Lymph node metastases, sentinel lymph node biopsy, and lymphadenectomy in soft tissue sarcoma — when and why?

The spread of soft tissue sarcomas (STS) through the lymphatic system occurs rarely, mainly in epithelioid sarcoma, angiosarcoma, rhabdomyosarcoma, and clear cell sarcoma (CARE). STS subtypes differ in terms of biological behavior. CARE histology and high-grade nodal disease are defined as risk factors in STS. The nodal involvement status in STS patients correlates with the subsequent development of distant metastases. Regional disease is considered clinically distinct from distant metastatic disease in case of recurrence, and it has a better prognosis and better outcomes in terms of long-term survival. Preoperative sentinel lymph node biopsy (SLNB) may be used to identify high-risk patients, as this technique also allows the determination of patients with occult microscopic lymph node disease. The positive result of SLNB may indicate regional lymphadenectomy (LND). Though data on LND in STS are limited, this tool may play a role in multimodal treatment. In the case of STS, a unified diagnosis protocol is needed but followed by an individual treatment approach depending on the results of nodal involvement.