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J Surg Oncol 1996 Feb;61(2):90-9
Soft tissue sarcomas: preoperative versus
postoperative radiotherapy.
Cheng EY, Dusenbery KE, Winters MR, Thompson RC
Department of Orthopaedic Surgery, University of
Minnesota, Minneapolis.
External beam radiation may be given either before
or after excision of a primary soft tissue sarcoma. This study was undertaken to determine
whether or not the timing of radiotherapy was associated with any difference in either
local control, survival, or incidence of complications. The files of 112 patients with a
primary, nonmetastatic, extremity soft tissue sarcoma, treated with limb salvage surgery
and irradiation were evaluated. There was no significant difference in the 5-year RFS
between patients receiving radiotherapy (RT) preoperatively versus postoperatively; 56 +/-
15% and 67 +/- 12% (P = 0.12, Mantel-Cox), respectively. There was no significant
difference in the overall survival between patients receiving RT preoperatively versus
postoperatively; 75 +/- 15% and 79 +/- 11% (P = 0.94), respectively. Actuarial local
control at 5 years for preoperative versus postoperative RT patients was not statistically
different; 83 +/- 12% versus 91 +/- 8% (P = 0.41), respectively. Wound complications were
more frequent in preoperative RT patients (31%) compared to postoperative RT patients (8%)
(P = 0.0014, chi-square). Preoperative irradiation was not associated with any benefit in
terms of relapse-free survival, overall survival or actuarial local control in this
series. A higher incidence of major wound complications was found among patients treated
with preoperative irradiation. We recommend that patients with a
resectable extremity soft tissue sarcoma be treated with postoperative irradiation,
reserving preoperative irradiation for those situations in which either the tumor is
initially thought to be unresectable or the original tumor boundaries are obscured.
Int J Radiat Oncol Biol Phys 1995 Jul
15;32(4):969-76
Management of extremity soft tissue sarcomas with
limb-sparing surgery and postoperative irradiation: do total dose, overall treatment time,
and the surgery-radiotherapy interval impact on local control?
Fein DA, Lee WR, Lanciano RM, Corn BW, Herbert
SH, Hanlon AL, Hoffman JP, Eisenberg BL, Coia LR
Department of Radiation Oncology, Fox Chase Cancer
Center, Philadelphia, PA 19111, USA.
Sixty-seven patients with extremity soft tissue
sarcomas were treated with curative intent by limb-sparing surgery and postoperative
radiation therapy at the Fox Chase Cancer Center or the Hospital of the University of
Pennsylvania, between October 1970 and March 1991. Follow-up ranged from 4-218 months. The median external beam dose was 60.4 Gy. In 13 patients,
interstitial brachytherapy was used as a component of treatment. RESULTS: The 5-year local
control rate for all patients was 87%. The 5-year local control rate
for patients who received < or = 62.5 Gy was 78% compared to 95% for patients who
received > 62.5 Gy had larger tumors (p = 0.008) and a higher percentage of
Grade 3 tumors and positive margins than patients who received < or = 62.5 Gy. The 5-year local control rate for patients with negative or close margins
was 100% vs. 56% in patients with positive margins (p = 0.002). Cox proportional
hazards regression analysis was performed using the following variables as covariates:
tumor dose, overall treatment time, interval from surgery to initiation of radiation
therapy, margin status, grade, and tumor size. Total dose (p = 0.04) and margin status (p
= 0.02) were found to significantly influence local control. Only tumor size significantly
influenced distant metastasis (p = 0.01) or survival (p = 0.03). CONCLUSION: Postoperative
radiation therapy doses > 62.5 Gy were noted to significantly improve local control in
patients with extremity soft tissue sarcomas. This is the first analysis in the literature
to demonstrate the independent influence of total dose on local control of extremity soft
tissue sarcomas treated with adjuvant postoperative irradiation.
Int J Radiat Oncol Biol Phys 1995 Jul
15;32(4):977-85
Conservative surgery and adjuvant radiation
therapy in the management of adult soft tissue sarcoma of the extremities: clinical and
radiobiological results.
Mundt AJ, Awan A, Sibley GS, Simon M, Rubin SJ,
Samuels B, Wong W, Beckett M, Vijayakumar S, Weichselbaum RR
Department of Radiation and Cellular Oncology,
University of Chicago/Michael Reese Hospitals, IL 60637, USA.
Sixty-four consecutive adult patients with soft
tissue sarcoma of the extremities (40 lower, 24 upper) who underwent conservative surgery
and adjuvant irradiation 7 preoperative, 50 postoperative, 7 perioperative) between 1978
and 1991 were reviewed. The initial radiation field margin surrounding the tumor bed/scar
was retrospectively analyzed in all postoperative patients. Initial field margins were
< 5 cm in 12 patients, 5-9.9 cm in 32 and > or = 10 cm in 6. Patients with negative
pathological margins were initially treated with traditional postoperative doses (64-66
Gy); however, in later years the postoperative dose was reduced to 60 Gy. Thirteen cell
lines were established prior to definite therapy, and radiobiological parameters
(multitarget and linear-quadratic) were obtained and correlated with outcome. RESULTS: Postoperative patients treated with an initial field margin of < 5 cm
had a 5-year local control of 30.4% vs. 93.2% in patients treated with an initial margin
of > or = 5 cm (p = 0.0003). Five-year local control rates were similar in
patients treated with initial field margins of 5-9.9 cm (91.6%) compared with those
treated with > or = 10 cm margins (100%) (p = 0.49). While
postoperative patients receiving < 60 Gy had a worse local control than those receiving
> or = 60 Gy (p = 0.08), no difference was seen in local control between patients
receiving less than traditional postoperative doses (60-63.9 Gy) (74.4% vs. those
receiving 64-66 Gy (87.0%) (p = 0.5). The local control of patients treated in the
later years of the study, with strict attention to surgical and radiotherapeutic
technique, was 87.6%. Severe late sequelae were more frequent in patients treated with
doses > or = 63 Gy compared to patients treated with lower doses (23.1% vs. 0%) (p <
0.05). Mean values for Do, alpha, beta, D, n and SF2 obtained from the 13 cell lines were
115.7, 0.66, 0.029, 2.15, 0.262, respectively. Four of the 13 cell lines established prior
to therapy ultimately failed locally. The radiobiological parameters of these cell lines
were similar to the other nine cell lines in terms of radiosensitivity. CONCLUSIONS: Our data confirm the importance of maintaining an initial field margin
of at least 5 cm around the tumor bed/scar in the postoperative setting. No
benefit was seen with the use of margins > or = 10 cm. In addition, patients undergoing
wide local excision with negative margins can be treated with
lower than traditional postoperative doses (60 Gy) without compromising local control
and with fewer chronic sequelae. Finally, it does not appear that inherent tumor cell
sensitivity is a major determinant of local failure following radiation therapy and
conservative surgery in soft tissue sarcoma.
Ann Acad Med Singapore 1996 Nov;25(6):855-61
Soft tissue sarcomas: radiation as a therapeutic
option.
Suit H, Spiro IJ
Department of Radiation Oncology, Massachusetts
General Hospital, Harvard Medical School 02114-2617, USA.
For most adult patients, this currently is
attempted by a combination of relatively conservative surgery and moderate dose of
radiation. The concept being that radiation at dose levels of 50 to 60 Gy is adequate to
inactivate the tumour cells which lie beyond the margins of a conservative resection,
i.e., it replaces the resection of large volumes of normal tissue. this combined modality
approach has been demonstrated to be effective. The frequency of
local control (85% to 90%) is at least as high as that combined by ablative surgery, but
with much lesser decrement in functional and cosmetic status. Additionally,
radiation at dose levels of about 75 Gy is effective in achieving worthwhile local control
rates when administered against small sarcomas of the soft tissues, e.g. volumes of <
or = 60 ml. Thus, for selected tumours, radiation alone does offer a reasonable option
when surgery is not feasible for technical reasons or the patient is not operable for
medical reasons. Available data do not indicate a clear advantage for adjuvant
chemotherapy for this group of tumours. Trials are in progress to assess the efficacy of
neo-adjuvant chemotherapy. We are conducting a phase II trial of MAID chemotherapy and
radiation preoperatively; the results to date are superior to matched concurrently treated
patients. For local therapy, high and approximately comparable local control rates are
being reported for several approaches: radical compartmental resection for selected
patients, surgery and postoperative radiation therapy, surgery and preoperative radiation
treatment, resection and intraoperative placement of catheters for brachytherapy and
intra-arterial adriamycin, radiation and resection. Our preferred approach for T 2, grades
II-III sarcomas of the soft tissues is radiation prior to surgery. There are, however, no
data on the functional and cosmetic status after treatment of patients whose sarcomas are
of a specified site and volume for treatment by these diverse methods. This is a
critically important question in the assessment of proper clinical role of each of these
approaches.
Eur J Cancer 1994;30A(6):746-51
Local control of soft tissue sarcoma of the
extremity: the experience of a multidisciplinary sarcoma group with definitive surgery and
radiotherapy.
Wilson AN, Davis A, Bell RS, O'Sullivan B, Catton
C, Madadi F, Kandel R, Fornasier VL
Department of Radiation Oncology, Princess
Margaret Hospital, Toronto, Canada.
Data gathered on 62 patients with soft tissue
sarcoma of an extremity, treated in entirety by an experienced multidisciplinary sarcoma
group, were analysed. With a philosophy of emphasising attainment of histologically
negative margins at carefully planned limb sparing surgery, combined with either
pre-operative or postoperative radiation therapy, a crude local
control rate of 95% (59 of 62 patients) at a minimum of 24 months follow-up was
obtained. Of 9 patients with microscopically positive margins after definitive surgery, 8
had undergone maximal resection compatible with preservation of function. One of these 9
failed locally, indicating that radiation therapy is effective in eradicating microscopic
disease in this tumour. The excellent local control obtained with limb-sparing surgery in
this series justifies early referral of patients with these uncommon cancers to an
experienced multidisciplinary unit. 26 patients (42%) failed
systemically at a minimum of 24 months follow-up, and 19 (30.6%) died of their disease,
confirming the need for effective systemic therapy in soft tissue sarcoma. Tumours
greater than 10 cm in diameter had a greater risk of systemic relapse.
Eur J Cancer 1994;30A(11):1636-42
Local recurrences of soft tissue sarcomas in
adults: a retrospective analysis of prognostic factors in 102 cases after surgery and
radiation therapy.
Dinges S, Budach V, Budach W, Feldmann HJ,
Stuschke M, Sack H
Dept. of Radiation Therapy, West German Tumour
Centre, University of Essen.
Between 1974 and 1990, 102 adult patients (age
18-86 years) with the diagnosis of a soft tissue sarcoma (STS) were treated with photons
and/or electrons in combination with surgery. The total doses in the
initial treatment volume (second order target volume) was 40-50 Gy. For the coning down
volume (first order target volume) the median total dose was 59 Gy (range 45-72 Gy).
A total of 18% (18/102) local failures was observed.
In multivariate analysis, prognostic factors for the occurrence of a local failure were
identified as follows: treatment of a primary or recurrent STS (P = 0.02), total dose (P =
0.025) and tumour grade (P = 0.05). Mode of surgery, tumour size (trunk versus extremity),
pre- or postoperative radiotherapy, combined chemotherapy and tumour size (T1 versus T2)
had no significant impact on the local relapse-free survival. These data give further
evidence that combined surgery and radiotherapy is an effective modality in treatment of
soft tissue sarcomas.
Oncology (Huntingt) 1996 Dec;10(12):1867-72;
discussion 1872-4
Role of radiation therapy in retroperitoneal
sarcomas.
Clark JA, Tepper JE
Department of Radiation Oncology, University of
North Carolina, School of Medicine, Chapel Hill, USA.
Historically, patients with retroperitoneal
sarcomas have had a poor prognosis. Surgical resection continues to be the standard
treatment for these tumors. However, their anatomic location and large size at
presentation often make complete surgical resection infeasible. Even with complete gross
removal of tumor, most patients will experience local failure. Adjuvant radiation therapy
has been used to improve local control rates. In the postoperative setting, radiation
doses to the tumor bed are limited by radiation tolerances of surrounding normal tissues.
Extrapolation of data from soft-tissue sarcomas at other sites suggests that delivery of
higher radiation doses, in combination with surgery, may favorably affect local control.
Preoperative radiation therapy, in combination with brachytherapy or intraoperative
radiation therapy at the time of surgical resection, allows for the safe delivery of
higher doses of radiation than is possible in the postoperative setting. These approaches
make it possible to maximize the likelihood of local control and cure while minimizing
normal tissue toxicity. |
