients who had complete resection of a single recurrent focus of metastatic disease was 65 months,
compared with 14 months for the 15 patients who had complete resection of two or more sites of recurrent
disease.
HEPATIC METASTASES — Isolated hepatic metastases may also be amenable to potentially curative
resection, although there are less available data than with pulmonary metastasectomy [31-35]:
● The largest series included 66 patients undergoing hepatic resection and/or open radiofrequency ablation
(RFA) for metastatic sarcoma at MD Anderson Cancer Center between 1996 and 2005 [34]. The histology
was predominantly gastrointestinal stromal tumors (GISTs; n = 36), but there were 18 leiomyosarcomas
and 12 cases of soft tissue sarcoma not otherwise specified. Treatment consisted of resection alone in 35,
resection plus RFA in 18, and RFA alone in 13. The majority of patients (n = 52) received some form of
systemic therapy prior to and following local therapy.
At a median follow-up of 36 months, 22 remained disease free. The overall one-, three-, and five-year
survival rates were 91, 65, and 27 percent, respectively. The median survival of the patients with GIST who
were treated with imatinib was significantly better than that of all the other patients, regardless of histologic
subtype or chemotherapy treatment (median survival not reached versus 37.1 months). In this latter group,
there were no survivors beyond 58 months. (See "Epidemiology, classification, clinical presentation,
prognostic features, and diagnostic work-up of gastrointestinal stromal tumors (GIST)".)
Given the highly responsive nature of GISTs to therapy with tyrosine kinase inhibitors such as imatinib, the
inclusion of a large number of these patients will skew the results towards favorable long-term outcomes.
(See "Tyrosine kinase inhibitor therapy for advanced gastrointestinal stromal tumors".)
● In a series of 11 patients undergoing hepatic resection for isolated metastases from leiomyosarcoma
originating in either the retroperitoneum or gastrointestinal tract, the median survival was 39 months [32].
Five of six patients undergoing complete resection were alive with a median follow-up of 53 months.
OTHER THERAPEUTIC OPTIONS — There are some situations in which surgery is not a viable option (eg,
due to patient comorbidities) but there is still the desire to treat a local site of tumor progression. In settings
such as these, local interventional therapies are increasingly being used. These include ablation with
radiofrequency ablation [34,36], cryoablation [37], and focal radiation techniques such as stereotactic body
radiation therapy [38-41]. In addition, for liver metastases, other interventional techniques include hepatic
arterial embolization, with or without chemotherapy, and radioembolization.
These techniques may control a single focus of disease that is progressing while other sites of disease
involvement are stable or responding to therapy. However, none of these forms of local therapy has been
proven to improve patient survival. Nonsurgical local ablative techniques and stereotactic radiation therapy for
the treatment of liver metastases, as well as radiofrequency ablation, stereotactic radiation therapy, and
cryoablation approaches for treatment of lung lesions, are discussed in more detail elsewhere. (See "Image-
guided ablation of lung tumors" and "Stereotactic body radiation therapy for lung tumors", section on 'Lung
metastases'.)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and
"Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade
reading level, and they answer the four or five key questions a patient might have about a given condition.
These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles
are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and
are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these
topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on
"patient info" and the keyword(s) of interest.)
● Basics topics (see "Patient education: Soft tissue sarcoma (The Basics)")
SUMMARY AND RECOMMENDATIONS — Soft tissue sarcomas are a heterogeneous group of rare tumors
arising from mesenchymal cells at all body sites. For the majority of patients, treatment of metastatic disease is
palliative and consists of systemic therapy. (See "Systemic treatment of metastatic soft tissue sarcoma".)
However, surgical resection of oligometastatic disease can provide long-term relapse-free survival and the
potential for cure in selected patients, the majority of whom have isolated pulmonary metastases. (See
'Introduction' above.)
Pulmonary metastasectomy — For appropriately selected patients with isolated, limited pulmonary
metastases from soft tissue sarcoma, we suggest pulmonary metastasectomy rather than palliative systemic
chemotherapy alone (Grade 2B). There is no consensus as to the optimal selection of surgical candidates;
however, the following criteria are generally agreed upon [8] (see 'Criteria for resection' above):
● No extrathoracic disease, pleural effusion, or mediastinal/hilar adenopathy
● The primary tumor is controlled or controllable
● The patient is a medically appropriate candidate for thoracotomy and pulmonary resection
● Complete resection appears feasible
There is also no consensus among thoracic surgical oncologists or sarcoma specialists as to what disease
burden represents an insurmountable obstacle, and this must be decided on a case-by-case basis. In our view,
outcomes are best when resection is limited to patients with a small number of pulmonary lesions and at least a
12- to 18-month metastasis-free interval.
Issues related to surgical technique and preoperative as well as intraoperative evaluation are discussed
elsewhere. (See "Surgical resection of pulmonary metastases: Benefits, indications, preoperative evaluation,
and techniques", section on 'Surgery'.)
There is no evidence to support a survival benefit from adjuvant chemotherapy following complete pulmonary
metastasectomy for patients with metastatic soft tissue sarcoma, and we suggest not pursuing this approach
outside of the context of a clinical trial (Grade 2C). An exception to this general rule is rhabdomyosarcoma, for
which multimodality treatment is a standard approach and the role of surgery for metastatic disease is less
clear. (See 'Adjuvant chemotherapy' above and "Rhabdomyosarcoma in childhood, adolescence, and
adulthood: Treatment".)
For most patients, we do not suggest the administration of neoadjuvant chemotherapy prior to resection of
pulmonary metastases (Grade 2C), although for certain chemosensitive subtypes of sarcoma, this approach
may be reasonable, with the goal of gaining a sense of the pace of change of disease and the responsiveness
to systemic therapy. If there are concerns as to the natural history of newly diagnosed untreated metastatic
disease, another option is to reevaluate disease status radiographically after an interval of six to eight weeks.
(See 'Neoadjuvant chemotherapy' above.)
For patients who develop a recurrence of pulmonary metastatic disease, repeat pulmonary resection is
reasonable, providing extrathoracic metastatic disease is absent. The decision to pursue a second
metastasectomy depends upon the disease-free interval, the extent of metastatic spread, and an evaluation of
the available systemic therapies that may be relevant to the specific histologic subtype.
Hepatic metastasectomy — Although far less data are available, isolated hepatic metastases may be
amenable to resection. There is no consensus as to appropriate eligibility requirements, and the decision to
operate must be made on a case-by-case basis. In addition, as with pulmonary lesions, it is critical to consider
the underlying histology of the tumor, the expected natural history, and the expected responsiveness to
systemic therapy when considering surgery as a component of the treatment plan for metastatic disease. (See
'Hepatic metastases' above.)
Other local treatment options — Other local interventional options for limited sites of metastatic disease
include radiofrequency ablation, cryoablation, image-guided radiation therapy, and for liver metastases, hepatic
arterial embolization, with or without chemotherapy, and radioembolization. The role of all of these therapies
compared with surgery or chemotherapy remains to be defined. (See 'Other therapeutic options' above.)
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12/18/2018 Surgical treatment and other localized therapy for metastatic soft tissue sarcoma - UpToDate

PULMONARY METASTASES — Complete pulmonary metastasectomy is feasible in approximately one-third of

● The primary tumor is controlled or controllable

● Complete resection of all disease appears possible

● In a single-institution series of 539 patients undergoing 760 therapeutic-intent pulmonary

Neoadjuvant chemotherapy — There are theoretical advantages to neoadjuvant chemotherapy (ie,

● No extrathoracic disease, pleural effusion, or mediastinal/hilar adenopathy

● The primary tumor is controlled or controllable

● Complete resection appears feasible

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