Localized and metastatic soft tissue sarcomas 

Authored by Michael Wagner, published on 2026-05-22 17:46:03.0

The algorithm is broadly consistent with contemporary soft tissue sarcoma practice: surgery with selective radiotherapy for localized disease, and anthracycline-based systemic therapy followed by histology-appropriate later-line options for metastatic disease. Key metastatic options listed (doxorubicin, gemcitabine/docetaxel, trabectedin for LMS/LPS, pazopanib for non-adipocytic STS, eribulin for LPS) align with major guidelines and pivotal trials. However, the localized neoadjuvant chemotherapy and especially neoadjuvant pembrolizumab + RT for UPS are more selective/center-dependent and supported by smaller or evolving evidence.

  1. Confirmed soft tissue sarcoma (STS)
    Foundational guidelines support the overall diagnostic/management framework and the localized vs metastatic treatment principles reflected across the algorithm.
    • Localized
      • Routine perioperative chemotherapy not clearly beneficial
        • Consider neoadjuvant doxorubicin + ifosfamide to shrink tumor and facilitate surgery
          • SURGERY
            • Extremity STS: often add RT
            • Abdominal/retroperitoneal STS: RT used selectively
        • Undifferentiated pleomorphic sarcoma (UPS): consider neoadjuvant pembrolizumab + radiation therapy
          • SURGERY
            • Extremity STS: often add RT
            • Abdominal/retroperitoneal STS: RT used selectively
    • Metastatic
      • Leiomyosarcoma (LMS)
        consider Doxo + trabectedin, followed by maintenance trab x 1 year
        • Consider doxorubicin + trabectedin (LMS)
          • Maintenance trabectedin for 1 year
      • Other soft tissue sarcomas
        • Doxorubicin
          • Gemcitabine + docetaxel
            • Trabectedin (LMS/LPS)
              (LMS + LPS)
            • Pazopanib (non-adipocytic STS)
              (not LPS)
            • Eribulin (LPS)
              (LPS)
            • Clinical trials
              (M6, Anlotinib; ledi: ???)
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