10.1245/ASO.2003.12.001
Annals of Surgical Oncology 10:961-971 (2003)
© 2003 Society of Surgical Oncology
Buttock Soft Tissue Sarcoma: Clinical Features, Treatment, and Prognosis
K.A. Behranwala, MS, FRCS (Ed.), FRCS (Glas.),
P. Barry, FRACS,
R. A’Hern, MSc and
J.M. Thomas, MS, FRCS, FRCP
From the Sarcoma and Melanoma Unit, Royal Marsden National Health Service Trust, London.
Correspondence: Address correspondence and reprint requests to: Kasim Behranwala, MD, Sarcoma and Melanoma Unit, Royal Marsden Hospital, Fulham Road, South Kensington, London SW3 6JJ, UK; Fax: 44-0-20-7808-2673; E-mail: kbehranwala{at}hotmail.com
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ABSTRACT
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Background: Primary buttock soft tissue sarcomas in adults are common entities that have been infrequently reported (three clinical series and isolated case reports). We present our experience of buttock sarcomas to better characterize and define the natural history of this condition.
Methods: Buttock tumors occurring in adults (>16 years) between January 1990 and January 2002 were identified from the Royal Marsden Hospital’s Sarcoma Unit prospective database.
Results: Seventy-three buttock sarcomas were evaluated and treated at the Royal Marsden Hospital during this period. Liposarcoma (n = 19), leiomyosarcoma (n = 13), and synovial sarcoma (n = 9) were the most frequent histological types. There were 8 T1 and 61 T2 tumors, and size was not available in 4 patients. Most tumors (n = 64) were located deep to the deep fascia. There were 15 grade 1, 20 grade 2, and 37 grade 3 tumors, and grade was not available in 1 patient. There were 29 tumors contained within the gluteus maximus. Wide excision was performed in 50 patients. Local recurrence and distant metastasis occurred in 15 and 35 patients with a median time of 18 and 8 months, respectively. The rate of local recurrence at 2 years was 20.9% (SE, 6.8%). The 2-year overall and disease-free survival rates were 64.1% (SE, 6.7%) and 48.5% (SE, 6.4%), respectively.
Conclusions: Buttock sarcomas present special surgical difficulties because of proximity of the sciatic nerve and the ability of tumors at this site to extend into the pelvis and perineum. Size and grade of the tumor were independent predictors for disease-free and overall survival.
Key Words: Buttock • Gluteus maximus • Sarcoma • Prognosis
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INTRODUCTION
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Soft tissue sarcomas of the buttock present the surgeon with specific difficulties because of the proximity to the sciatic nerve, adherence to the sacrum, and a tendency to migrate through the greater sciatic notch to occupy the pelvic sidewall or to involve the perineum by direct extension or through the lesser sciatic notch. They are typically of an extensive nature by the time of diagnosis. With regard to functional considerations, preservation of the sciatic nerve is important whenever possible, as is preservation of one or more glutei to prevent or reduce the Trendelenburg deformity.
Soft-tissue sarcomas are rare, malignant neoplasms that arise from mesenchymal tissues; they account for 1% of all adult malignancies.1 The major prognostic factors regarding sarcomas are size, grade, histological subtype, primary lesion site, and surgical margins. The literature on buttock sarcomas is scarce; most are case reports.2–9 The 5-year survival rates (local recurrence rates) at this site, as reported by Gerson et al.5 and Wanebo et al.,8 are 40% (45%) and 39% (39%), respectively. There was a trend toward limb-conserving radical buttockectomy in the former study, compared with more hemipelvectomies in the latter study. Gerson et al.5 noted that there were fewer sarcomas of small size in the study by Wanebo et al.8 Both of these studies were retrospective. There has been no recent literature on this topic except for the study by Ham et al.2 in 1998. They reported no local recurrence in a series of nine patients treated with buttockectomy and an overall and disease-free 5-year survival of 38% and 25%, respectively. We present our experience of buttock soft tissue sarcomas.
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PATIENTS AND METHODS
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Patients
Patients with buttock soft tissue tumors were identified from the Sarcoma Unit database at the Royal Marsden Hospital. Data have been collected prospectively for all admissions from January 1990 and include demographics, investigations, treatment, and outcomes. Further information was collected from a review of the written hospital records, referral letters, and imaging records.
Pathology
Macroscopic tumor-related factors, including size and depth, were noted. The size of the tumor was recorded from the pathologic specimen or from imaging analysis and was classified as T1 (<5 cm) or T2 (>5 cm). Depth was categorized as superficial or deep relative to the deep fascia. Tumor grade was classified as low, intermediate, or high on the basis of the degree of cellularity, differentiation, and vascularity; nuclear pleomorphism; number of mitoses per high-power field; and amount of stromal necrosis.
Microscopic margins were assessed histologically. Wide excision was defined as a resection in which microscopic margins were negative (tumor >1 mm from the inked margin); marginal resection was defined as a tumor that extended up to the margins of resection (positive microscopic margins). Those who had a marginal excision performed at another hospital and were subsequently found to have no residual tumor on re-excision at our hospital were considered to have had wide excision. Intracapsular excision was defined as one in which macroscopic residual disease was left behind or in which there was a positive gross margin.
Diagnosis and Treatment
Routine staging evaluation included complete physical examination; imaging studies, such as computed tomography (CT) or magnetic resonance imaging, of the locoregional area; and radiological evaluation of the chest. Diagnoses were confirmed by the histological examination of incisional or core biopsy material or re-evaluation of the original excision specimens if these were performed elsewhere. Histological confirmation is essential before embarking on a major surgical procedure or offering adjuvant therapy. Patients deemed resectable and without evident metastases were treated by surgery as the primary modality. Those with marginal excision, high-grade tumors, or both were offered postoperative external beam radiotherapy (RT), 60 Gy, within the limits of normal tissue tolerance in 6 weeks. RT was given with anterior and posterior portals to encompass the origin of the glutei but falling short of the midline. It extended proximally to include the pelvic floor but with an attempt to exclude the bowel. All decisions were discussed at the Sarcoma Unit’s multidisciplinary team meeting.
Follow-Up
Careful surveillance was based on guided history and thorough physical examination. Plain chest radiographs were initially performed every 4 months (for the first 2 years if high grade and otherwise for 1 year) and then yearly. Axial imaging studies (CT or magnetic resonance imaging) for detection of recurrence was not routine but was performed if the patient was symptomatic (pain or mass) or if a clinical examination (mass) was abnormal.
Follow-up data are presented as the time in months from the initial diagnosis. Local recurrence was defined as a tumor being within or contiguous to the previously excised field 
3 months after primary therapy.
Statistical Analysis
Analysis of the effect of prognostic factors on local recurrence, time to metastasis, disease-free survival, and overall survival was undertaken by using Cox’s regression. The aim was to evaluate the relationship of size, grade, histology, and margins of excision to local recurrence, metastasis, and survival. Life-table curves were constructed by using the Kaplan-Meier method; the confidence intervals shown are 95% confidence intervals.
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RESULTS
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Between January 1990 and January 2002, 2678 patients with soft tissue tumors (of which 2286 were sarcomas) were evaluated and treated at the Royal Marsden Hospital. Ninety-two buttock soft tissue tumors (73 malignant and 19 benign) were evaluated and treated at the Royal Marsden Hospital during this period. The buttock was the second most common site, after the thigh, for extremity sarcoma. The distribution of each variable for patients with buttock soft tissue sarcoma is listed in Table 1.
Patients
The median age at presentation was 52 years (range, 16–88 years). The presenting complaints were mass (n = 53), sciatica (n = 13), local pain (n = 6), fungating tumor (n = 3), and foot drop (n = 1). Lymph node involvement was observed in two patients at initial clinical presentation. Specific presenting symptoms were not recorded in five patients. The local pain caused increasing difficulties during walking in a few patients. The patient with foot drop (sciatic nerve destruction) had a loss of power in the hamstrings and a loss of dorsiflexion and plantarflexion. In the patients who complained of sciatica, a few went to osteopaths for massage therapy, one was diagnosed with a disc prolapse, and one had been operated on for concomitant intervertebral disc prolapse. The buttock mass was diagnosed as an abscess and drained in one patient, and in another patient it was discovered accidentally during the course of a routine examination for another problem. Lymph node involvement was clinically observed in another three patients during the course of the disease; one of them had distant metastasis at the time. Radiation-induced buttock sarcoma was observed in two patients after treatment of a testicular tumor. Definitive surgery was performed in nine patients at the referring hospital. The rest were referred after biopsy or suspected diagnosis of soft tissue sarcoma.
Pathology
The histopathologic types of these sarcomas are listed in Table 2. Liposarcoma (n = 19), leiomyosarcoma (n = 13), and synovial sarcoma (n = 9) were the most frequent histological types. The tumors ranged from 2 to 35 cm in diameter (median, 12 cm). Multifocality was observed in two patients (epithelioid sarcoma and leiomyosarcoma).
By depth, there were 9 superficial and 64 deep tumors. Spread to lymph nodes was observed in two patients with epithelioid sarcoma and in one patient each with sarcoma not otherwise specified, synovial sarcoma, and malignant fibrous histiocytoma.
Imaging and Diagnosis
CT helped in determining the exact location of the tumor in all patients. The site of the tumor in relation to the muscles with its variable extension is listed in Table 3. This shows that the buttock is a difficult anatomical site in which to treat soft tissue sarcoma because it allows involvement of different muscle layers with extension. The most common location of the tumor was within the gluteus maximus muscle (n = 29).
After the tumor extended through the greater sciatic notch, it was seen displacing the rectum to varying degrees in four patients. Tumor was seen extending to the perineum and reaching close to the anus and puborectalis sling in four patients. In two patients, the tumor was seen extending between the ischial tuberosity and femur, and in one of them, it was thought to be arising from the quadratus femoris. Direct invasion of bone (sacrum, coccyx, or ilium) was picked up on CT scan in three patients.
Core (trucut) biopsy allowed definitive histological diagnoses in 52 patients. In only one patient was it falsely negative for malignancy (reported as angiomyxoma). Open biopsy was performed in 11 patients, and core biopsy did not yield sufficient material for histological diagnosis in two patients at the referring hospital. Fine-needle aspiration cytology was performed in two patients at the referring hospital, and it was negative in both patients. The mode of diagnosis was not available in five patients.
Treatment
Fifty-seven (78%) patients presented with tumors that were considered resectable. Surgery was performed in six patients after neoadjuvant treatment. Gross margins of resection were negative in all surgically excised sarcomas except in the one patient who had an intracapsular excision. Nine patients did not undergo resection. Palliative treatment was given to eight patients with either distant metastases (n = 4) or extensive unresectable neoplasms (n = 4) at the time of initial presentation. One patient did not undergo surgery because of medical reasons and was offered palliative treatment.
Wide and marginal excision was performed in 50 and 13 patients, respectively. A component of the sciatic nerve was sacrificed, in one patient each, because of invasion of the perineurium and destruction of the nerve. The external sphincter was excised in one patient. Hindquarter amputation was performed in two patients (an anteriorly based flap was used in one patient), with palliative intent in one who had known metastatic disease. Two patients had lymph nodes removed at the time of excision of the primary tumor, and one patient underwent an ilioinguinal node dissection as treatment of the first site of recurrence. Lung metastasectomy was performed in five patients. Local excision of subcutaneous metastasis in patients with myxoid liposarcoma was performed in three patients.
Adjuvant RT was not offered to one patient because of old age and in one patient because of the local extent of the primary tumor. Adjuvant CT was not routinely used at this unit. Neoadjuvant chemotherapy was given to two patients with Ewing’s sarcoma, two patients with synovial sarcoma, and one patient with embryonal rhabdomyosarcoma. Neoadjuvant RT was given to one patient each with rhabdomyosarcoma, Ewing’s sarcoma, sarcoma not otherwise specified, and synovial sarcoma. All these patients had large tumors at presentation. Neoadjuvant therapy helped in obtaining wide excision in five patients and marginal excision in one patient. Chemotherapy was given to 17 patients with metastatic disease.
Recurrence
The rate of local recurrence was 20.9% (SE, 6.8%) at 2 years and 35.4% (SE, 8.3%) at 5 years. Local recurrence was associated with distant metastasis in five patients and followed distant metastases in three patients. The local recurrences were adequately treated with wide local excision in five patients; one of them had bone involvement, and one had multiple recurrences. The nodal recurrence was not treated in one patient at the last follow-up. Distant metastases were observed in 35 patients. The sites of metastasis were lung (n = 29), bone (n = 6), subcutaneous (n = 4), liver (n = 2), intraperitoneal (n = 2), and adrenal (n = 1).
Disease-Free Survival and Overall Survival
The median follow-up of living patients was 18 months (range, 2–114 months). The median time to first local recurrence and distant metastasis was 18 and 8 months, respectively. Twenty deaths were due to distant metastatic disease, commonly in the lung (n = 19). Two patients died as a result of locally recurrent disease. Two patients who had lung metastasectomy are alive with no evidence of disease at a follow-up of 23 and 68 months.
The 2-year overall and disease-free survival were 64.1% (SE, 6.7%) and 48.5% (SE, 6.4%), respectively. The 5-year overall and disease-free survival were 47.7% (SE, 7.6%) and 31.3% (SE, 6.7%), respectively (Fig. 1).
Analysis of Prognostic Factors
Local recurrence, metastasis, and survival contribute to the compound end point disease-free survival; there are therefore more events for this end point and consequently greater statistical power to detect prognostic effects than for the individual end points. The univariate (Table 4) and multivariate (Table 5) predictors for local recurrence, disease-free survival, and overall survival are presented. Grade was an important prognostic factor for disease-free and overall survival (Fig. 2). On multivariate analysis, size and grade were found to be independent predictors for disease-free survival (P < .05). Margin of excision (wide vs. marginal) just failed to reach statistical significance. Grade 2 and 3 patients had approximately twice the local recurrence rate of grade 1 patients, but this failed to reach statistical significance because of the small size of the study. Figures 3, 4, and 5 
show the effects of size, depth, and margin of excision on disease-free survival. Disease-free survival was analyzed because of relatively short follow-up time. The fact that margin was significant for disease-free survival, as shown in Fig. 5, is due to the inclusion of the single patient with intracapsular disease. This patient was excluded from the analysis in Tables 4 and 5 HREF="#TBL5">. The division of tumor according to size into three groups (<5, 5–10, and >10 cm) did not impart more prognostic significance to size than the two-group division (<5 and >5 cm; Fig. 3). Finally, the effect of size on time to metastasis was close to, but just failed to reach, significance (P = .05).
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FIG. 2. Disease-free survival by grade. Chis,  2. N, number of patients; O, observed events; E, expected events.
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FIG. 3. Disease-free survival by size. Chis, 2. N, number of patients; O, observed events; E, expected events.
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FIG. 4. Disease-free survival by depth. Chis, 2; HR, hazard ratio; CI, confidence interval. N, number of patients; O, observed events; E, expected events.
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FIG. 5. Disease-free survival by margin. Chis, 2. N, number of patients; O, observed events; E, expected events.
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DISCUSSION
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The buttock extends from the level of the perineal body inferiorly to the top of the iliac crest superiorly. Its lateral border is a line extending from the greater trochanter through the anterior inferior and anterior superior iliac spines. Hidden by the thickened panniculus of the gluteal region, these tumors often remain undetected until they become large and deeply attached. Thus, a high degree of suspicion must be maintained for any gluteal mass or sciatica type of pain that cannot be explained. Sciatica can be caused from compression of the sciatic nerve at the greater sciatic notch or along its course.10 It can be the first manifestation of a gluteal sarcoma.3 CT and magnetic resonance imaging can be extremely helpful to diagnose the problem, evaluate the extent of tumor invasion, and plan therapy.
CT demonstrates fat, cystic components, calcification, or necrosis within the mass and provides detailed anatomical cross-sectional information essential to the surgeon and radiotherapist. Contrast-enhanced CT scan depicts the presence and origin of a mass, provides tissue characterization, and shows the extent of the lesion, often demonstrating the intrapelvic component. It also demonstrates the asymmetry between the gluteal region. The margins of the muscle may be lost if the tumor extends into the perigluteal fat. Radiological features to note are the plane of cleavage between the tumor and the group of muscles, evidence of bony erosion, extension into the pelvis, and lymph node involvement. Bony erosion was observed in three of our patients. CT can sometimes visualize the sciatic nerve, and if it is not visible, its approximate location can be established.11 It is difficult to distinguish on CT scan whether a mass is adjacent to and surrounding the nerve or actually infiltrating it. It is an essential part of the preoperative work-up that a CT of the local region, as well as the retroperitoneum, be extensively studied to be sure that the buttock tumor is not part of a retroperitoneal sarcoma growing through the greater sciatic foramen into the buttock region. Inoperability features well demonstrated on CT scan are a large intrapelvic component with sacral intervertebral foramina and spinal canal involvement.
Liposarcomas are predominantly fat density, but unlike with lipomas, there are streaky densities throughout. A well-defined spherical myxoid liposarcoma can resemble a cyst or abscess on CT scan.12 The intramuscular location and the extent of fibrosarcomas and malignant fibrohistioctyomas are well established on CT. Their enlargement may cause pressure erosion on the bone. Calcification occurs in these tumors.12
Core (trucut) biopsy was positive in 52 patients, with only 1 false negative. We discourage the use of open biopsies performed at referring institutions because they interfere with siting of the definitive incision.13 Liposarcoma and malignant fibrous histiocytomas have been reported as the most frequent histological types at this site.2,5 In our series, liposarcoma, leiomyosarcoma, and synovial sarcoma were the most frequent histological types. Liposarcoma is the second (or third) most common histological type of soft-tissue sarcoma, representing between 8% and 18% of soft-tissue sarcomas in most series.14,15 The myxoid form is usually described as being low grade, with low metastatic potential similar to that of well-differentiated liposarcoma,16 but a round-cell component confers a greater potential for metastasis.17 Spillane et al.18 suggest that myxoid liposarcoma (with or without a round-cell component) is a distinct subtype of liposarcoma with a unique propensity for soft tissue metastasis. This behavior occurred in three of our patients. Ham et al.2 reported one patient with myxoid liposarcomas and retroperitoneal metastasis, who died at 29 months. We report another case, which had retroperitoneal metastasis of the round cell type of myxoid liposarcoma that was excised at 48 months. The patient is alive with no evidence of disease at 87 months.
Twenty-two cases of radiation-induced sarcomas in the buttock or sacral area in women were reported by Ruka et al.19 In our series, we found an additional two patients who developed radiation-induced sarcoma of the buttock after treatment of testicular tumors 28 and 9 years before presentation.
Buttockectomy has been described for circumscribed tumors confined within the gluteal musculature.8,20,21 This technique was used in most of our patients, unlike the recommendation by Sugarbaker and Chretien20 that it be used infrequently and for low-grade tumors. The standard incision was the gluteal skin crease incision extended superiorly and laterally. This incision has the advantage that it can be included in the incision for hindquarter amputation if required in the future. The incision is sometimes modified to incorporate the scar of a previous incision biopsy or to include threatened skin. If the tumor is in the uppermost part of the buttock, a transverse incision is used. The skin flaps are raised at the level of the deep fascia. Most of the buttock tumors lie within the gluteus maximus muscle, and they are amenable to functional compartmental resection.22 The margins of the gluteus maximus muscle are defined, and the insertion of this muscle into the greater trochanter of the femur (superiorly) and fascia lata (iliotibial tract; inferiorly) is divided. This allows the muscle to be reflected from lateral to medial. At this point, the sciatic nerve is easily identified, as are the gluteus medius and minimus. The sciatic nerve, inferior gluteal vessels, and posterior cutaneous nerve are on the undersurface of the gluteus maximus muscle posterior to the quadratus femoris muscle. Sometimes the tumor is present at the deep excision margin, which overlies the sciatic nerve. The perineurium is stripped in these cases to obtain a plane of clearance. The neurovascular bundle (superior and inferior gluteal pedicles) is then ligated and divided as proximally as possible. The origin of the gluteus maximus is then separated from the sacrum and posterior superior iliac crest in the subperiosteal plane whenever possible. The outer table of the sacrum is excised as a clearance margin when the tumor lies close to the origin of the gluteus maximus muscle from the sacrum. It is also separated from the sacrotuberous ligament. The origin of the hamstrings at the ischial tuberosity has to be preserved. Because the two minor glutei are preserved with their neurovascular innervation, this avoids the Trendelenburg deformity on walking. When considered necessary, resection of a part of the gluteus medius and minimus muscles and the piriformis is performed in the presence of tumor extension through the gluteus maximus.
When the tumor is deep to the gluteus maximus, this muscle is raised with the buttock skin flap, preserving its neurovascular pedicles. The sciatic nerve is preserved wherever possible. The gluteus medius, minimus, piriformis, and quadratus femoris are resected, depending on where the tumor lies. The origin and insertion of the two minor glutei are divided as close as possible to their attachments when the tumor lies in these muscles. With extension of the tumor through the greater sciatic notch, the intrapelvic component usually prolapses with minimal dissection. In difficulty, the sacrotuberous and sacrospinous ligaments are divided, and this allows access to the part of the tumor that extends into the true pelvis. A window of bone is excised as a clearance margin with an osteotome whenever there is erosion or limited involvement of the ilium. The tendon of the gluteus maximus is then repaired with strong Vicryl (Ethicon, Inc., Somerville, NJ). The wound is closed with two large suction drains. There is little functional deficit after rehabilitation in most patients. Only four patients in our series developed a Trendelenburg deformity after excision of the tumor. The postoperative problems are pain, recurring seroma, and sensory changes over that site and an obvious surgical defect in the buttock.
Buttock tumors with perineal extension are removed, taking care to preserve the puborectalis sling and the anal sphincters. The extension into the perineum is either though the lesser sciatic notch or direct extension. Sometimes a locally recurrent tumor may involve the entire extent of the buttock by virtue of previous dissection and tumor seeding. There is no realistic form of reconstruction at this site, and, thus, hemipelvectomy is the only alternative for patients with extensive tumors, deep penetration of muscle, significant bone or sciatic nerve involvement, or recurrent tumors after previous radical excision and radiation. A large posterior skin flap is designed. The retroperitoneal space is explored. The ureter and internal iliac vessels are preserved. The external iliac vessels and the femoral and the sciatic nerve are divided. The bone cuts are through the pubic symphysis and posterior extremity of the iliac blade through the greater sciatic notch. Sometimes, because of buttock skin loss, an anterior flap based on the superficial femoral vessels is used.23 The patient with hemipelvectomy had local recurrence and simultaneous metastasis at 29 months.
RT was not offered to one patient after an intracapsular excision because the residual tumor was in the presacral space, and RT would carry the risk of proctitis. RT has the additional risk of producing fertility problems and early menopause in women. The dose to the ovary should be limited to 5%. Paresthesia on the sole of the foot could present later because of radiation-induced damage to the sciatic nerve. There might be bowel in the treatment volume, and hyperfractionated RT cannot be used. Preoperative irradiation may be used to reduce tumor size, allowing buttockectomy to be performed rather than hemipelvectomy.
The chemotherapeutic drugs variably used were doxorubicin, ifosfamide, actinomycin D, cisplatin, vincristine, and liposomal daunorubicin. Cryopreservation of semen was offered to patients before the start of chemotherapy. There has been little success to date in the use of chemotherapy to control this disease. The benefit of adjuvant chemotherapy needs to be demonstrated by prospective clinical trials.
Our results, compared with previous studies for buttock sarcomas, are listed in Table 6, with a trend to more conservational surgery. The rate of local recurrence and overall survival at this site at 5 years was 35.4% and 47.7%, compared with 26% and 60%, respectively, for limb and limb girdle sarcomas.24 This is probably explained by the technical difficulties in achieving wide excisional surgery, compared with other limb and limb girdle sites, because of the tendency to spread through the greater sciatic notch and into the perineum. Contributing poor prognostic factors may be the deep location, proximity of the sciatic nerve, and large tumor size, because tumors at this site can grow undetected for long time. Grade is not an important predictor of local recurrence, as stated in the study by Gerson et al.5
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CONCLUSION
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Buttock tumors are mostly amenable to functional compartmental resection. Trucut biopsy and a CT scan are helpful in obtaining histology and evaluating the extent of the tumor, respectively. Nearly half of the tumors are located within the gluteus maximus muscle. The aim of surgical treatment should be to obtain negative microscopic margins. Patients should be carefully followed up clinically, with special imaging studies reserved for patients with symptoms or abnormal clinical examination. Size and grade of the tumors were independent predictors for disease-free and overall survival. Effective adjuvant therapies are needed to improve overall survival rates. The 2-year overall and disease-free survival at this site were 64.1% (SE, 6.7%) and 48.5% (SE, 6.4%), respectively.
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ACKNOWLEDGMENTS
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The acknowledgments are available online at www.annalssurgicaloncology.org.
Supported by the Sarcoma research fund. The authors thank M. Omar for his help in data collection.
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FOOTNOTES
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The rate of local recurrence at 2 years was 20.9%. The 2-year overall and disease-free survival rates were 64.1% and 48.5%, respectively. Size and grade of the tumor were independent predictors for survival.
Received for publication December 2, 2002.
Accepted for publication May 27, 2003.
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ABSTRACT
INTRODUCTION
