The risk of local recurrence with surgery alone in extremity soft tissue sarcoma is substantial, ranging from about 40% to 90% after marginal excision and 25% to 30% after wide excision, but adding radiation reduces recurrence to under 10%.

NCI randomized trials show that limb-sparing surgery combined with radiation achieves local control in the 85% to 90% range, and adjuvant radiation lowers local recurrence to roughly 0% to 4% versus 19% to 33% with surgery alone.

The speaker notes that, in his experience, no patient has requested an amputation for functional reasons.

ASTRO guidelines now favor preoperative radiation for most deep extremity tumors, aiming to balance recurrence risk with concerns about wound healing and fibrosis.

Historically more than half of extremity soft tissue sarcomas were treated with amputation in the 1970s, whereas current practice achieves limb preservation in about 95% of cases.

Decades of trial data show how radiation timing, dose, and patient selection affect local control and long-term limb function, with ongoing trials potentially reshaping practice.

Limb-sparing radiotherapy plus surgery now preserves limbs in the vast majority of patients with extremity soft-tissue sarcoma, according to ASTRO presentations.

Most patients will undergo both surgery and radiation, while surgery alone remains appropriate for selected small, superficial, low-grade tumors that have been widely resected.

A Canadian trial found preoperative radiation leads to higher wound complication rates (about 35%) compared with postoperative radiation (about 17%), though postoperative radiation involves larger fields and higher doses with risks of fibrosis, joint stiffness, and edema.

Local recurrence correlates with distant metastases and roughly triples the risk of death from sarcoma in high-grade disease, underscoring the critical importance of effective local control.