Risk stratification in soft-tissue sarcoma using Sarculator: a single-center experience

Soft-tissue sarcomas (STS) are rare, histologically heterogeneous malignancies where individual risk prediction is crucial to guide perioperative management. The Sarculator nomogram is a validated prognostic tool for overall survival (OS) in patients with resected extremity and trunk STS, but its performance in real-world, multimodally treated populations remains underexplored. We retrospectively analyzed 54 patients with localized extremity or trunk STS treated with perioperative ifosfamide–epirubicin chemotherapy between 2014 and 2023 at a tertiary center. Prognostic accuracy of the Sarculator nomogram was evaluated using Harrell’s C-index and the Brier score. Patients were stratified into risk groups by Sarculator and American Joint Committee on Cancer (AJCC) staging. Kaplan–Meier and Cox regression analyses assessed survival and prognostic factors. Fifty-four patients received ifosfamide–epirubicin chemotherapy in either neoadjuvant or adjuvant setting. Most patients (90.7%) had tumors >5 cm and 75.9% had grade 3 histology. The observed 5-year OS was 64.7%, slightly lower than previous Sarculator validations. Discrimination was modest (C-index: 0.457) and calibration was limited (Brier score: 0.327). Survival outcomes overlapped between high- and low-risk groups as defined by both Sarculator and AJCC criteria. Chemotherapy response was the only variable significantly associated with OS (hazard ratio 4.99, P = 0.0087). The Sarculator nomogram showed limited prognostic performance in our high-risk STS cohort treated with perioperative chemotherapy at a tertiary referral center. The aggressive clinical features of this selected population likely contributed to these results. Our findings underscore the importance of validating and adapting prognostic tools in real-world, multimodality-treated, high-risk settings. • Sarculator nomogram showed limited prognostic discrimination and calibration in a high-risk, chemotherapy-treated STS cohort. • Most patients (90.7%) had tumors >5 cm and 75.9% had grade 3 histology, indicating a population with adverse features. • Observed 5-year OS and PFS overlapped across Sarculator and AJCC risk groups, highlighting poor performance in this setting. • Pathologic response to chemotherapy was the only variable significantly associated with OS. • Further refinement of prognostic tools is needed for high-risk STS patients undergoing perioperative treatment.