Annals of Surgical Oncology, 10(8):961–971

DOI: 10.1245/ASO.2003.12.001

Buttock Soft Tissue Sarcoma: Clinical Features, Treatment,

and Prognosis

K. A. Behranwala, MS, FRCS (Ed.), FRCS (Glas.), P. Barry, FRACS, R. A’Hern, MSc, and
J. M. Thomas, MS, FRCS, FRCP

Background: Primary buttock soft tissue sarcomas in adults are common entities that have been
infrequently reported (three clinical series and isolated case reports). We present our experience of
buttock sarcomas to better characterize and define the natural history of this condition.
Methods: Buttock tumors occurring in adults (⬎16 years) between January 1990 and January
2002 were identified from the Royal Marsden Hospital’s Sarcoma Unit prospective database.
Results: Seventy-three buttock sarcomas were evaluated and treated at the Royal Marsden
Hospital during this period. Liposarcoma (n ⫽ 19), leiomyosarcoma (n ⫽ 13), and synovial sarcoma
(n ⫽ 9) were the most frequent histological types. There were 8 T1 and 61 T2 tumors, and size was
not available in 4 patients. Most tumors (n ⫽ 64) were located deep to the deep fascia. There were
15 grade 1, 20 grade 2, and 37 grade 3 tumors, and grade was not available in 1 patient. There were
29 tumors contained within the gluteus maximus. Wide excision was performed in 50 patients. Local
recurrence and distant metastasis occurred in 15 and 35 patients with a median time of 18 and 8
months, respectively. The rate of local recurrence at 2 years was 20.9% (SE, 6.8%). The 2-year
overall and disease-free survival rates were 64.1% (SE, 6.7%) and 48.5% (SE, 6.4%), respectively.
Conclusions: Buttock sarcomas present special surgical difficulties because of proximity of the
sciatic nerve and the ability of tumors at this site to extend into the pelvis and perineum. Size and
grade of the tumor were independent predictors for disease-free and overall survival.
Key Words: Buttock—Gluteus maximus—Sarcoma—Prognosis.

Soft tissue sarcomas of the buttock present the surgeon
with specific difficulties because of the proximity to the
sciatic nerve, adherence to the sacrum, and a tendency to
migrate through the greater sciatic notch to occupy the
pelvic sidewall or to involve the perineum by direct
extension or through the lesser sciatic notch. They are
typically of an extensive nature by the time of diagnosis.
With regard to functional considerations, preservation of
the sciatic nerve is important whenever possible, as is
preservation of one or more glutei to prevent or reduce
the Trendelenburg deformity.
Received December 2, 2002; accepted May 27, 2003.
From the Sarcoma and Melanoma Unit, Royal Marsden National
Health Service Trust, London.
Address correspondence and reprint requests to: Kasim Behranwala,
MD, Sarcoma and Melanoma Unit, Royal Marsden Hospital, Fulham
Road, South Kensington, London SW3 6JJ, UK; Fax: 44-0-20-7808-
2673; E-mail: kbehranwala@hotmail.com.
Published by Lippincott Williams & Wilkins © 2003 The Society of Surgical
Oncology, Inc.
Soft-tissue sarcomas are rare, malignant neoplasms
that arise from mesenchymal tissues; they account for
1% of all adult malignancies.1 The major prognostic
factors regarding sarcomas are size, grade, histologi-
cal subtype, primary lesion site, and surgical margins.
The literature on buttock sarcomas is scarce; most are
case reports.2–9 The 5-year survival rates (local recur-
rence rates) at this site, as reported by Gerson et al.5
and Wanebo et al.,8 are 40% (45%) and 39% (39%),
respectively. There was a trend toward limb-conserv-
ing radical buttockectomy in the former study, com-
pared with more hemipelvectomies in the latter study.
Gerson et al.5 noted that there were fewer sarcomas of
small size in the study by Wanebo et al.8 Both of these
studies were retrospective. There has been no recent
literature on this topic except for the study by Ham et
al.2 in 1998. They reported no local recurrence in a
series of nine patients treated with buttockectomy and
an overall and disease-free 5-year survival of 38% and

961
962 K. A. BEHRANWALA ET AL.
25%, respectively. We present our experience of but-
tock soft tissue sarcomas.
PATIENTS AND METHODS
Patients
Patients with buttock soft tissue tumors were identi-
fied from the Sarcoma Unit database at the Royal Mars-
den Hospital. Data have been collected prospectively for
all admissions from January 1990 and include demo-
graphics, investigations, treatment, and outcomes. Fur-
ther information was collected from a review of the
written hospital records, referral letters, and imaging
records.
Pathology
Macroscopic tumor-related factors, including size and
depth, were noted. The size of the tumor was recorded
from the pathologic specimen or from imaging analysis
and was classified as T1 (⬍5 cm) or T2 (⬎5 cm). Depth
was categorized as superficial or deep relative to the deep
fascia. Tumor grade was classified as low, intermediate,
or high on the basis of the degree of cellularity, differ-
entiation, and vascularity; nuclear pleomorphism; num-
ber of mitoses per high-power field; and amount of
stromal necrosis.
Microscopic margins were assessed histologically.
Wide excision was defined as a resection in which mi-
croscopic margins were negative (tumor ⬎1 mm from
the inked margin); marginal resection was defined as a
tumor that extended up to the margins of resection (pos-
itive microscopic margins). Those who had a marginal
excision performed at another hospital and were subse-
quently found to have no residual tumor on re-excision at
our hospital were considered to have had wide excision.
Intracapsular excision was defined as one in which mac-
roscopic residual disease was left behind or in which
there was a positive gross margin.
Diagnosis and Treatment
Routine staging evaluation included complete physical
examination; imaging studies, such as computed tomog-
raphy (CT) or magnetic resonance imaging, of the lo-
coregional area; and radiological evaluation of the chest.
Diagnoses were confirmed by the histological examina-
tion of incisional or core biopsy material or re-evaluation
of the original excision specimens if these were per-
formed elsewhere. Histological confirmation is essential
before embarking on a major surgical procedure or of-
fering adjuvant therapy. Patients deemed resectable and
without evident metastases were treated by surgery as the
primary modality. Those with marginal excision, high-
Ann Surg Oncol, Vol. 10, No. 8, 2003
grade tumors, or both were offered postoperative exter-
nal beam radiotherapy (RT), 60 Gy, within the limits of
normal tissue tolerance in 6 weeks. RT was given with
anterior and posterior portals to encompass the origin of
the glutei but falling short of the midline. It extended
proximally to include the pelvic floor but with an attempt
to exclude the bowel. All decisions were discussed at the
Sarcoma Unit’s multidisciplinary team meeting.
Follow-Up
Careful surveillance was based on guided history and
thorough physical examination. Plain chest radiographs
were initially performed every 4 months (for the first 2
years if high grade and otherwise for 1 year) and then
yearly. Axial imaging studies (CT or magnetic resonance
imaging) for detection of recurrence was not routine but
was performed if the patient was symptomatic (pain or
mass) or if a clinical examination (mass) was abnormal.
Follow-up data are presented as the time in months
from the initial diagnosis. Local recurrence was defined
as a tumor being within or contiguous to the previously
excised field ⱖ3 months after primary therapy.
Statistical Analysis
Analysis of the effect of prognostic factors on local
recurrence, time to metastasis, disease-free survival, and
overall survival was undertaken by using Cox’s regres-
sion. The aim was to evaluate the relationship of size,
grade, histology, and margins of excision to local recur-
rence, metastasis, and survival. Life-table curves were
constructed by using the Kaplan-Meier method; the con-
fidence intervals shown are 95% confidence intervals.
RESULTS
Between January 1990 and January 2002, 2678 pa-
tients with soft tissue tumors (of which 2286 were sar-
comas) were evaluated and treated at the Royal Marsden
Hospital. Ninety-two buttock soft tissue tumors (73 ma-
lignant and 19 benign) were evaluated and treated at the
Royal Marsden Hospital during this period. The buttock
was the second most common site, after the thigh, for
extremity sarcoma. The distribution of each variable for
patients with buttock soft tissue sarcoma is listed in
Table 1.
Patients
The median age at presentation was 52 years (range,
16 – 88 years). The presenting complaints were mass (n
⫽ 53), sciatica (n ⫽ 13), local pain (n ⫽ 6), fungating
tumor (n ⫽ 3), and foot drop (n ⫽ 1). Lymph node
involvement was observed in two patients at initial clin-
 SOFT TISSUE SARCOMA OF THE BUTTOCK 963

TABLE 1. Distribution of variables of patients with testicular tumor. Definitive surgery was performed in
buttock soft tissue sarcoma nine patients at the referring hospital. The rest were
Variable No. Patients referred after biopsy or suspected diagnosis of soft tissue
Sex
sarcoma.
Male 38
Female 35 Pathology
Size (cm)
⬍5 8
The histopathologic types of these sarcomas are listed
⬎5 61 in Table 2. Liposarcoma (n ⫽ 19), leiomyosarcoma (n ⫽
Not known 4 13), and synovial sarcoma (n ⫽ 9) were the most fre-
Grade
High 37
quent histological types. The tumors ranged from 2 to 35
Intermediate 20 cm in diameter (median, 12 cm). Multifocality was ob-
Low 15 served in two patients (epithelioid sarcoma and
Not known 1
Surgical resection margin status
leiomyosarcoma).
Negative microscopic and gross 50 By depth, there were 9 superficial and 64 deep tumors.
margins Spread to lymph nodes was observed in two patients with
Positive microscopic and negative 13
gross margins
epithelioid sarcoma and in one patient each with sarcoma
Positive microscopic and gross 1 not otherwise specified, synovial sarcoma, and malignant
margins fibrous histiocytoma.
Nonsurgical 9
Radiation
Neoadjuvant 4 Imaging and Diagnosis
Adjuvant 24 CT helped in determining the exact location of the
Palliative 5
Chemotherapy
tumor in all patients. The site of the tumor in relation to
Neoadjuvant 5 the muscles with its variable extension is listed in Table
Adjuvant 8 3. This shows that the buttock is a difficult anatomical
Palliative 17 site in which to treat soft tissue sarcoma because it allows
Local recurrence
Yes 15
No 58
Distant metastasis TABLE 2. Histology of buttock soft tissue sarcomas
Yes 35
No 38 Diagnosis No. Patients
Survival status
Alive with no evidence of disease 35 Angiomatoid MFH 1
Alive with disease 10 Chondrosarcoma 1
Died of disease 22 Clear cell sarcoma 1
Died of other causes 6 Epithelioid leiomyosarcoma 1
Epithelioid sarcoma 2
Ewing’s sarcoma 2
Fibrosarcoma 2
Leiomyosarcoma 11
ical presentation. Specific presenting symptoms were not Liposarcoma 9
recorded in five patients. The local pain caused increas- Well differentiated 8
ing difficulties during walking in a few patients. The Pleomorphic 1
Malignant nerve sheath tumor 1
patient with foot drop (sciatic nerve destruction) had a MFH 8
loss of power in the hamstrings and a loss of dorsiflexion Myxoid MFH 1
and plantarflexion. In the patients who complained of Myxofibrosarcoma 4
Myxoid chondrosarcoma 1
sciatica, a few went to osteopaths for massage therapy, Myxoid leiomyosarcoma 1
one was diagnosed with a disc prolapse, and one had Myxoid liposarcoma 10
been operated on for concomitant intervertebral disc Without round cell differentiation 2
Focal round cell differentiation 7
prolapse. The buttock mass was diagnosed as an abscess Significant transition to round cell 1
and drained in one patient, and in another patient it was Myxoid sarcoma NOS 1
discovered accidentally during the course of a routine Primitive neuroectodermal tumor 1
Rhabdomyosarcoma 2
examination for another problem. Lymph node involve- Sarcoma NOS 4
ment was clinically observed in another three patients Synovial sarcoma 9
during the course of the disease; one of them had distant Total 73
metastasis at the time. Radiation-induced buttock sar- MFH, malignant fibrous histiocytoma; NOS, not otherwise speci-
coma was observed in two patients after treatment of a fied.

Ann Surg Oncol, Vol. 10, No. 8, 2003

964 K. A. BEHRANWALA ET AL.

TABLE 3. Location of buttock soft tissue sarcomas Wide and marginal excision was performed in 50 and
Location No. Patients 13 patients, respectively. A component of the sciatic
nerve was sacrificed, in one patient each, because of
Gluteus maximus muscle 29
Deep to gluteus maximus with extension 4 invasion of the perineurium and destruction of the nerve.
through the greater sciatic notch The external sphincter was excised in one patient. Hind-
Gluteus maximus involvement with extension 4 quarter amputation was performed in two patients (an
into the perineum
Subcutaneous 9 anteriorly based flap was used in one patient), with
Gluteus medius and minimus 3 palliative intent in one who had known metastatic dis-
Gluteus minimus 1 ease. Two patients had lymph nodes removed at the time
Extension into pelvis through pelvic floor 2
Piriformis and obturator muscle involvement 1 of excision of the primary tumor, and one patient under-
along with gluteus maximus went an ilioinguinal node dissection as treatment of the
Extension between ischial tuberosity and femur 2 first site of recurrence. Lung metastasectomy was per-
All the layers 3
Not recorded 15 formed in five patients. Local excision of subcutaneous
metastasis in patients with myxoid liposarcoma was per-
formed in three patients.
Adjuvant RT was not offered to one patient because of
involvement of different muscle layers with extension. old age and in one patient because of the local extent of
The most common location of the tumor was within the the primary tumor. Adjuvant CT was not routinely used
gluteus maximus muscle (n ⫽ 29). at this unit. Neoadjuvant chemotherapy was given to two
After the tumor extended through the greater sciatic patients with Ewing’s sarcoma, two patients with syno-
notch, it was seen displacing the rectum to varying vial sarcoma, and one patient with embryonal rhabdo-
degrees in four patients. Tumor was seen extending to myosarcoma. Neoadjuvant RT was given to one patient
the perineum and reaching close to the anus and pubo- each with rhabdomyosarcoma, Ewing’s sarcoma, sar-
rectalis sling in four patients. In two patients, the tumor coma not otherwise specified, and synovial sarcoma. All
was seen extending between the ischial tuberosity and these patients had large tumors at presentation. Neoad-
femur, and in one of them, it was thought to be arising juvant therapy helped in obtaining wide excision in five
from the quadratus femoris. Direct invasion of bone patients and marginal excision in one patient. Chemo-
(sacrum, coccyx, or ilium) was picked up on CT scan in therapy was given to 17 patients with metastatic disease.
three patients.
Core (trucut) biopsy allowed definitive histological Recurrence
diagnoses in 52 patients. In only one patient was it The rate of local recurrence was 20.9% (SE, 6.8%) at
falsely negative for malignancy (reported as angio- 2 years and 35.4% (SE, 8.3%) at 5 years. Local recur-
myxoma). Open biopsy was performed in 11 patients, rence was associated with distant metastasis in five pa-
and core biopsy did not yield sufficient material for tients and followed distant metastases in three patients.
histological diagnosis in two patients at the referring The local recurrences were adequately treated with wide
hospital. Fine-needle aspiration cytology was performed local excision in five patients; one of them had bone
in two patients at the referring hospital, and it was involvement, and one had multiple recurrences. The
negative in both patients. The mode of diagnosis was not nodal recurrence was not treated in one patient at the last
available in five patients. follow-up. Distant metastases were observed in 35 pa-
tients. The sites of metastasis were lung (n ⫽ 29), bone
Treatment (n ⫽ 6), subcutaneous (n ⫽ 4), liver (n ⫽ 2), intraperi-
Fifty-seven (78%) patients presented with tumors that toneal (n ⫽ 2), and adrenal (n ⫽ 1).
were considered resectable. Surgery was performed in
six patients after neoadjuvant treatment. Gross margins Disease-Free Survival and Overall Survival
of resection were negative in all surgically excised sar- The median follow-up of living patients was 18
comas except in the one patient who had an intracapsular months (range, 2–114 months). The median time to first
excision. Nine patients did not undergo resection. Pallia- local recurrence and distant metastasis was 18 and 8
tive treatment was given to eight patients with either months, respectively. Twenty deaths were due to distant
distant metastases (n ⫽ 4) or extensive unresectable metastatic disease, commonly in the lung (n ⫽ 19). Two
neoplasms (n ⫽ 4) at the time of initial presentation. One patients died as a result of locally recurrent disease. Two
patient did not undergo surgery because of medical rea- patients who had lung metastasectomy are alive with no
sons and was offered palliative treatment. evidence of disease at a follow-up of 23 and 68 months.

Ann Surg Oncol, Vol. 10, No. 8, 2003

 SOFT TISSUE SARCOMA OF THE BUTTOCK
The 2-year overall and disease-free survival were
64.1% (SE, 6.7%) and 48.5% (SE, 6.4%), respectively.
The 5-year overall and disease-free survival were 47.7%
(SE, 7.6%) and 31.3% (SE, 6.7%), respectively (Fig. 1).
Analysis of Prognostic Factors
Local recurrence, metastasis, and survival contribute
to the compound end point disease-free survival; there
are therefore more events for this end point and conse-
quently greater statistical power to detect prognostic
effects than for the individual end points. The univariate
(Table 4) and multivariate (Table 5) predictors for local
recurrence, disease-free survival, and overall survival are
presented. Grade was an important prognostic factor for
disease-free and overall survival (Fig. 2). On multivari-
ate analysis, size and grade were found to be independent
predictors for disease-free survival (P ⬍ .05). Margin of
excision (wide vs. marginal) just failed to reach statisti-
cal significance. Grade 2 and 3 patients had approxi-
mately twice the local recurrence rate of grade 1 patients,
but this failed to reach statistical significance because of
the small size of the study. Figures 3, 4, and 5 show the
effects of size, depth, and margin of excision on disease-
free survival. Disease-free survival was analyzed be-
cause of relatively short follow-up time. The fact that
margin was significant for disease-free survival, as
shown in Fig. 5, is due to the inclusion of the single
patient with intracapsular disease. This patient was ex-
cluded from the analysis in Tables 4 and 5. The division
of tumor according to size into three groups (⬍5, 5–10,
965
and ⬎10 cm) did not impart more prognostic signifi-
cance to size than the two-group division (⬍5 and ⬎5
cm; Fig. 3). Finally, the effect of size on time to metas-
tasis was close to, but just failed to reach, significance
(P ⫽ .05).
DISCUSSION
The buttock extends from the level of the perineal
body inferiorly to the top of the iliac crest superiorly. Its
lateral border is a line extending from the greater tro-
chanter through the anterior inferior and anterior superior
iliac spines. Hidden by the thickened panniculus of the
gluteal region, these tumors often remain undetected
until they become large and deeply attached. Thus, a
high degree of suspicion must be maintained for any
gluteal mass or sciatica type of pain that cannot be
explained. Sciatica can be caused from compression of
the sciatic nerve at the greater sciatic notch or along its
course.10 It can be the first manifestation of a gluteal
sarcoma.3 CT and magnetic resonance imaging can be
extremely helpful to diagnose the problem, evaluate the
extent of tumor invasion, and plan therapy.
CT demonstrates fat, cystic components, calcification,
or necrosis within the mass and provides detailed ana-
tomical cross-sectional information essential to the sur-
geon and radiotherapist. Contrast-enhanced CT scan de-
picts the presence and origin of a mass, provides tissue
characterization, and shows the extent of the lesion, often
demonstrating the intrapelvic component. It also demon-
FIG. 1. Overall and dis-
ease-free survival.
Ann Surg Oncol, Vol. 10, No. 8, 2003
966 K. A. BEHRANWALA ET AL.

TABLE 4. Univariate analysis of prognostic factors

Local recurrence Disease-free survival Overall survival
No. 5-y P value 5-y P value 5-y P value
Prognostic factor Patients survival (SE) HR (95% CI) survival (SE) HR (95% CI) survival (SE) HR (95% CI)
Sex .05 .31 .9
Male 38 43 (13) 1.00 35 (10) 1.00 50 (11) 1.00
Female 35 82 (9) .34 (.11–.99) 27 (9) .73 (.40–1.34) 45 (11) .95 (.44–2.1)
Age (y) .60 .24 .09
⬍ 50 36 68 (10) 1.00 37 (9) 1.00 52 (10) 1.00
⬎ 50 37 51 (18) 1.33 (.46–3.8) 25 (11) 1.44 (.78–2.7) 48 (11) 1.96 (.90–4.2)
Location .26 .03 .12
Superficial 64 58 (10) 1.00 22 (7) 1.00 40 (8) 1.00
Deep 9 89 (10) .31 (.04–2.4) 89 (10) .20 (.05–.83) 100 .03 (0–2.4)
Histology .70 .12 .02
Liposarcoma 19 74 (15) 1.00 49 (16) 1.00 84 (9) 1.00
Leiomyosarcoma 13 31 (25) 2.2 (.44–11.4) 0 2.76 (1.1–6.9) 13 (12) 6.22 (1.7–23)
Synovial 9 80 (18) .83 (.14–5.0) 30 (16) 1.51 (0.54–4.2) 50 (18) 2.26 (.50–10.1)
sarcoma
Remainder 32 62 (12) 1.26 (.32–4.9) 35 (10) 1.26 (.54–2.9) 48 (12) 2.13 (.58–7.8)
Grade .56 ⬍.001 .003
Low 15 86 (13) 1.00 86 (13) 1.00 100 0
Intermediate 20 60 (16) 2.3 (.45–12) 30 (14) 5.92 (1.27–27) 57 (17) 1.00
High 37 59 (12) 2.2 (.46–10) 16 (7) 10.4 (2.46–44) 29 (9) 2.33 (.87–6.21)
Type of excision .33 .24 .45
Wide 50 69 (9) 1.00 40 (9) 1.00 54 (9) 1.00
Marginal 13 61 (18) 1.79 (.55–5.8) 25 (14) 1.76 (.81–3.9) 53 (16) 1.44 (.55–3.8)
(Intracapsular) 1
Tumor size (cm) .05 .015 .07
⬍5 8 100 0 86 (13) 1.00 83 (15) 1.00
5–10 19 78 (15) 1.00 27 (14) 7.2 (.91–57) 51 (18) 3.98 (.46–34)
⬎ 10 42 48 (12) 2.35 (.52–10) 21 (8) 9.2 (1.24–68) 39 (10) 5.48 (.73–41)

HR, hazard ratio; CI, confidence interval; SE, standard error.

strates the asymmetry between the gluteal region. The
margins of the muscle may be lost if the tumor extends
into the perigluteal fat. Radiological features to note are
the plane of cleavage between the tumor and the group of
muscles, evidence of bony erosion, extension into the
pelvis, and lymph node involvement. Bony erosion was
observed in three of our patients. CT can sometimes
visualize the sciatic nerve, and if it is not visible, its
approximate location can be established.11 It is difficult
to distinguish on CT scan whether a mass is adjacent to
and surrounding the nerve or actually infiltrating it. It is
an essential part of the preoperative work-up that a CT of
the local region, as well as the retroperitoneum, be ex-
tensively studied to be sure that the buttock tumor is not
part of a retroperitoneal sarcoma growing through the
greater sciatic foramen into the buttock region. Inoper-

TABLE 5. Multivariate analysis of prognostic factors

Local recurrence Disease-free survival Overall survival
Prognostic factor HR 95% CI P value HR 95% CI P value HR 95% CI P value
Grade ⬍.001 ⬍.001
Low 1.00 0
Intermediate 10.6 1.35–83 1.00
High 27.1 3.64–202 3.2 1.18–8.7
Type of excision
Wide 1.00
Marginal 1.98 .97–4.1 .06
Intracapsular (NS)
Tumor size (cm) .05 .001 .003
⬍5 0 1.00 1.00
5–10 1.00 15.0 1.84–122 6.96 .80–60
⬎10 2.35 .52–10 20.2 2.67–152 10.4 1.4–78

HR, hazard ratio; CI, confidence interval; NS, nonsignificant.

Ann Surg Oncol, Vol. 10, No. 8, 2003

 SOFT TISSUE SARCOMA OF THE BUTTOCK 967

FIG. 2. Disease-free sur-

vival by grade. Chis, ␹2. N,
number of patients; O, ob-
served events; E, expected
events.

ability features well demonstrated on CT scan are a large
intrapelvic component with sacral intervertebral foram-
ina and spinal canal involvement.
Liposarcomas are predominantly fat density, but un-
like with lipomas, there are streaky densities throughout.
A well-defined spherical myxoid liposarcoma can resem-
ble a cyst or abscess on CT scan.12 The intramuscular
location and the extent of fibrosarcomas and malignant
fibrohistioctyomas are well established on CT. Their
enlargement may cause pressure erosion on the bone.
Calcification occurs in these tumors.12
Core (trucut) biopsy was positive in 52 patients, with
only 1 false negative. We discourage the use of open
biopsies performed at referring institutions because they

FIG. 3. Disease-free sur-

vival by size. Chis, ␹2. N,
number of patients; O, ob-
served events; E, expected
events.

Ann Surg Oncol, Vol. 10, No. 8, 2003

968 K. A. BEHRANWALA ET AL.

FIG. 4. Disease-free sur-

vival by depth. Chis, ␹2; HR,
hazard ratio; CI, confidence
interval. N, number of pa-
tients; O, observed events; E,
expected events.

interfere with siting of the definitive incision.13 Liposar-
coma and malignant fibrous histiocytomas have been
reported as the most frequent histological types at this
site.2,5 In our series, liposarcoma, leiomyosarcoma, and
synovial sarcoma were the most frequent histological
types. Liposarcoma is the second (or third) most com-
mon histological type of soft-tissue sarcoma, represent-
ing between 8% and 18% of soft-tissue sarcomas in most
series.14,15 The myxoid form is usually described as
being low grade, with low metastatic potential similar to
that of well-differentiated liposarcoma,16 but a round-cell
component confers a greater potential for metastasis.17
Spillane et al.18 suggest that myxoid liposarcoma (with
or without a round-cell component) is a distinct subtype
of liposarcoma with a unique propensity for soft tissue
metastasis. This behavior occurred in three of our pa-

FIG. 5. Disease-free sur-

vival by margin. Chis, ␹2. N,
number of patients; O, ob-
served events; E, expected
events.

Ann Surg Oncol, Vol. 10, No. 8, 2003

 SOFT TISSUE SARCOMA OF THE BUTTOCK
tients. Ham et al.2 reported one patient with myxoid
liposarcomas and retroperitoneal metastasis, who died at
29 months. We report another case, which had retroper-
itoneal metastasis of the round cell type of myxoid
liposarcoma that was excised at 48 months. The patient is
alive with no evidence of disease at 87 months.
Twenty-two cases of radiation-induced sarcomas in
the buttock or sacral area in women were reported by
Ruka et al.19 In our series, we found an additional two
patients who developed radiation-induced sarcoma of the
buttock after treatment of testicular tumors 28 and 9
years before presentation.
Buttockectomy has been described for circumscribed
tumors confined within the gluteal musculature.8,20,21
This technique was used in most of our patients, unlike
the recommendation by Sugarbaker and Chretien20 that it
be used infrequently and for low-grade tumors. The
standard incision was the gluteal skin crease incision
extended superiorly and laterally. This incision has the
advantage that it can be included in the incision for
hindquarter amputation if required in the future. The
incision is sometimes modified to incorporate the scar of
a previous incision biopsy or to include threatened skin.
If the tumor is in the uppermost part of the buttock, a
transverse incision is used. The skin flaps are raised at
the level of the deep fascia. Most of the buttock tumors
lie within the gluteus maximus muscle, and they are
amenable to functional compartmental resection.22 The
margins of the gluteus maximus muscle are defined, and
the insertion of this muscle into the greater trochanter of
the femur (superiorly) and fascia lata (iliotibial tract;
inferiorly) is divided. This allows the muscle to be re-
flected from lateral to medial. At this point, the sciatic
nerve is easily identified, as are the gluteus medius and
minimus. The sciatic nerve, inferior gluteal vessels, and
posterior cutaneous nerve are on the undersurface of the
gluteus maximus muscle posterior to the quadratus fem-
oris muscle. Sometimes the tumor is present at the deep
excision margin, which overlies the sciatic nerve. The
perineurium is stripped in these cases to obtain a plane of
clearance. The neurovascular bundle (superior and infe-
rior gluteal pedicles) is then ligated and divided as prox-
imally as possible. The origin of the gluteus maximus is
then separated from the sacrum and posterior superior
iliac crest in the subperiosteal plane whenever possible.
The outer table of the sacrum is excised as a clearance
margin when the tumor lies close to the origin of the
gluteus maximus muscle from the sacrum. It is also
separated from the sacrotuberous ligament. The origin of
the hamstrings at the ischial tuberosity has to be pre-
served. Because the two minor glutei are preserved with
their neurovascular innervation, this avoids the Tren-
969
delenburg deformity on walking. When considered nec-
essary, resection of a part of the gluteus medius and
minimus muscles and the piriformis is performed in the
presence of tumor extension through the gluteus
maximus.
When the tumor is deep to the gluteus maximus, this
muscle is raised with the buttock skin flap, preserving its
neurovascular pedicles. The sciatic nerve is preserved
wherever possible. The gluteus medius, minimus, piri-
formis, and quadratus femoris are resected, depending on
where the tumor lies. The origin and insertion of the two
minor glutei are divided as close as possible to their
attachments when the tumor lies in these muscles. With
extension of the tumor through the greater sciatic notch,
the intrapelvic component usually prolapses with mini-
mal dissection. In difficulty, the sacrotuberous and sa-
crospinous ligaments are divided, and this allows access
to the part of the tumor that extends into the true pelvis.
A window of bone is excised as a clearance margin with
an osteotome whenever there is erosion or limited in-
volvement of the ilium. The tendon of the gluteus maxi-
mus is then repaired with strong Vicryl (Ethicon, Inc.,
Somerville, NJ). The wound is closed with two large
suction drains. There is little functional deficit after
rehabilitation in most patients. Only four patients in our
series developed a Trendelenburg deformity after exci-
sion of the tumor. The postoperative problems are pain,
recurring seroma, and sensory changes over that site and
an obvious surgical defect in the buttock.
Buttock tumors with perineal extension are removed,
taking care to preserve the puborectalis sling and the anal
sphincters. The extension into the perineum is either
though the lesser sciatic notch or direct extension. Some-
times a locally recurrent tumor may involve the entire
extent of the buttock by virtue of previous dissection and
tumor seeding. There is no realistic form of reconstruc-
tion at this site, and, thus, hemipelvectomy is the only
alternative for patients with extensive tumors, deep pen-
etration of muscle, significant bone or sciatic nerve in-
volvement, or recurrent tumors after previous radical
excision and radiation. A large posterior skin flap is
designed. The retroperitoneal space is explored. The
ureter and internal iliac vessels are preserved. The exter-
nal iliac vessels and the femoral and the sciatic nerve are
divided. The bone cuts are through the pubic symphysis
and posterior extremity of the iliac blade through the
greater sciatic notch. Sometimes, because of buttock skin
loss, an anterior flap based on the superficial femoral
vessels is used.23 The patient with hemipelvectomy had
local recurrence and simultaneous metastasis at 29
months.
Ann Surg Oncol, Vol. 10, No. 8, 2003
970 K. A. BEHRANWALA ET AL.
TABLE 6. Comparison with previous studies of buttock sarcomas
Treated by
Duration No. Median size surgical
Study (y) Patients (cm) resection
Wanebo et al.8 33 71 12 52 (73%)
Gerson et al.5 13 40 13 25 (63%)
Ham et al.2 10 9 14 (mean) 7 (78%)
Our study 13 73 12 63 (86%)
RT was not offered to one patient after an intracapsu-
lar excision because the residual tumor was in the pre-
sacral space, and RT would carry the risk of proctitis. RT
has the additional risk of producing fertility problems
and early menopause in women. The dose to the ovary
should be limited to 5%. Paresthesia on the sole of the
foot could present later because of radiation-induced
damage to the sciatic nerve. There might be bowel in the
treatment volume, and hyperfractionated RT cannot be
used. Preoperative irradiation may be used to reduce
tumor size, allowing buttockectomy to be performed
rather than hemipelvectomy.
The chemotherapeutic drugs variably used were doxo-
rubicin, ifosfamide, actinomycin D, cisplatin, vincristine,
and liposomal daunorubicin. Cryopreservation of semen
was offered to patients before the start of chemotherapy.
There has been little success to date in the use of che-
motherapy to control this disease. The benefit of adju-
vant chemotherapy needs to be demonstrated by prospec-
tive clinical trials.
Our results, compared with previous studies for but-
tock sarcomas, are listed in Table 6, with a trend to more
conservational surgery. The rate of local recurrence and
overall survival at this site at 5 years was 35.4% and
47.7%, compared with 26% and 60%, respectively, for
limb and limb girdle sarcomas.24 This is probably ex-
plained by the technical difficulties in achieving wide
excisional surgery, compared with other limb and limb
girdle sites, because of the tendency to spread through
the greater sciatic notch and into the perineum. Contrib-
uting poor prognostic factors may be the deep location,
proximity of the sciatic nerve, and large tumor size,
because tumors at this site can grow undetected for long
time. Grade is not an important predictor of local recur-
rence, as stated in the study by Gerson et al.5
CONCLUSION
Buttock tumors are mostly amenable to functional
compartmental resection. Trucut biopsy and a CT scan
are helpful in obtaining histology and evaluating the
extent of the tumor, respectively. Nearly half of the
tumors are located within the gluteus maximus muscle.
Ann Surg Oncol, Vol. 10, No. 8, 2003
Buttockectomy Hemipelvectomy Local recurrence Survival at
(n) (n) rate at 5 y (%) 5 y (%)
36 16 39 39
22 3 45 40
7 – 0 38
61 2 35 48
The aim of surgical treatment should be to obtain nega-
tive microscopic margins. Patients should be carefully
followed up clinically, with special imaging studies re-
served for patients with symptoms or abnormal clinical
examination. Size and grade of the tumors were inde-
pendent predictors for disease-free and overall survival.
Effective adjuvant therapies are needed to improve over-
all survival rates. The 2-year overall and disease-free
survival at this site were 64.1% (SE, 6.7%) and 48.5%
(SE, 6.4%), respectively.
ACKNOWLEDGMENTS
The acknowledgments are available online at
www.annalssurgicaloncology.org.
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