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Fungating Soft-Tissue Sarcomas: Treatment Implications and Prognostic Importance of Malignant Ulceration

Potter, Benjamin K. MD; Adams, Sheila C. MD; Qadir, Rabah BA; Pitcher, J. David MD; Temple, H. Thomas MD

Journal of Bone & Joint Surgery - American Volume: 01 March 2009 - Volume 91 - Issue 3 - p 567–574
doi: 10.2106/JBJS.H.00071
Scientific Articles

Background: Several variables have been reported as being prognostic with regard to the outcomes of soft-tissue sarcomas. Although the tumors are subjectively ominous, no prior study has been performed to evaluate the treatment or prognosis of fungating soft-tissue sarcomas.

Methods: We performed a retrospective review of all soft-tissue sarcomas treated at our institution between 1989 and 2004 that had been followed for a minimum of two years or until the death of the patient. Our study group consisted of twenty-four patients with a primary high-grade fungating tumor, and our control group consisted of 146 consecutive patients with a primary high-grade non-fungating tumor. The study cohorts were compared with regard to disease presentation, treatment, and oncologic outcomes.

Results: There were no significant differences in tumor size, tumor depth, or histopathologic diagnoses between the cohorts, although the patients with a fungating tumor tended to be older (mean, sixty-five years compared with fifty-five years in the control group; p = 0.004) and have shorter postoperative follow-up (mean, thirty-eight months compared with sixty-five months in the control group; p = 0.03). The proportion of patients presenting with metastases was significantly greater in the group with a fungating tumor (33% compared with 9% in the control group; p = 0.003). Significantly more patients with a fungating tumor underwent amputation (35% compared with 12% in the control group; p = 0.01), while a greater proportion of control patients received radiation therapy (68% compared with 39% in the group with a fungating tumor; p = 0.02). There was no difference in the proportions of patients receiving chemotherapy or in the local recurrence rates between the two cohorts. The Kaplan-Meier five-year overall survival estimates were 20% in the group with a fungating tumor compared with 63% (p < 0.0001) in the control group. The Kaplan-Meier five-year disease-specific survival estimates for patients presenting with localized disease was 58% in the group with a fungating tumor and 74% in the control group (p = 0.05). Multivariate analysis demonstrated that disease stage, fungation, and a tumor size of ≥10 cm were significant independent negative prognostic factors for disease-specific survival.

Conclusions: Malignant tumor ulceration is an independent predictor of a poor prognosis for patients with a high-grade soft-tissue sarcoma. Despite the discouraging overall prognosis, aggressive multidisciplinary treatment can lead to long-term survival in an important subgroup of patients with fungating lesions.

Level of Evidence: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

1Walter Reed Army Medical Center, 6900 Georgia Avenue N.W., Building 2A, Room 205, Washington, DC 20307. E-mail address:

2Department of Orthopaedics, University of Miami Miller School of Medicine, D-27, P.O. Box 016960, Miami, FL 33101

3Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112

Copyright 2009 by The Journal of Bone and Joint Surgery, Incorporated
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