Book Review

Soft Tissue Sarcomas: Diagnosis and Treatment

N Engl J Med 1993; 329:1284-1285October 21, 1993

Article

Soft Tissue Sarcomas: Diagnosis and Treatment
Edited by John H. Raaf. 483 pp., illustrated. St. Louis, Mosby-Year Book, 1993. $95. ISBN: 0-8151-7003-3

The average general surgeon will see only a single soft-tissue sarcoma during his or her career. Only 5000 to 6000 new cases of sarcoma are diagnosed each year, evenly distributed among age groups and accounting for less than 1 percent of all cancers in adults. Sarcomas are one of the main tumor types found in the rare Li-Fraumeni syndrome. No adjuvant chemotherapy has been proved effective in treating soft-tissue sarcomas, nor has chemotherapy been shown to extend survival in the presence of metastatic disease. Local resection, often coupled with some form of radiation therapy, can cure up to 85 percent of patients with sarcoma of the extremities. Pulmonary metastasectomy, which can be curative in up to 30 percent of patients, is perhaps the best example of successful surgical therapy for metastatic disease. Surgery that spares the limbs when possible appears to be the treatment of choice for sarcoma of the extremities. The cause of this diverse set of tumors remains poorly understood but may involve many of the recently identified suppressor genes, including RB-1 and p53. The editor, John Raaf, summarizes much of this information in the excellent first chapter of this book. Is there a reason to read on?

Perhaps. Sarcoma is the prototypical tumor treated by the surgical oncologist. Much of the remainder of the book focuses on tumors at individual sites or involving a particular clinical problem. Even though over 90 percent of the cells in the body (cells of the bone, muscle, and fat and cells of hematopoietic lineage) are derived from the mesenchyma, less than 1 percent of all tumors are derived from this tissue. Is there something about the mesenchyma that is important for resisting the neoplastic phenotype? Certainly, the fibroblasts, osteoclasts, and myoblasts go through multiple rounds of division in the full course of human life and are susceptible to the mutations we know are responsible for cancer. Why they develop into cancers so infrequently remains an unanswered question.

The question that this book addresses is how to manage these unusual tumors -- information that should be particularly helpful to surgeons. The book contains numerous well-illustrated examples of conventional surgical procedures at various sites (including hemicorporectomy, which is now rarely performed). Unfortunately, much of the book appears to have been written over the course of several years, and the level of detail varies. For example, we are told that cystosarcomas occur in the left breast more often than in the right and that leiomyosarcoma is the most common tumor in a duodenal diverticulum, but we are given little information about hemangiopericytomas and the difficulties of their management when they occur in the head and neck, despite considerable literature on this topic. In addition, although retroperitoneal and abdominal-wall sarcomas represent 15 percent of all tumors, only 6 of the 483 pages in this book discuss their management. The chapters on sarcomas of the female genital tract and the genitourinary tract are particularly good.

This book is largely descriptive, containing case histories, compilations of series, and histologic discussions. In this respect, it is useful. The lack of detail about the biology of sarcomas reflects the need for more studies in this area. Other, more recently developed areas could also have been addressed in greater detail. For example, several centers are treating soft-tissue sarcomas by perfusion of the extremities with chemotherapy and now tumor necrosis factor. Such information should find its way into the next edition. This book is recommended for the specialist who treats a fair number of diverse cancers and, in particular, for the surgical oncologist.

Michael T. Lotze, M.D.
University of Pittsburgh School of Medicine, Pittsburgh, PA 15261