The use of chemotherapy in soft tissue sarcomas is controversial in tumors other than Peripheral neuroectodermal tumors and Rhabdomyosarcomas. The prognosis of other soft tissue sarcomas is poor in high-grade sarcomas and this had prompted the use of chemotherapy in high grade tumors.

Prognosis in soft tissue sarcomas

· High grade 50% 5-year survival

· Low grade 90% 5-year survival

Previous studies had shown certain histological subtypes to respond better than others to chemotherapy.

· Good reaponders: Malignant fibrous histiocytoma and Synovial sarcoma

· Bad responders: Liposarcoma and leiomyosarcoma

Therefore the contraindications to chemotherapy would reasonably be:

· Low grade

· Intermediate grade (<10cm)

· High grade (< 5 cm)

· Localized cutaneous or subcutaneous sarcomas

· Poor histology

· Poor medical health

· 65 years or older

· Advanced disease????

A reasonable consideration for chemothrapy would be:

· Deep, intermediate grade (≥ 10 cm)

· Deep, high grade (≥ 5cm)

· Locally recurrent

· Metastatic

Evidence for chemotherapy in soft tissue sarcomas:

1. Sarcoma meta-analysis collaboration: adjuvant chemotherapy for localized resectable soft-tissue sarcoma of adults: meta-analysis of individual data (Lancet 1997)

· 14 trials of doxorubicin based adjuvant chemotherapy

· Significantly improved time to local and distant recurrence and overall recurrence-free survival

· Improved overally survival in only 4% at 10 years

· However,

· The 14 studies were from the 70’s and 80’s

· Improvements in supportive care including erythropoietin, G-CSF, thrombopietin now allow more aggressive chemotherapeutic regimes

· Many centers have moved to neoadjuvant studies

2. Adjuvant chemotherapy for adult soft tissue sarcomas of the extremitites and girdles: Results of the Italian Randomized cooperative trial (J Clin Oncol 2001)

· Statistically significant improvement in both disease-free and overall survival

· 19% survival benefit at 4 years

3. Neo-adjuvant chemotherapy for primary high-grade extremity soft tissue sarcoma(Ann Oncol2004 )

· 21% survival benefit with ifosfamide based regimes at 3 years