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This publication is provided for historical reference only and the information may be out of date.

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46Limb-Sparing Treatment of Adult Soft-Tissue Sarcomas and Osteosarcomas

National Institutes of Health Consensus Development Conference Statement, December 3-5, 1984

Introduction and Conclusions

Introduction

Soft-tissue sarcomas and osteosarcomas are relatively rare tumors that represent less than 2 percent of all new cancer cases occurring each year in the United States. The number of new soft-tissue sarcomas and malignant bone tumors diagnosed yearly is 4,800 and 1,900, respectively, according to American Cancer Society estimates. Clinical advances in the treatment of these tumors have been hampered by the difficulty of accruing adequate numbers of patients in valid prospective therapeutic trials.

Surgical resection has always had a major role in the treatment of the primary lesion in adult patients with either soft-tissue sarcoma or osteosarcoma of the extremities. Amputation of an extremity has been a relatively frequent choice of resection for soft-tissue sarcomas in the past because of high local treatment failure rates when wide surgical margins could not be achieved by a limb-sparing resection as the only treatment. For osteosarcomas in the extremities of both young and older adults, amputation has been the mainstay of treatment of the primary extremity lesion in most patients. The recognition of the possible role of radiation therapy and/or regional or systemic chemotherapy in the treatment of both soft-tissue sarcomas and osteosarcomas has raised many questions regarding the preoperative evaluation, extent of surgical resection required when these modalities are employed, the results of this treatment in comparison to amputation, and the optimal treatment strategy.

In an effort to resolve some of the questions surrounding these issues, the National Institutes of Health convened a
Consensus Development Conference on Limb-Sparing Treatment of Adult Soft-Tissue Sarcomas and Osteosarcomas on December 3-5, 1984. During a day and a half, presentations were made by experts in the field who reported their experience with the management of over 2,000 patients with high-grade extremity sarcomas. A consensus panel drawn from the medical and allied health professions considered the evidence and agreed on answers to the following key questions:

  • What is the optimal pretreatment evaluation of the high-grade sarcoma patient regarding diagnosis, extent of disease workup, and staging?
  • Are there types of patients for whom limb-sparing treatment should be considered appropriate therapy?
  • If so, what is the optimal limb-sparing treatment strategy? Consider the following: indications and contraindications, extent of surgical resection, need for and form of radiation therapy and/or chemotherapy, treatment morbidity and function of the limb, and end results.
  • Are there types of extremity sarcoma patients for whom adjuvant chemotherapy is indicated?
  • What directions should be taken for future research on the treatment of extremity sarcomas?

It should be stressed that the panel considered only issues related to high-grade soft-tissue sarcomas and osteosarcomas since low-grade sarcomas do not pose the major problems addressed in this conference.

Panel's Conclusions

High-grade extremity sarcomas are life-threatening or potentially disabling neoplasms that require aggressive management by an experienced multidisciplinary team. Data reviewed from recent clinical experience have shown the feasibility and appropriateness of limb-sparing treatment for a significant proportion of these patients. The concepts of limb-sparing treatment for some of these sarcoma patients is a clearly established treatment option, but questions remain regarding optimal therapeutic strategies.

What Is the Optimal Pretreatment Evaluation of the Sarcoma Patient Regarding Diagnosis, Extent of Disease Workup, and Staging?

Diagnosis and Pretreatment Evaluation of Soft-Tissue Sarcoma and Osteosarcoma

Soft-Tissue Sarcoma

Diagnosis is established by a biopsy, following identification of a mass. The biopsy site should be located and oriented so as to be incorporated into the subsequent definitive excision with the least sacrifice of normal tissue. The biopsy should be adequate to allow full histologic evaluation. In some instances, this will require the use of special techniques such as electron microscopy or immunohistochemistry.

The dimensions of the primary disease and regional extensions can best be determined in extremity sarcomas by contrast-enhanced CT scan. Supplemental arteriography in certain cases may better define the exact relationship of the primary sarcoma to the vascular system. If the tumor is located in proximity to bone, conventional radiographs are required; when questionable bone involvement is present, radionuclide bone scan may be useful. A chest X-ray must be taken to evaluate metastatic disease, and a CT scan or tomograms of the lungs are recommended in the face of a negative chest X-ray.

Osteosarcoma

Presumptive diagnosis of bone sarcoma is generally made by conventional diagnostic imaging, usually radiographs. The minimum criteria for pretreatment evaluation should include biplanar conventional X-rays of the local lesion and a radionuclide bone scan to evaluate the possibilities of multicentric and/or metastatic disease as well as the extent of the disease within the involved bone. Prior to definitive surgical treatment, a CT scan of the involved limb should be obtained to evaluate both intraosseous and extraosseous extent of disease. The use of contrast media in association with the CT scan is helpful in delineating the extent of the disease relative to the vascular system, and this may be supplemented by an arteriogram when indicated. Conventional PA and lateral chest radiographs and a CT scan of the chest (or tomograms of the lungs) to increase screening sensitivity are considered necessary.

A histologic diagnosis is considered essential prior to treatment planning. Depending on the location of the tumor, and the expertise of the available pathologist, either an open or a needle biopsy should be performed. The biopsy technique itself is critical to a successful outcome, and the same considerations expressed for soft-tissue sarcoma apply here. There are certain sarcomas of bone that should be treated with a one-stage excisional biopsy, specifically the juxtacortical (parasteal) osteosarcoma, where the radiographic characteristics should define the extent of the tumor prior to surgical intervention.

Staging Systems

Staging is necessary to plan appropriate treatment, provide a prognosis, and allow comparison of varying therapeutic strategies. Histologic grading of the tumor is an integral part of all staging systems for sarcomas. The criteria for histologic grading in soft-tissue tumors have not been well defined, or generally accepted, and vary based on a number of determinants such as histologic subtype, frequency of mitosis, and degree of necrosis. Recent reports from two separate laboratories suggest that the combination of histologic type and degree of tumor necrosis in soft-tissue sarcomas can predict metastatic potential. In contrast, bone sarcomas are graded on their histologic and radiographic appearance.

In addition to grading, the extent of local and/or distant disease must be included to provide some correlation with treatment choice and prognosis. Currently, the staging systems endorsed by the American Joint Committee (AJC) and the Musculoskeletal Tumor Society assign varying degrees of significance to these determinants. The AJC staging system assigns three histologic grades to the tumor, which dictate the stage of disease in nonmetastatic cases, with modifiers for each histologic grade based on tumor size. The Musculoskeletal Tumor Society grading system assigns only two histologic grades and modifies these based on anatomic location of the tumor. Neither of these systems is without drawbacks, yet both have positive correlations with survival. Until a unified staging system can be developed, results of therapy for these tumors, including limb-sparing surgery, should be reported in terms of both systems.

Are There Types of Patients for Whom Limb-Sparing Treatment Should Be Considered Appropriate Therapy?

Yes. Multiple studies reported from major medical centers have shown that control of disease in both highgrade soft-tissue sarcomas and osteosarcomas can be achieved with surgical resection less than amputation in a significant proportion of patients. Some patients, previously requiring amputation, can now undergo limb-sparing operative procedures without jeopardizing the end result in terms of either local or distant disease control. These results often have been associated with the concomitant use of radiation therapy and/or regional chemotherapy. This general approach is clearly appropriate at the present time for a significant proportion of carefully selected adult patients with high-grade soft-tissue sarcomas and osteosarcomas, when treated at facilities that possess the required technology and expertise. However, the optimal use of multimodal therapy is not yet established for patients with high-grade extremity sarcomas.

If So, What Is the Optimal Limb-Sparing Treatment Strategy? Consider the Following: Indications and Contraindications, Extent of Surgical Resection, Need for and Form of Radiation Therapy and/or Chemotherapy, Treatment Morbidity and Function of the Limb, and End Results?

Indications and Contraindications

Limb-sparing surgery is a procedure that removes a soft-tissue or bone sarcoma while preserving the extremity with a satisfactory functional and cosmetic result. All of the investigators reported to the panel that limb-sparing surgery is the preferred approach in the management of patients with high-grade soft-tissue sarcomas when local disease can be completely resected. Because of the risk of local recurrence, other therapeutic modalities may be used in conjunction with surgery, such as 1) preoperative radiation therapy, 2) preoperative chemotherapy, 3) postoperative radiation therapy, 4) postoperative chemotherapy, or combinations of these adjuvant treatments.

There are situations when limb-sparing surgery for soft-tissue sarcoma may not be indicated. These include the following:

  • Lesions of the extremities in which it is impossible to achieve adequate surgical margins and when radiotherapy cannot be added without risk of major radiation therapy complications.
  • Primary lesions that involve major vessels and nerves, either at the proximal extremity or in a site that will critically compromise function.

For patients with osteosarcoma, potential candidates for limb-sparing must have tumors in an anatomical location that will allow complete resection with clear surgical margins. Reconstruction following resection should provide limb function that is equal to or superior to the function of a prosthetic device. Reasonable expectation for weight bearing in the lower extremities and functional use of the hand after surgery are prerequisites for limb-sparing surgery. Some patients who did not initially fulfill the above criteria have become suitable candidates for limb-sparing surgery following preoperative chemotherapy.

Limb-sparing surgery for osteosarcoma is contraindicated when the extent of a tumor is such that a clear surgical margin cannot be achieved and still allow a functional limb; in such situations, amputation is indicated. In some centers, this determination is made at the time of initial presentation, while other groups evaluate lesions after one or more cycles of chemotherapy. Metastatic disease is not necessarily a contraindication for limb-sparing surgery.

Children under the age of 10 years with osteosarcoma and anticipated growth remaining in the unaffected limb are generally considered for amputation. With limb-sparing surgery, they would have a limb length discrepancy inadequate for function when resection of the tumor includes the growth plates in the involved extremity.

Extent of Surgical Resection

The extent of surgical resection for limb-sparing surgery in soft-tissue sarcoma requires a microscopic-free margin for optimum control of disease. Surgical resections may vary from radical compartment removal to marginal excision, depending on the location and size of the tumor, age of the patient, and stage of disease. Limited resection margins dictate the need for regional radiotherapy. Apposition of the sarcoma to periosteum or neurovascular structures does not necessarily eliminate the possibility of a limb-sparing procedure, providing reasonable limb function can be achieved by reconstructive alternatives that will be required following adequate resection.

For osteosarcomas, it is generally accepted that en bloc resection of tissue should yield a clear surgical margin. All dissection should be performed in normal tissue outside the reactive zone of the tumor; however, the margin of normal bone resected proximal or distal to the tumor has not been clearly defined, nor is there uniformity of opinion relative to the need for extra-articular resection in metaphyseal lesions.

Reconstructive alternatives following resection include a variety of complex procedures. Soft-tissue reconstruction in certain anatomic locations is acceptable, while some mechanical correction is required when stability is essential for function. The choice available for replacing bone and/or joints include internal prosthetic devices, allografts, and arthrodesis. The selection of the optimum methods of reconstruction are currently under evaluation in several centers.

Need for and Form of Radiation Therapy and/or Chemotherapy

Soft-Tissue Sarcomas

In some centers, regional (intra-arterial) chemotherapy in combination with radiation therapy and surgery has been used in limb-sparing treatment of soft-tissue sarcomas. The results of this approach have not been established as superior to other multimodality approaches.

In many cases, radiation therapy plays an integral role in the limb-sparing treatment of soft-tissue sarcomas. Various centers have employed radiation preoperatively while others have used postoperative therapy; to date, there is no evidence to suggest an advantage of one treatment approach over the other, and both are considered acceptable. Preoperative radiation therapy may allow for limb-sparing treatment of marginally resectable or large tumors that otherwise would have required amputation.

The volume of the extremity that requires radiation is controversial. Some centers favor treatment of the tumor bed with wide margins, while others feel that the entire muscle compartment should be irradiated. Most experts feel that special attention must be paid to the following areas:

  • Shrinking fields should be employed to limit the highest dose of radiation to the area of greatest risk for tumor persistence, and surgical clips placed at the time of resection facilitate accurate definition of this area.
  • A longitudinal strip of normal tissue along the limb must be spared to minimize radiation-induced edema.
  • Precise immobilization and shaped fields are important to ensure reproducible treatment and optimal results.
  • Most radiation oncologists deliver doses of 5,500 to 6,500 cGy over a period of 5 1/2 to 7 weeks.

Osteosarcoma

Virtually all centers treating osteosarcoma with limb-sparing surgery employ some form of adjuvant chemotherapy. Clinical trials combining limb-sparing surgery plus intra-arterial and/or intravenous chemotherapy have shown comparable survival rates compared to trials employing amputation plus chemotherapy. To date, there are no studies suggesting o superiority of intra-arterial over intravenous chemotherapy, and both are acceptable.

One institution also employed low doses of radiation therapy immediately following intra-arterial chemotherapy. It remains to be proved whether this radiation therapy has a beneficial effect.

There is evidence to suggest that some form of adjuvant treatment is beneficial in limb-sparing treatment of osteosarcoma. Local recurrence appears to be reduced when adjuvant therapy is added before or after operation. In addition, the majority of patients who received preoperative regional chemotherapy with or without radiation had greater than 90 percent tumor necrosis in the surgical specimen.

Treatment Morbidity and Function of the Limb

Patients who undergo limb-sparing surgery for either soft-tissue sarcoma or osteosarcoma may experience early and late complications. For both, the primary surgery may be complicated by serious wound healing problems, infection, pathological fracture, and necrosis. Occasionally, these problems require further resection or subsequent amputation. The incidence of these complications may be reduced with refined surgical and radiation therapy techniques and appropriate rehabilitation.

In osteosarcoma, if the initial surgery is followed by or includes reconstruction with an internal prosthesis, complications may include fracture above or below fixation points, nonunion, or mechanical failure of the prosthesis.

In both groups of patients, ongoing functional concerns include restrictions in range-of-motion, pain, edema, decreased stability, deformity, inadequate strength, and emotional acceptance. In many patients with soft-tissue sarcoma, these limitations appear to interfere minimally with function and lifestyle; however, for others, significant changes may be necessary. Some patients with osteosarcoma require the use of prosthetic and orthotic devices and walking aids to accomplish activities of daily living. However, employment choices, lifestyle, and activity level may have to be altered.

Patients who receive intensive chemotherapy as part of the limb-sparing treatment plan may experience moderate to severe morbidity (e.g., myelosuppression, electrolyte abnormality, cardiomyopathy) and occasional treatment-related mortality. The long-term sequelae of multi-drug chemotherapy are not yet fully known.

Radiation therapy may also be associated with serious long-term morbidity, including, on occasion, severe fibrosis or necrosis and, rarely, radiation-induced secondary malignancy. Radiation directed to the upper thigh in young men will produce low-dose scatter radiation in the testes and has been reported to reduce sperm counts in some patients.

The psychosocial sequelae of limb-sparing treatment may clearly have profound effects on patients and families. Although data are not available, these issues are considered significant.

The management of treatment complications and functional limitations requires the close coordination of the entire health team. This team should include the surgeon, medical oncologist, radiotherapist, primary care physician, rehabilitation staff, nursing staff, social worker, and, most important, the patient and family. The team should address biomedical decisions, psychosocial issues, and all considerations that affect quality of life. Team collaboration and intervention should begin prior to treatment and continue throughout the patient's course.

End Results

For soft-tissue sarcoma, patients undergoing either adequate limb-sparing surgery, often combined with radiation therapy and/or chemotherapy, or amputation show similar disease-free and overall survival. The evidence for this includes a randomized prospective study where patients having limb-sparing surgery plus postoperative radiation therapy and chemotherapy were compared to patients undergoing radical amputation plus chemotherapy.

Disease-free survival and overall survival data for patients with osteosarcoma treated by limb-sparing surgery combined with adjuvant chemotherapy (and radiation in some instances) are similar to those of patients treated with amputation and adjuvant chemotherapy.

Pulmonary metastasis is the most common site of distal treatment failure for these sarcomas and is frequently amenable to surgical resection. For both soft-tissue sarcoma and osteosarcoma, resection of pulmonary metastases may lead to cure in a significant number of such patients if removal of all clinical evidence of metastasis can be accomplished.

Are There Types of Extremity Sarcoma Patients for Whom Adjuvant Systemic Chemotherapy Is Indicated?

The role of adjuvant systemic chemotherapy in the treatment of high-grade soft-tissue sarcoma of extremities remains unsettled. Several studies utilizing adjuvant chemotherapy have failed to demonstrate a therapeutic advantage, whereas one study has shown an increase in disease-free and overall survival. The efficacy of adjuvant systemic chemotherapy for high-grade soft-tissue sarcomas remains to be established within the context of prospective clinical trials.

Adjuvant systemic chemotherapy as a component of treatment for patients with osteosarcoma has been studied extensively over the past decade. Published reports using historical controls indicate a benefit for drug-treated patients. One published prospective trial, which randomized patients to adjuvant chemotherapy or no chemotherapy, indicated no difference in disease-free and overall survival between drug-treated and observed patients. However, both groups of patients demonstrated better results than the other published studies not utilizing adjuvant chemotherapy. These results led to two new prospective randomized trials using intensive multidrug chemotherapy. Both of these studies are showing an advantage in the disease-free survival for the drug-treated patients in analyses that were presented to the panel but are not yet published. Although further followup of these patients is required, the panel is optimistic that adjuvant systemic chemotherapy will ultimately prove beneficial to the well-being and survival of patients with osteosarcoma.

What Directions Should Be Taken for Future Research on the Treatment of Extremity Sarcomas?

As a consequence of this review, several research issues have been identified that would significantly affect our success in the diagnosis and treatment of this group of diseases if progress in these areas was achieved. The panel endorses the following items for future studies:

  • Uniform and reliable staging systems for sarcomas based on correlative prognostic data.
  • Reproducible criteria for grading soft-tissue sarcomas and the development of a review panel of pathologists available for developing a registry.
  • Magnetic resonance imaging (MRI) or other means of improving the pretreatment and followup assessment of patients with sarcomas.
  • MRI and MR spectroscopy or other means of evaluating the effect of preoperative chemotherapy on the tumor, and thereby refining the treatment program.
  • Identification and evaluation of markers (e.g., antigens, monoclonal antibodies) for monitoring tumor response and recurrence.
  • Types of musculoskeletal reconstruction including the appropriate application and relative benefits of prosthesis, arthrodesis, and allografts. Development of more durable prosthetic devices, including those for growing children.
  • Optimal treatment prescriptions for adjuvant therapies (route and scheduling of chemotherapy, biological agents, and radiation therapies), particularly the role of adjuvant chemotherapy for soft-tissue sarcomas.
  • Evaluation of quality-of-life issues for treated sarcoma patients.
  • Identification of etiologic factors for soft-tissue sarcomas and osteosarcomas.


Consensus Development Panel

  • Walter Lawrence, Jr., M.D.
  • Panel Chairman
  • Professor of Surgery and Director
  • Massey Cancer Center
  • Medical College of Virginia
  • Richmond, Virginia
  • Laurence H. Baker, D.O.
  • Professor of Medicine
  • Wayne State University
  • Director, Division of Medical Oncology
  • Comprehensive Cancer Center of Metropolitan Detroit
  • Detroit, Michigan
  • Charles M. Balch, M.D.
  • American Cancer Society Professor of Clinical Oncology
  • Chief of Surgical Oncology
  • University of Alabama in Birmingham
  • Birmingham, Alabama
  • R. L. Scotte Doggett, M.D., F.A.C.R.
  • Radiation Oncologist
  • Radiation Oncology Center of Sutter Community Hospital
  • Sacramento, California
  • Edmund A. Gehan, Ph.D.
  • Biometrician and Professor of Biometrics
  • University of Texas System Cancer Center
  • Houston, Texas
  • Margaret Adams Greenly, C.S.W.
  • Assistant Director Department of Social Work
  • Memorial Sloan-Kettering Cancer Center
  • New York, New York
  • E. Douglas Holyoke, M.D.
  • Chief of Surgery
  • Roswell Park Memorial Institute
  • Buffalo, New York
  • Allen S. Lichter, M.D.
  • Associate Professor and Chairman
  • Department of Radiation Therapy
  • University of Michigan Medical School
  • Ann Arbor, Michigan
  • L. Robert Martin, M.D.
  • Program Director
  • University of Southern California
  • Presbyterian Intercommunity Hospital
  • Family Practice Residency
  • Whittier, California
  • Nicholas L. Petrakis, M.D.
  • Professor and Chairman
  • Department of Epidemiology and International Health
  • University of California, San Francisco School of Medicine
  • San Francisco, California
  • Phyllis K. Teich, M.A., R.P.T.
  • Director of Physical Therapy
  • Downstate Medical Center-Kings County Hospital Center
  • Bayside, New York
  • Roby C. Thompson, Jr., M.D.
  • Professor and Head
  • Department of Orthopaedic Surgery
  • University of Minnesota
  • Minneapolis, Minnesota
  • Richard E. Wilson, M.D.
  • Professor of Surgery
  • Harvard Medical School
  • Chief, Surgical Oncology
  • Brigham and Women's Hospital
  • Dana-Farber Cancer Institute
  • Boston, Massachusetts
  • Stanley H. Winokur, M.D.
  • Medical Oncologist
  • Georgia Oncology Hematology Clinic
  • Atlanta, Georgia

Speakers

  • Karen Antman, M.D.
  • "Adjuvant Doxorubicin for Sarcomas: Data From the Eastern Cooperative Oncology Group and Dana-Farber Cancer Institute/Massachusetts General Hospital Studies"
  • Assistant Professor of Medicine
  • Dana-Farber Cancer Institute Harvard Medical School
  • Boston, Massachusetts
  • Vivien H.C. Bramwell, M.R.C.P.(UK), Ph.D.
  • "The European Experience of Adjuvant Chemotherapy for Soft-tissue Sarcomas: Mayo Clinic Experience"
  • Associate Professor and Consultant
  • London Regional Cancer Centre
  • University of Western Ontario
  • London, Ontario CANADA
  • Murray Brennan, M.D.
  • "Management of Soft-tissue Sarcomas: Memorial Sloan-Kettering Cancer Center Experience"
  • Alfred P. Sloan Professor of Surgery
  • Chief, Bastric and Mixed Tumor Service
  • Memorial Sloan-Kettering Cancer Center
  • New York, New York
  • Professeur Jose Costa
  • "Histological Classification and Grading of Sarcomas"
  • Institut de Pathologie Centre
  • Hospitalier Universitaire Vaudois Lausanne
  • SWITZERLAND
  • Jeffery J. Eckardt, M.D.
  • "The UCLA Experience in the Management of Stage 2B Osteosarcoma"
  • Assistant Professor of Orthopedic Surgery
  • University of California
  • Los Angeles Hospital and Clinics
  • Los Angeles, California
  • John H. Edmonson, M.D.
  • "Systemic Chemotherapy Following Complete Excision of Nonosseous Sarcomas: Mayo Clinic Experience"
  • Consultant in Medical Oncology
  • Associate Professor
  • Mayo Medical School
  • Mayo Clinic
  • Rochester, Minnesota
  • Frederick R. Eilber, M.D.
  • "Limb Salvage for High-grade Sarcomas: UCLA Experience"
  • Professor of Surgery and Oncology
  • University of California Los Angeles School of Medicine
  • Los Angeles, California
  • William F. Enneking, M.D.
  • "Preoperative Evaluation of Soft-tissue Sarcomas"
  • "Limb Salvage in Soft-tissue Sarcomas: Experience at the University of Florida in Gainesville"
  • Distinguished Service Professor and Eugene L. Jewett Professor of Orthopedics
  • Department of Orthopedics
  • University of Florida College of Medicine
  • Gainesville, Florida
  • Eli Glatstein, M.D.
  • "Treatment of High-grade Soft-tissue Sarcomas of the Extremities at the National Cancer Institute"
  • Chief, Radiation Oncology Branch
  • National Cancer Institute
  • National Institutes of Health
  • Bethesda, Maryland
  • Allen M. Goorin, M.D.
  • "The Dana-Farber Cancer Institute/Children's Hospital Adjuvant Chemotherapy Trials for Osteosarcoma"
  • Associate Physician
  • Dana-Farber Cancer Institute and Children's Hospital
  • Instructor in Pediatrics
  • Harvard Medical School
  • Boston, Massachusetts
  • Robert Lindberg, M.D.
  • "Treatment of Localized Soft-tissue Sarcomas in Adults: M.D. Anderson Hospital, 1960 thru 1981"
  • Professor and Chariman Department of Therapeutic Radiology
  • University of Louisville School of Medicine
  • Louisville, Kentucky
  • Michael P. Link, M.D.
  • "The Role of Adjuvant Chemotherapy in the Treatment of Osteosarcoma of the Extremity: Preliminary Results of the Multi-Institutional Osteosarcoma Study"
  • Associate Professor of Pediatrics
  • Stanford University School of Medicine
  • Staff Hematologist and Oncologist
  • Children's Hospital at Stanford
  • Palo Alto, California
  • John A. Murray, M.D.
  • "Limb-salvage Surgery in Osteosarcoma: Experience at M.D. Anderson Hospital and Tumor Institute"
  • Chief of Orthopedic Service
  • M.D. Anderson Hospital and Tumor Institute
  • Houston, Texas
  • Stephen G. Pauker, M.D.
  • "Decision-Theoretical Framework for Considering the Treatment of Extremity Sarcomas"
  • Professor of Medicine
  • Tufts University School of Medicine
  • New England Medical Center
  • Boston, Massachusetts
  • Steven A. Rosenberg, M.D., Ph.D.
  • "Adjuvant Chemotherapy for the Treatment of Extremity Soft-tissue Sarcomas: National Cancer Institute Experience"
  • Chief of Surgery
  • National Cancer Institute
  • National Institutes of Health
  • Bethesda, Maryland
  • Franklin H. Sim, M.D.
  • "Limb-sparing Surgery in Osteosarcoma: Mayo Clinic Experience"
  • Professor of Orthopedic Surgery
  • Mayo Clinic
  • Rochester, Minnesota
  • Herman D. Suit, M.D., D.Phil.
  • "Staging System for Sarcoma of Soft Tissues and Bone Sarcoma"
  • "Results of Treatment of Sarcoma of Soft Tissue by Radiation and Surgery at Massachusetts General Hospital"
  • Professor and Chairman Department of Radiation Therapy
  • Harvard Medical School at Massachusetts General Hospital
  • Boston, Massachusetts

Planning Committee

  • Alfred E. Chang, M.D. (Chairman)
  • Senior Investigator
  • Surgery Branch
  • National Cancer Institute
  • National Institutes of Health
  • Bethesda, Maryland
  • Michael J. Bernstein
  • Director of Communications
  • Office of Medical Applications of Research
  • National Institutes of Health
  • Bethesda, Maryland
  • Joyce Doherty
  • Information Specialist
  • Office of Cancer Communications
  • National Cancer Institute
  • National Institutes of Health
  • Bethesda, Maryland
  • John H. Edmonson, M.D.
  • Consultant in Medical Oncology
  • Associate Professor
  • Mayo Medical School
  • Mayo Clinic
  • Rochester, Minnesota
  • Eli Glatstein, M.D.
  • Chief, Radiation Oncology Branch
  • National Cancer Institute
  • National Institutes of Heath
  • Bethesda, Maryland
  • Itzhak Jacoby, Ph.D.
  • Acting Director
  • Office of Medical Applications of Research
  • National Institutes of Health
  • Bethesda, Maryland
  • Timothy Kinsella, M.D.
  • Senior Investigator
  • Radiation Oncology Branch
  • National Cancer Institute
  • National Institutes of Health
  • Bethesda, Maryland
  • Walter Lawrence, Jr., M.D.
  • Professor of Surgery and Director
  • Massey Cancer Center
  • Medical College of Virginia
  • Richmond, Virginia
  • Martin M. Malawer, M.D.
  • Associate Professor
  • Orthopedic/Oncology, Surgery
  • Children's Hospital National Medical Center
  • George Washington University
  • Medical Center
  • Washington, D.C.
  • Steven A. Rosenberg, M.D., Ph.D.
  • Chief of Surgery
  • Naitonal Cancer Institute
  • National Institutes of Heath
  • Bethesda, Maryland
  • Elliott H. Stonehill, Ph.D.
  • Assistant Director
  • National Cancer Institute
  • National Institutes of Health
  • Bethesda, Maryland
  • Robert C. Young, M.D.
  • Chief, Medicine Branch
  • National Cancer Institute
  • National Institutes of Health
  • Bethesda, Maryland

Sponsors

  • National Cancer Institute
  • Vincent T. DeVita, Jr., M.D.
  • Director
  • Office of Medical Applications of Research, NIH
  • Itzhak Jacoby, Ph.D.
  • Acting Director

This statement was originally published as: Limb-Sparing Treatment of Adult Soft-Tissue Sarcomas and Osteosarcomas. NIH Consens Statement 1984 Dec 3-5; 5(6):1-7.

For making bibliographic reference to the statement in the electronic form displayed here, it is recommended that the following format be used: Limb-Sparing Treatment of Adult Soft-Tissue Sarcomas and Osteosarcomas. NIH Consens Statement Online 1984 Dec 3-5 [cited year month day]; 5(6):1-7.

NIH Consensus Statements are prepared by a nonadvocate, non-Federal panel of experts, based on (1) presentations by investigators working in areas relevant to the consensus questions during a 2-day public session; (2) questions and statements from conference attendees during open discussion periods that are part of the public session; and (3) closed deliberations by the panel during the remainder of the second day and morning of the third. This statement is an independent report of the consensus panel and is not a policy statement of the NIH or the Federal Government.

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