812 consecutive patients with soft tissue sarcoma of the extremity were studied to compare the characteristics and outcome of patients who had primary amputations and limb preserving surgery.

Patients with primary amputations were more likely to have metastases at presentation, high-grade tumours, larger tumours and were older.

The most frequent indications for primary amputation were tumour excision which would result in inadequate function and large extracompartmental tumours with composite tissue involvement including major vessels, nerves and bone.

The requirement for primary amputation was a poor prognostic factor independent of tumour grade, tumour size and patients’ age.

To determine if rates of local recurrence and metastasis differ in upper versus lower extremity sarcomas.

Prospectively collected data relating to patients undergoing limb-sparing surgery for extremity soft tissue sarcoma between January 1986 and April 1997 were analysed. Local recurrence-free and metastasis-free rates were calculated using the method of Kaplan and Meier. Univariate and multivariate analyses of potential predictive factors were evaluated with the log-rank test and the Cox proportional hazards model.

Of 480 eligible patients, 48 (10. 0%) had a local recurrence and 131 (27. 3%) developed metastases. Median follow-up of survivors was 4. 8 years (0. 1 to 12. 9). There were 139 upper and 341 lower extremity tumours. Upper extremity tumours were more often treated by unplanned excision before referral (89 vs 160, p< 0. 001) and were smaller (6. 0cm vs 9. 3cm, p< 0. 000). Lower extremity tumours were more often deep to or involving the investing fascia (280 vs. 97, p< 0. 003). The distribution of histological types differed in each extremity. Fewer upper extremity tumours were treated with adjuvant radiotherapy (98 vs. 289, p< 0. 000).

The 5-year local recurrence-free rate was 82% in the upper and 93% in the lower extremity (p< 0. 002). Local recurrence was predicted by surgical margin status (hazard ratio 3. 16, p< 0. 000) but not extremity (p=0. 127) or unplanned excision before referral (p=0. 868).

The 5-year metastasis-free rate was 82% in the upper and 69% in the lower extremity (p< 0. 013). Metastasis was predicted by high histological grade (hazard ratio 17. 28, p< 0. 000), tumour size in cm (hazard ratio 1. 05, p< 0. 001) and deep location (hazard ratio 1. 93, p< 0. 028) but not by extremity (p=0. 211).

Local recurrence is more frequent after treatment for upper compared with lower extremity sarcomas. Variation in the use of radiotherapy and differences in histological type may be contributory. Metastasis is more frequent after treatment for lower extremity sarcomas because tumours tend to be large and deep.