1 2 3 4 5 5 6 7 3 8 11 12 13 subjective objective management 14 Patients and Methods n n 15 16 n n n n n n n 17 18 19 1 Table 1 PNET PUS MPNST FU na Age (years) Sex  Histology Grade AJCC stage Level EBRT Amputation FU 18 Female Primary Embryonal rhabdomyosarcoma 3 3 Iliacal No No 159 44 Female Recurrent  Myxoid liposarcoma 1 1 Iliacal Yes No 152 43 Male Primary Synovial sarcoma 3 3 Iliacal Yes No 151 18 Male Primary Myxoid chondrosarcoma 2 3 Popliteal  Yes Yes 149 48 Female Primary Well-differentiated liposarcoma 1 1 Iliacal Yes No 143 56 Female Primary PNET 3 3 Iliacal Yes Yes 137 50 Female Recurrent  PUS 3 3 Popliteal  No No 135 25 Female Primary Synovial sarcoma 2 3 Popliteal  Yes No 132 44 Male Primary Myxoid liposarcoma 1 1 Iliacal Yes No 131 24 Male Recurrent  Synovial sarcoma 2 3 Popliteal  Yes No 129 37 Female Primary MPNST 2 3 Axillary  Yes No 121 48 Male Primary Myxoid liposarcoma 2 3 Iliacal Yes No 111 63 Female Recurrent  PUS 2 3 Popliteal  No Yes 107 37 Male Primary Myxoid liposarcoma 1 1 Iliacal Yes No 105 58 Male Primary PUS 2 3 Iliacal Yes No 98 71 Female Primary Leiomyosarcoma 1 1 Femoral  No No 94 45 Female Primary PUS 3 3 Iliacal No No 82 56 Female Primary PUS 3 3 Popliteal  Yes No 61 63 Male Primary Myxoid chondrosarcoma na 3 Femoral  Yes No 50 37 Female Primary Leiomyosarcoma 1 1 Femoral  Yes No 36 28 Male Primary Synovial sarcoma 2 3 Femoral  Yes No 36 57 Female Primary PUS 3 3 Femoral  Yes No 35 42 Female Primary Synovial sarcoma 2 3 Iliacal Yes Yes 32 47 Female Primary PUS 3 3 Axillary  Yes No 30 58 Female Primary PUS 3 3 Popliteal  Yes No 26 27 Male Primary Epithelioid sarcoma 3 4 Axillary  Yes No 26 71 Male Recurrent  Myxoid fibrosarcoma 1 1 Axillary  No No 24 56 Female Primary PUS 3 3 Axillary  No No 22 14 Male Primary PUS 3 3 Popliteal  Yes No 20 65 Female Primary Synovial sarcoma 2 3 Popliteal  No Yes 18 63 Male Primary Synovial sarcoma 3 3 Iliacal Yes No 17 71 Male Primary Rhabdomyosarcoma 3 3 Iliacal Yes No 17 Local status of the treated limb was first globally assessed using a checklist including the following items: lymphedema, color, stiffness, hypesthesia, paresthesia, muscle atrophy, pain, scar status, function and use of aids. 14 20 21 22 Results 2 Table 2 Local status in 32 patients: deviating symptoms and signs Symptom No. % Lymphedema 14 44 Discoloration 18 56 Stiffness 16 50 Atrophy 27 84 Pain 5 16 Hypesthesia 17 53 Paresthesia 13 41 Function   - Limited 18 56   - Severely limited 4 13 LENT-SOMA Scales 3 Table 3 Modified LENT-SOMA scores  Maximum grade of toxicity 0 1 2 3 4 n   Subjective 6 19% 9 29% 2 6% 14 45% 0 0%   Objective 0 0% 0 0% 15 48% 16 52% 0 0%   Management 20 65% 1 3% 9 29% 1 3% 0 0% n   Subjective 6 20% 3 10% 9 30% 12 40% 0 0% a 6 21% 12 43% 7 25% 3 11% 0 0%   Management 23 77% 1 3% 4 13% 2 7% 0 0% n   Subjective 8 30% 15 56% 2 7% 2 7% 0 0%   Objective 1 4% 6 22% 15 56% 5 19% 0 0%   Management 23 85% 0 0% 0 0% 2 7% 2 7% n   Subjective 16 64% 4 16% 4 16% 1 4% 0 0%   Objective 13 52% 8 32% 2 8% 1 4% 1 4%   Management 18 72% 4 16% 0 0% 1 4% 2 8% a n Muscle/Soft Tissue 4 Table 4 n  Grade of toxicity 0 1 2 3 4 NA Subjective   - Pain 20 65% 7 23% 2 6% 2 6% 0 0% 0 0%   - Function 6 19% 9 29% 2 6% 14 45% 0 0% 0 0% Objective   - Edema 14 45% 10 32% 4 13% 2 6% 0 0% 1 3%   - Mobility and extremity function 6 19% 9 29% 11 35% 5 16% 0 0% 0 0%   - Fibrosis 1 3% 3 10% 15 48% 10 32% 0 0% 0 0%   - Atrophy 0 0% 3 10% 16 52% 10 32% 0 0% 2 6%   - Contraction 18 58% 0 0% 12 39% 0 0% 0 0% 1 3% Management   - Pain 25 81% 3 10% 3 10% 0 0% 0 0% 0 0%   - Edema 24 77% 0 0% 5 16% 1 3% 0 0% 1 3%   - Mobility and extremity function 27 87% 1 3% 2 6% 1 3% 0 0% 0 0%   - Fibrosis 29 94% 1 3% 0 0% 0 0% 0 0% 1 3%   - Atrophy 29 94% 0 0% 1 3% 0 0% 0 0% 1 3% Peripheral Nerves 5 Table 5 n  Grade of toxicity 0 1 2 3 4 NA Subjective   - Pain 20 67% 7 23% 1 3% 2 7% 0 0% 0 0%   - Strength 7 23% 1 3% 12 40% 8 27% 0 0% 2 7%   - Sensory 10 33% 11 37% 2 7% 6 20% 0 0% 1 3%   - Motor paresis 14 47% 8 27% 5 17% 2 7% 0 0% 1 3% Objective   - Motor dysfunction 7 23% 11 37% 7 23% 2 7% 1 3% 2 7%   - Sensory dysfunction 12 40% 12 40% 3 10% 1 3% 0 0% 2 7%   - Reflex 17 57% 7 23% 3 10% 0 0% 0 0% 3 10% Management   - Pain 22 73% 3 10% 4 13% 0 0% 0 0% 1 3%   - Motor dysfunction 25 83% 0 0% 0 0% 2 7% 0 0% 3 10%   - Sensory dysfunction 27 90% 0 0% 0 0% 0 0% 0 0% 3 10%   - Sensory 27 90% 0 0% 0 0% 0 0% 0 0% 3 10% Skin/Subcutaneous Tissue 6 Table 6 n  Grade of toxicity 0 1 2 3 4 NA Subjective   - Scaliness/ roughness 9 33% 16 59% 0 0% 2 7% 0 0% 0 0%   - Sensation 20 74% 5 19% 2 7% 0 0% 0 0% 0 0% Objective   - Edema 11 41% 8 30% 5 19% 2 7% 0 0% 1 4%   - Alopecia (scalp) 9 33% 13 48% 3 11% 1 4% 0 0% 1 4%   - Pigmentation change 6 22% 8 30% 11 41% 1 4% 0 0% 1 4%   - Ulcer/ necrosis 25 93% 1 4% 1 4% 0 0% 0 0% 0 0%   - Teleangiectasia 16 59% 7 26% 3 11% 0 0% 0 0% 1 4%   - Fibrosis/ scar 2 7% 19 70% 6 22% 0 0% 0 0% 0 0%   - Atrophy/ contraction 2 7% 15 56% 6 22% 2 7% 0 0% 2 7% Management   - Dryness 23 85% 1 4% 1 4% 1 4% 0 0% 1 4%   - Sensation 26 96% 0 0% 0 0% 0 0% 0 0% 1 4%   - Ulcer 26 96% 0 0% 0 0% 0 0% 1 4% 0 0%   - Edema 25 93% 0 0% 0 0% 2 7% 0 0% 0 0%   - Fibrosis/ scar 26 96% 0 0% 0 0% 0 0% 1 4% 0 0% Vessels 7 Table 7 n  Grade of toxicity 0 1 2 3 4 NA Subjective   - Arterial 20 80% 1 4% 3 12% 1 4% 0 0% 0 0%   - Venous 20 80% 4 16% 1 4% 0 0% 0 0% 0 0% Objective   - Arterial 22 88% 0 0% 1 4% 1 4% 1 4% 0 0%   - Venous 16 64% 8 32% 1 4% 0 0% 0 0% 0 0% Management   - Arterial 22 88% 0 0% 0 0% 1 4% 2 8% 0 0%   - Venous 21 84% 4 16% 0 0% 0 0% 0 0% 0 0% Subjective Objective Management subjective objective management n Discussion 5 6 23 24 25 However, acute toxicity and long-term morbidity due to the combined treatment procedure of ILP, surgical resection and EBRT cannot be prevented. In ILP, normal tissue in the limb is exposed to the same concentrations of cytostatic agents as the tumor. The effects of the perfusate on normal tissue vary widely among individuals and long-term morbidity also varies widely in severity. As far as we know, this is the first study to assess late functional morbidity with the LENT-SOMA scales in patients treated for STS with ILP, surgical resection and EBRT. Neurotoxicity 26 28 29 30 31 32 . Functional Morbidity 12 33 34 Scoring Systems 35 32 36 37 21 Quality of Life 38 39 40 Future Perspectives 30 15 30 41 30 31 7 32 In conclusion, the Subjective, Objective, and Management parts of the LENT-SOMA scoring system confirm late toxic effects on surrounding normal tissue in all patients treated with a combined treatment modality for locally advanced STS of the extremity. Two-thirds of the patients have severe Subjective or Objective damage, but half of all patients do not require any Management for their symptoms. To prevent long-term morbidity in the future, efforts should be made to reduce acute toxic reactions after ILP, and a fasciotomy and a customized rehabilitation program are recommended. Furthermore, anti-fibrotic therapies might be considered.