1
|
Martinez C, Asso RN, Rastogi N, Freeman CR, Cury FL. Neutrophil-to-lymphocyte ratio for the prediction of soft tissue sarcomas response to pre-operative radiation therapy. Radiother Oncol 2024; 195:110239. [PMID: 38521165 DOI: 10.1016/j.radonc.2024.110239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 02/27/2024] [Accepted: 03/19/2024] [Indexed: 03/25/2024]
Abstract
PURPOSE/OBJECTIVE This study aims to assess the prognostic value of the neutrophil-to-lymphocyte ratio (NLR) in soft tissue sarcomas (STS) treated with pre-operative hypofractionated radiotherapy (HFRT). MATERIALS/METHODS This retrospective analysis included patients treated with pre-operative HFRT of 30 Gy in 5 fractions between 2016 and 2023. Clinical, demographic, and complete blood count (CBC) data were collected. NLR was calculated by dividing the absolute neutrophil count by the absolute lymphocyte count. Only patients with CBCs conducted within 6 months after radiotherapy were included. Cox proportional-hazard regression models were used to assess the impact of NLR and different variables on outcomes. Kaplan Meier were used to illustrate survival curves. A p-value < 0.05 was considered significant, and 95 % confidence intervals (CI) were employed. RESULTS A total of 40 patients received HFRT and had CBCs within 6 months after radiotherapy. There were 17 (42.5 %) females and 23 (57.5 %) males with a mean age of 66 years. The mean largest tumor size dimension was 7.1 cm, and the mean NLR post-RT was 5.3. The most frequent histological subtypes were myxofibrosarcoma (17.5 %), pleomorphic spindle cell sarcoma (10 %), leiomyosarcoma (7.5 %), and myxoid liposarcoma (5 %). The median follow-up period was 15.4 months. From all patients, 14 patients had disease progression, 12 metastatic disease and 3 died of disease. Multivariable Cox proportional-hazards regression analysis displayed that a higher post-RT NLR was associated with worse disease-free survival (DFS) (HR: 1.303 [1.098-1.548], p = 0.003), and distant metastasis-free survival (DMFS) (HR: 1.38 [1.115-1.710], p = 0.003). Moreover, post-NLR ≥ 4 as a single variable was associated with worse DFS, DMFS, but not worse local recurrence or overall survival. CONCLUSION This study is the first to evaluate NLR as a prognostic biomarker in STS patients treated with pre-operative radiotherapy. A higher NLR after pre-operative radiotherapy was associated with increased disease progression.
Collapse
Affiliation(s)
- Constanza Martinez
- Division of Radiation Oncology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Rie N Asso
- Division of Radiation Oncology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Neelabh Rastogi
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Carolyn R Freeman
- Division of Radiation Oncology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Fabio L Cury
- Division of Radiation Oncology, McGill University Health Centre, Montreal, Quebec, Canada.
| |
Collapse
|
2
|
Laskar S, Manjali JJ, Chargari C, Chard J. Brachytherapy for Organ and Function Preservation in Soft-Tissue Sarcomas in Adult and Paediatric Patients. Clin Oncol (R Coll Radiol) 2023:S0936-6555(23)00218-2. [PMID: 37344243 DOI: 10.1016/j.clon.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 05/31/2023] [Accepted: 06/06/2023] [Indexed: 06/23/2023]
Abstract
Adjuvant radiotherapy is an integral component in the management of soft-tissue sarcomas. Brachytherapy is a very convenient and conformal way of delivering adjuvant radiotherapy in such tumours, which spares the surrounding normal tissue. Randomised studies have established the efficacy of brachytherapy in the adjuvant setting, with a 5-year local control of 80-85%. High dose rate, low dose rate and pulsed dose rate have shown equivalent local control, but high dose rate has gained popularity owing to patient convenience, radiation safety and flexibility in dose optimisation. Freehand insertion perioperative brachytherapy (intraoperative placement and postoperative treatment) is the most commonly used technique in soft-tissue sarcomas, with intraoperative radiotherapy and radioactive seed placement being the less commonly used techniques. Brachytherapy can be used as monotherapy or in combination with external beam radiotherapy, such as in cases of close/positive margins for safe dose escalation. Although the quantum of side-effects with external beam radiotherapy has considerably reduced with the evolution of technology and the introduction of intensity modulation (intensity-modulated radiotherapy), brachytherapy still scores better in terms of dose conformality, especially in recurrent tumours (previously irradiated) and when used to treat paediatric and geriatric patients.
Collapse
Affiliation(s)
- S Laskar
- Department of Radiation Oncology, Tata Memorial Centre (TMC), Mumbai, India; Homi Bhabha National Institute (HBNI), Anushakti Nagar, Mumbai, India.
| | - J J Manjali
- Department of Radiation Oncology, Tata Memorial Centre (TMC), Mumbai, India; Homi Bhabha National Institute (HBNI), Anushakti Nagar, Mumbai, India
| | - C Chargari
- Department of Radiation Oncology, Institute Gustave Roussy, France
| | - J Chard
- Department of Radiation Oncology, Westmead Hospital, Sydney, Australia
| |
Collapse
|
3
|
Brachytherapy in the Treatment of Soft-Tissue Sarcomas of the Extremities-A Current Concept and Systematic Review of the Literature. Cancers (Basel) 2023; 15:cancers15041133. [PMID: 36831476 PMCID: PMC9954233 DOI: 10.3390/cancers15041133] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/02/2023] [Accepted: 02/06/2023] [Indexed: 02/12/2023] Open
Abstract
INTRODUCTION Evidence on the use of brachytherapy in soft-tissue sarcoma (STS) is sparse. Therapy regimens are determined more by local interdisciplinary tumor conferences than by standardized protocols. Patient-specific factors complicate the standardized application of therapy protocols. The individuality of the treatment makes it difficult to compare results. MATERIALS AND METHODS A comprehensive literature search was conducted, whereby the literature from a period of almost 44 years (1977-2021) was graded and included in this systematic review. For this purpose, PubMed was used as the primary database. Search string included "soft-tissue sarcoma", "brachytherapy", and "extremity." Four independent researchers reviewed the literature. Only full-text articles written in English or German were included. RESULTS Of the 175 identified studies, 70 were eligible for analysis based on the inclusion and exclusion criteria. The key points to compare were local complications, recurrence rate and correlation with margins of resection, and the use of brachytherapy regarding tumor grading. CONCLUSION Brachytherapy represents an important subset of radiotherapy techniques used in STSs, whose indications and applications are constantly evolving, and for which a local control rate of 50% to 96% has been reported as monotherapy, depending on risk factors. However, the best benefit is seen in the combination of further resection and brachytherapy, and most authors at many other centers agree with this treatment strategy.
Collapse
|
4
|
Hatoum GF, Temple HT, Garcia SA, Zheng Y, Kfoury F, Kinley J, Wu X. Neoadjuvant Radiation Therapy with Interdigitated High-Dose LRT for Voluminous High-Grade Soft-Tissue Sarcoma. Cancer Manag Res 2023; 15:113-122. [PMID: 36776730 PMCID: PMC9910204 DOI: 10.2147/cmar.s393934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 01/18/2023] [Indexed: 02/05/2023] Open
Abstract
Purpose To report a case of large extremity soft tissue sarcoma (2933 cc), safely treated with a novel approach of interdigitating high-dose LATTICE radiation therapy (LRT) with standard radiation therapy as a neoadjuvant treatment to surgery. Patients and Methods Four sessions of high-dose LRT were delivered in a weekly interval, interdigitated with standard radiation therapy. The LRT plan consisted of 15 high-dose vertices receiving a dose >12 Gy per session, with 2-3 Gy to the peripheral margin of the tumor. The patient underwent surgical excision 2 months after the new regimen of induction radiation therapy. Results and Discussion The patient tolerated the radiation therapy regimen well. The post-operative assessment revealed a negative surgical margin and over 95% necrosis of the total tumor volume. The post-surgical wound complication was mitigated by outpatient wound care. Interdigitating multiple sessions of high-dose LATTICE radiation treatments with standard neoadjuvant radiation therapy as a neoadjuvant therapy for soft tissue sarcoma was feasible and did not incur additional toxicity in this clinical case. A phase-I/II trial will be conducted to further evaluate the toxicity and efficacy of the new treatment strategy with the intent to increase the rate of pathologic necrosis, which has been shown to positively correlate with the overall survival.
Collapse
Affiliation(s)
- Georges F Hatoum
- Department of Radiation Oncology, HCA Florida JFK Medical Center Comprehensive Cancer Institute, Lake Worth, FL, USA
| | - H Thomas Temple
- Department of Orthopedic Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Silvio A Garcia
- Department of Radiation Oncology, HCA Florida JFK Medical Center Comprehensive Cancer Institute, Lake Worth, FL, USA
| | - Yi Zheng
- Department of Radiation Oncology, HCA Florida JFK Medical Center Comprehensive Cancer Institute, Lake Worth, FL, USA,Department of Research and Development, Executive Medical Physics Associates, North Miami Beach, FL, USA
| | - Fouad Kfoury
- Pharmacy Department, South Miami Hospital, South Miami, FL, USA
| | - Jill Kinley
- Department of Clinical Research, HCA Florida JFK Medical Center, Atlantis, FL, USA
| | - Xiaodong Wu
- Department of Radiation Oncology, HCA Florida JFK Medical Center Comprehensive Cancer Institute, Lake Worth, FL, USA,Department of Research and Development, Executive Medical Physics Associates, North Miami Beach, FL, USA,Correspondence: Xiaodong Wu, Executive Medical Physics Associates, 19470 NE 22nd Road, North Miami Beach, FL, 33179, USA, Tel +1 305 775 0333, Email
| |
Collapse
|
5
|
Low rate of function-limiting side effects with high-dose adjuvant radiotherapy in high-grade soft tissue extremity sarcomas: a retrospective single-center analysis over 10 years. J Cancer Res Clin Oncol 2022:10.1007/s00432-022-04423-1. [PMID: 36287264 PMCID: PMC9607852 DOI: 10.1007/s00432-022-04423-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 10/14/2022] [Indexed: 11/17/2022]
Abstract
Background Over the years, radiotherapy has been established as a tool to improve local control for high-grade sarcomas. Although the European Society for Medical Oncology guidelines has taken notice of a shift toward a neoadjuvant radiotherapy approach, the American Society for Radiation Oncology guidelines clearly favor a neoadjuvant approach, citing debilitating long-term adverse effects when radiotherapy is applied postoperatively. In this study, we examined these irradiation-associated adverse events for adjuvant radiotherapy and focused on the prognostic factors for disease outcome, including local control. Methods In this retrospective study, data for 106 patients with extremity soft-tissue sarcomas diagnosed between 1997 and 2021, of which 40 received adjuvant radiotherapy, were collected from the clinical and radiological information systems of a high-volume sarcoma treatment center. These data were then analyzed for radiation-associated side effects as well as predictive factors for overall survival, disease-free survival, local control, and surgical complications. Results Radiotherapy was beneficial to patients improving local control, especially for high-grade sarcomas, even when those were resected with negative margins. Side effects due to radiotherapy occurred in 87.5% of the patients, and these effects primarily included radiation dermatitis in 67.5%; however, only 40.0% had any adverse event of ≥ grade 2 according to Common Terminology Criteria for Adverse Events. Long-term function-limiting side effects occurred in 45.0% of the patients; 10% exhibited ≥ grade 2 function-limiting adverse events. Greater time between surgery and adjuvant radiotherapy was beneficial for the patients, whereas joint infiltrating sarcomas were associated with more severe long term, function-limiting adverse events. 28.3% of the patients experienced a recurrence at any location (median time 18.35 months) and in 16% the recurrence was local (median time 16.11 months), resulting in 1, 3, and 5 year disease-free survival rates of 74.1, 58.9, and 38.5% and local control rates of 78.7, 61.6, and 42.8% were observed, respectively. Conclusion Recurrences may be avoided with high-dose radiation, especially for high-grade G2 and G3 sarcomas, even after complete R0 resection. This resulted in a low rate of severe long-term function-limiting adverse events. Thus, adjuvant radiotherapy should be seriously considered when planning patient treatment, especially when treating patients that present with high-grade sarcomas. Supplementary Information The online version contains supplementary material available at 10.1007/s00432-022-04423-1.
Collapse
|
6
|
Cammelli S, Cortesi A, Buwenge M, Zamagni A, Ferioli M, Ghigi G, Romeo A, Morganti AG. The role of radiotherapy in adult soft tissues sarcoma of the extremities. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:1583-1596. [PMID: 33954820 PMCID: PMC8702420 DOI: 10.1007/s00590-021-02990-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 04/18/2021] [Indexed: 01/19/2023]
Abstract
Local management of adult soft tissue sarcoma of the extremities has evolved over the past decades. Until the 1970s, radical surgery (amputations) was the standard therapeutic procedure resulting in significant physical and psychological morbidity for the patients. In the present era, limb sparing surgery combined with radiotherapy represents the current standard of care for high grade and > 5 cm STSs. This approach guarantees high local control rate and function preservation. The aim of this paper is to summarize the current evidence for RT in STSs of the extremities. Outcomes, technical details (techniques, timing, dose, volumes of treatment) and the emerging role of RT in the management of oligometastatic disease will be analysed. Finally, results of the recent clinical trials testing new scenarios in RT of STSs will be described.
Collapse
Affiliation(s)
- Silvia Cammelli
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy. .,Department of Experimental, Diagnostic and Specialty Medicine-DIMES, Alma Mater Studiorum University of Bologna, Bologna, Italy.
| | - Annalisa Cortesi
- Radiotherapy Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Milly Buwenge
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Experimental, Diagnostic and Specialty Medicine-DIMES, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Alice Zamagni
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Experimental, Diagnostic and Specialty Medicine-DIMES, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Martina Ferioli
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Experimental, Diagnostic and Specialty Medicine-DIMES, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Giulia Ghigi
- Radiotherapy Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Antonino Romeo
- Radiotherapy Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Alessio G Morganti
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Experimental, Diagnostic and Specialty Medicine-DIMES, Alma Mater Studiorum University of Bologna, Bologna, Italy
| |
Collapse
|
7
|
Reddy VK, Jain V, Venigalla S, Levin WP, Wilson RJ, Weber KL, Kalbasi A, Sebro RA, Shabason JE. Radiotherapy Remains Underused in the Treatment of Soft-Tissue Sarcomas: Disparities in Practice Patterns in the United States. J Natl Compr Canc Netw 2021; 19:295-306. [PMID: 33556919 DOI: 10.6004/jnccn.2020.7625] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 07/22/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND Practice patterns of radiation therapy (RT) use for soft-tissue sarcoma (STS) remain quite variable, despite clinical practice guidelines recommending the addition of RT to surgery for patients with high-grade STS, particularly for larger tumors. Using the National Cancer Database (NCDB), we assessed patterns of overall RT use, neoadjuvant versus adjuvant treatment, and specific RT modalities in this population. PATIENTS AND METHODS Patients aged ≥18 years with stage II/III STS in 2004 through 2015 were identified from the NCDB. Patterns of care were assessed using multivariable logistic regression analysis. RESULTS Of 27,426 total patients, 11,654 (42%) were treated with surgery alone versus 15,772 (58%) with RT in addition to surgery, with no overall increase in RT use over the study period. Notable clinical predictors of receipt of RT included tumor size (>5 cm), grade III, and tumors arising in the extremities. Conversely, female sex, older age (≥70 years), Black race, noncommercial insurance coverage, farther distance to treatment, and poor performance status were negative predictors of RT use. Of those receiving RT, 27% were treated with neoadjuvant RT and 73% with adjuvant RT. The proportion of those receiving neoadjuvant RT increased over time. Relevant factors associated with neoadjuvant RT included treatment at academic centers, larger tumor size, and extremity tumors. Of those who received RT with a modality specified as either intensity-modulated RT (IMRT) or 3D conformal RT (3DCRT), 61% were treated with IMRT and 39% with 3DCRT. The proportion of patients treated with IMRT increased over time. Relevant factors associated with IMRT use included treatment at academic centers, commercial insurance coverage, and larger and nonextremity tumors. CONCLUSIONS Although use of neoadjuvant RT and IMRT has increased over time, a significant number of patients with STS are not receiving adjuvant or neoadjuvant RT. Our findings also note potential sociodemographic disparities and highlight the concern that not all patients with STS are being equally considered for RT.
Collapse
Affiliation(s)
| | | | | | | | - Robert J Wilson
- 2Department of Orthopedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kristy L Weber
- 2Department of Orthopedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anusha Kalbasi
- 3Department of Radiation Oncology, UCLA Medical Center, Los Angeles, California
| | - Ronnie A Sebro
- 2Department of Orthopedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.,4Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and.,5Department of Genetics and.,6Department of Biostatistics, Epidemiology and Bioinformatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | | |
Collapse
|
8
|
Ngan SY, Chu J, Chander S. The Role of Radiotherapy for Sarcoma. Sarcoma 2021. [DOI: 10.1007/978-981-15-9414-4_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
|
9
|
Radiation Therapy in Adult Soft Tissue Sarcoma-Current Knowledge and Future Directions: A Review and Expert Opinion. Cancers (Basel) 2020; 12:cancers12113242. [PMID: 33153100 PMCID: PMC7693687 DOI: 10.3390/cancers12113242] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 12/13/2022] Open
Abstract
Simple Summary Radiation therapy (RT) is an integral part of the treatment of adult soft-tissue sarcomas (STS). Although mainly used as perioperative therapy to increase local control in resectable STS with high risk features, it also plays an increasing role in the treatment of non-resectable primary tumors, oligometastatic situations, or for palliation. This review summarizes the current evidence for RT in adult STS including typical indications, outcomes, side effects, dose and fractionation regimens, and target volume definitions based on tumor localization and risk factors. It covers the different overall treatment approaches including RT either as part of a multimodal treatment strategy or as a sole treatment and is accompanied by a summary on ongoing clinical research pointing at future directions of RT in STS. Abstract Radiation therapy (RT) is an integral part of the treatment of adult soft-tissue sarcomas (STS). Although mainly used as perioperative therapy to increase local control in resectable STS with high risk features, it also plays an increasing role in the treatment of non-resectable primary tumors, oligometastatic situations, or for palliation. Modern radiation techniques, like intensity-modulated, image-guided, or stereotactic body RT, as well as special applications like intraoperative RT, brachytherapy, or particle therapy, have widened the therapeutic window allowing either dose escalation with improved efficacy or reduction of side effects with improved functional outcome. This review summarizes the current evidence for RT in adult STS including typical indications, outcomes, side effects, dose and fractionation regimens, and target volume definitions based on tumor localization and risk factors. It covers the different overall treatment approaches including RT either as part of a multimodal treatment strategy or as a sole treatment, namely its use as an adjunct to surgery in resectable STS (perioperative RT), as a primary treatment in non-resectable tumors (definitive RT), as a local treatment modality in oligometastatic disease or as palliative therapy. Due to the known differences in clinical course, general treatment options and, consequently, outcome depending on lesion localization, the main part of perioperative RT is divided into three sections according to body site (extremity/trunk wall, retroperitoneal, and head and neck STS) including the discussion of special applications of radiation techniques specifically amenable to this region. The review of the current evidence is accompanied by a summary on ongoing clinical research pointing at future directions of RT in STS.
Collapse
|
10
|
Six-Week Interval Between Preoperative Radiation and Surgery Is Associated With Fewer Major Wound Complications in Soft Tissue Sarcoma. Am J Clin Oncol 2020; 43:491-495. [PMID: 32217853 DOI: 10.1097/coc.0000000000000692] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES A total of 30% to 40% of soft tissue sarcoma (STS) patients develop major wound complications (MWCs) after preoperative radiation (preRT). The optimal preRT-surgery interval and its association with MWCs is unknown. This study investigated whether a longer preRT-surgery interval is associated with fewer MWCs compared with historical controls. METHODS All patients treated by a single surgeon after preRT with limb-sparing wide resection for extremity and trunk STS were retrospectively reviewed from 2004 to 2014. The primary outcome was MWCs defined as a secondary operation, invasive procedure, wound packing, or readmission for wound care. Secondary outcomes of local recurrence and survival were followed and independent variables were analyzed for an association with MWCs. RESULTS Fifty-four patients were included with a median follow-up of 32 months and age of 61 years. The majority of tumors were deep (91%), large (median size of 11 cm), high grade (78%) and within the lower extremity (78%). The median preRT-surgery interval was 43 days and 80% of patients received surgery 35 to 49 days after radiation. MWCs were observed in 15% of patients and 88% occurred within 40 days. Predictors for MWCs on multivariate analysis were peripheral vascular disease (P=0.03), location in the medial compartment of the thigh (P=0.03), and neurovascular involvement (P=0.03). CONCLUSIONS This study presents a cohort of STS patients with an extended preRT-surgery interval of ~6 weeks. MWCs in this population occurred at a lower rate than historical controls. Overall these findings support the exploration of a longer interval to reduce MWCs and their associated morbidity.
Collapse
|
11
|
Neoadjuvant Radiotherapy-Related Wound Morbidity in Soft Tissue Sarcoma: Perspectives for Radioprotective Agents. Cancers (Basel) 2020; 12:cancers12082258. [PMID: 32806601 PMCID: PMC7465163 DOI: 10.3390/cancers12082258] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 07/10/2020] [Accepted: 08/10/2020] [Indexed: 12/18/2022] Open
Abstract
Historically, patients with localized soft tissue sarcomas (STS) of the extremities would undergo limb amputation. It was subsequently determined that the addition of radiation therapy (RT) delivered prior to (neoadjuvant) or after (adjuvant) a limb-sparing surgical resection yielded equivalent survival outcomes to amputation in appropriate patients. Generally, neoadjuvant radiation offers decreased volume and dose of high-intensity radiation to normal tissue and increased chance of achieving negative surgical margins-but also increases wound healing complications when compared to adjuvant radiotherapy. This review elaborates on the current neoadjuvant/adjuvant RT approaches, wound healing complications in STS, and the potential application of novel radioprotective agents to minimize radiation-induced normal tissue toxicity.
Collapse
|
12
|
Roeder F, Morillo V, Saleh-Ebrahimi L, Calvo FA, Poortmans P, Ferrer Albiach C. Intraoperative radiation therapy (IORT) for soft tissue sarcoma - ESTRO IORT Task Force/ACROP recommendations. Radiother Oncol 2020; 150:293-302. [PMID: 32679306 DOI: 10.1016/j.radonc.2020.07.019] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 07/07/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE To describe guidelines for the use of intraoperative radiation therapy (IORT) in the treatment of soft-tissue sarcomas (STS). METHODS A panel of experts in the field performed a systematic literature review, supplemented their clinical experience and developed recommendations for the use of IORT in the treatment of STS. RESULTS Based on the evidence from the systematic literature review and the clinical experience of the panel members, recommendations regarding patient selection, incorporation into multimodal treatment concepts and the IORT procedure itself are made. The rationale for IORT in extremity and retroperitoneal STS is summarized and results of the major series in terms of patient and treatment characteristics, oncological outcome and toxicity are presented. We define surgical factors, volumes for irradiation, technical requirements, dose prescription, recording and reporting, treatment delivery and care during the course of IORT covering the main IORT techniques used for the treatment of STS. In extremity STS, evidence originates from a few small prospective and mainly from retrospective single centre studies. Based on those reports, IORT containing-approaches result in very high local control rates with low rates of acute and late toxicity. In retroperitoneal sarcomas, evidence is derived from one prospective randomized trial, a few prospective and a large number of retrospective studies. The randomized trial compared IORT combined with moderate doses of postoperative external-beam radiation therapy (EBRT) to high-dose postoperative EBRT alone after gross total resection, clearly favouring the IORT-containing approach. These results have been confirmed by the prospective and retrospective studies, which similarly showed high local control rates with acceptable toxicity, mainly favouring combinations of preoperative EBRT and IORT. CONCLUSIONS IORT-containing approaches result in high rates of local control with low to acceptable toxicity rates. Based on the available evidence, we made recommendations for the use of IORT in STS. Clinicians and researchers are encouraged to use these guidelines in clinical routine as well as in the design of future trials.
Collapse
Affiliation(s)
- Falk Roeder
- Department of Radiotherapy and Radio-Oncology, Paracelsus Medical University Hospital Salzburg, Landeskrankenhaus, Salzburg, Austria.
| | - Virginia Morillo
- Department of Radiation Oncology, Instituto de Oncologia, Hospital Provincial de Castellon, Spain
| | | | - Felipe A Calvo
- Department of Oncology, Clínica Universidad de Navarra, Madrid, Spain
| | | | - Carlos Ferrer Albiach
- Department of Radiation Oncology, Instituto de Oncologia, Hospital Provincial de Castellon, Spain
| |
Collapse
|
13
|
Kalbasi A, Kamrava M, Chu FI, Telesca D, Van Dams R, Yang Y, Ruan D, Nelson SD, Dry SM, Hernandez J, Chmielowski B, Singh AS, Bukata SV, Bernthal NM, Steinberg ML, Weidhaas JB, Eilber FC. A Phase II Trial of 5-Day Neoadjuvant Radiotherapy for Patients with High-Risk Primary Soft Tissue Sarcoma. Clin Cancer Res 2020; 26:1829-1836. [PMID: 32054730 DOI: 10.1158/1078-0432.ccr-19-3524] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 12/09/2019] [Accepted: 01/24/2020] [Indexed: 12/27/2022]
Abstract
PURPOSE In a single-institution phase II study, we evaluated the safety of a 5-day dose-equivalent neoadjuvant radiotherapy (RT) regimen for high-risk primary soft tissue sarcoma. PATIENTS AND METHODS Patients received neoadjuvant RT alone (30 Gy in five fractions) to the primary tumor with standard margins. The primary endpoint was grade ≥2 late-radiation toxicity. Major wound complications, local recurrences, and distant metastases were also examined. In exploratory analysis, we evaluated germline biomarkers for wound toxicity and the effects of the study on treatment utilization. RESULTS Over 2 years, 52 patients were enrolled with median follow-up of 29 months. Seven of 44 evaluable patients (16%) developed grade ≥2 late toxicity. Major wound complications occurred in 16 of 50 patients (32%); a signature defined by 19 germline SNPs in miRNA-binding sites of immune and DNA damage response genes, in addition to lower extremity tumor location, demonstrated strong predictive performance for major wound complications. Compared with the preceding 2-year period, the number of patients treated with neoadjuvant RT alone at our institution increased 3-fold, with a concomitant increase in the catchment area. CONCLUSIONS A shorter 5-day neoadjuvant RT regimen results in favorable rates of wound complications and grade ≥2 toxicity after 2-year follow-up. Five-day RT significantly increased utilization of neoadjuvant RT at our high-volume sarcoma center. With further validation, a putative germline biomarker for wound complications may guide safer RT utilization.
Collapse
Affiliation(s)
- Anusha Kalbasi
- Department of Radiation Oncology, University of California Los Angeles (UCLA), Los Angeles, California. .,Division of Surgical-Oncology, Department of Surgery, University of California Los Angeles, Los Angeles, California.,University of California Los Angeles Jonsson Comprehensive Cancer Center Sarcoma Program, Los Angeles, California
| | | | - Fang-I Chu
- Department of Radiation Oncology, University of California Los Angeles (UCLA), Los Angeles, California
| | - Donatello Telesca
- Department of Biostatistics, University of California Los Angeles Fielding School of Public Health, Los Angeles, California
| | - Ritchell Van Dams
- Department of Radiation Oncology, University of California Los Angeles (UCLA), Los Angeles, California
| | - Yingli Yang
- Department of Radiation Oncology, University of California Los Angeles (UCLA), Los Angeles, California
| | - Dan Ruan
- Department of Radiation Oncology, University of California Los Angeles (UCLA), Los Angeles, California
| | - Scott D Nelson
- University of California Los Angeles Jonsson Comprehensive Cancer Center Sarcoma Program, Los Angeles, California.,Department of Pathology, University of California Los Angeles, Los Angeles, California
| | - Sarah M Dry
- University of California Los Angeles Jonsson Comprehensive Cancer Center Sarcoma Program, Los Angeles, California.,Department of Pathology, University of California Los Angeles, Los Angeles, California
| | - Jackie Hernandez
- Department of Radiation Oncology, University of California Los Angeles (UCLA), Los Angeles, California
| | - Bartosz Chmielowski
- University of California Los Angeles Jonsson Comprehensive Cancer Center Sarcoma Program, Los Angeles, California.,Division of Hematology-Oncology, Department of Medicine, University of California Los Angeles, Los Angeles, California
| | - Arun S Singh
- Division of Surgical-Oncology, Department of Surgery, University of California Los Angeles, Los Angeles, California.,University of California Los Angeles Jonsson Comprehensive Cancer Center Sarcoma Program, Los Angeles, California.,Division of Hematology-Oncology, Department of Medicine, University of California Los Angeles, Los Angeles, California
| | - Susan V Bukata
- University of California Los Angeles Jonsson Comprehensive Cancer Center Sarcoma Program, Los Angeles, California.,Department of Orthopedic Surgery, University of California Los Angeles, Los Angeles, California
| | - Nicholas M Bernthal
- University of California Los Angeles Jonsson Comprehensive Cancer Center Sarcoma Program, Los Angeles, California.,Department of Orthopedic Surgery, University of California Los Angeles, Los Angeles, California
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California Los Angeles (UCLA), Los Angeles, California.,University of California Los Angeles Jonsson Comprehensive Cancer Center Sarcoma Program, Los Angeles, California
| | - Joanne B Weidhaas
- Department of Radiation Oncology, University of California Los Angeles (UCLA), Los Angeles, California.,University of California Los Angeles Jonsson Comprehensive Cancer Center Sarcoma Program, Los Angeles, California
| | - Fritz C Eilber
- Division of Surgical-Oncology, Department of Surgery, University of California Los Angeles, Los Angeles, California. .,University of California Los Angeles Jonsson Comprehensive Cancer Center Sarcoma Program, Los Angeles, California
| |
Collapse
|
14
|
Report of the First Patient Treated for Pelvic Sarcoma With a Directional 103Pd Brachytherapy Device. Adv Radiat Oncol 2019; 5:127-133. [PMID: 32051899 PMCID: PMC7004947 DOI: 10.1016/j.adro.2019.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 05/16/2019] [Accepted: 06/24/2019] [Indexed: 11/24/2022] Open
|
15
|
Ortiz González I, Morera Cano D, Roncero Sánchez R, Mateos Salvador P, Valencia Blanco L, Vidal Borrás M, Aymar Salís N, Gadea Quinteiro J, Jiménez Jiménez E, Gelabert JF, Pardo Masferrer J. Dosimetric comparison of volumetric-arc therapy versus sliding window intensity-modulated radiotherapy in postoperative treatment for primary soft tissue sarcoma of the thigh. Asia Pac J Clin Oncol 2019; 15:371-376. [PMID: 31321885 DOI: 10.1111/ajco.13220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 06/07/2019] [Indexed: 12/01/2022]
Abstract
AIM Intensity-modulated radiotherapy (IMRT) has demonstrated improved local control in extremity soft tissue sarcoma (STS) after limb-sparing surgery compared with three-dimensional conformal radiation therapy. Our purpose was to evaluate sliding-window IMRT (SW-IMRT) and volumetric arc therapy (VMAT) in planning target volume (PTV) coverage and dose to organs-at-risk (OAR). METHODS Sixteen patients undergoing postoperative RT for lower extremity STS were included. For each patient, one VMAT plan and one SW-IMRT plan were proposed. Both were evaluated using cumulative dose-volume histogram data for OAR and PTVs. Prescribed dose was 66 Gy (2 Gy/fraction) to PTV1 and 56 Gy (1.69 Gy/fraction) to PTV2. OARs contoured were femur, neurovascular bundle, minimum tissue corridor, normal tissue outside PTV2, joint and genitalia. T-Student test was performed. RESULTS Eleven male (69%) and five female patients (31%) were analyzed. Mean age was 60 years. Both techniques showed optimal target coverage, conformity index (CI) and homogeneity index (HI). VMAT PTV2 CI was 1.13 (mean) ± 0.08 (standard deviation) versus 1.19 ± 0.10 SW-IMRT PTV2 CI (P < 0.05). VMAT PTV1 HI was 0.09 ± 0.01 versus 0.08 ± 0.01 SW-IMRT PTV1 HI (P < 0.05). Regarding OARs, VMAT delivered lower dose to femur, genitalia, normal tissue outside PTV2 and joints. SW-IMRT spared tissue corridor mean dose (10.4 Gy ± 6.8 Gy) versus (14.7 ± 6.5 Gy) VMAT (P < 0.05). CONCLUSIONS Both techniques achieved great conformity, homogeneity and coverage of PTV. VMAT produced lower dose to OARS and SW-IMRT was superior in sparing dose to normal-tissue-corridor, which could reduce risk of lymphedema.
Collapse
Affiliation(s)
- Irene Ortiz González
- Radiation Oncology Department, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | - Daniel Morera Cano
- Medical Physics Department, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | - Raquel Roncero Sánchez
- Radiation Oncology Department, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | | | | | - Meritxell Vidal Borrás
- Radiation Oncology Department, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | - Neus Aymar Salís
- Radiation Oncology Department, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | - Jon Gadea Quinteiro
- Radiation Oncology Department, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | - Esther Jiménez Jiménez
- Radiation Oncology Department, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Joan Font Gelabert
- Medical Physics Department, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | - José Pardo Masferrer
- Radiation Oncology Department, Hospital Universitari Son Espases, Palma de Mallorca, Spain.,Institut d'Investigació Sanitaria de Illes Balears, Palma de Mallorca, Spain.,Hospital General de Catalunya Quironsalud, Sant Cugat del Vallès, Spain
| |
Collapse
|
16
|
Wang J, Song Y, Liu X, Jin J, Wang W, Yu Z, Liu Y, Li N, Fang H, Ren H, Tang Y, Tang Y, Chen B, Lu N, Qi S, Wang S, Li Y. Comparison of outcome and toxicity of postoperative intensity-modulated radiation therapy with two-dimensional radiotherapy in patients with soft tissue sarcoma of extremities and trunk. Cancer Med 2019; 8:902-909. [PMID: 30740916 PMCID: PMC6434203 DOI: 10.1002/cam4.1919] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 11/21/2018] [Accepted: 11/22/2018] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND To compare the survival outcomes and late toxicities of postoperative intensity-modulated radiation therapy (IMRT) with two-dimensional radiotherapy (2D-RT) for patients with soft tissue sarcoma (STS) of extremities and trunk. METHODS 274 consecutive patients with nonmetastatic STS of extremities and trunk treated with postoperative IMRT (n = 187) and 2D-RT (n = 87) were analyzed. Survival was calculated by using Kaplan-Meier method. Independent prognostic factors were identified using Cox stepwise regression analysis for variables with a P-value <0.1 in univariate analysis. RESULTS With a median follow-up time of 58.1 months, 30 local recurrences, 66 distant metastases, and 40 deaths occurred. Compared to 2D-RT group, the IMRT group had higher 5-year local recurrence-free survival (LRFS) (91.1% vs 80.8%; P = 0.029), distant metastasis-free survival (DMFS) (80.0% vs 69.7%; P = 0.048), disease-free survival (DFS) (75.2% vs 59.2%; P = 0.021), and overall survival (OS) (90.2% vs 81.0%; P = 0.029). Multivariate analysis showed IMRT was an independent favorable factor for LRFS, DMFS, DFS, and OS. For late toxicities, the patients in IMRT group enjoyed lower incidences of ≥Grade 2 joint stiffness (3.9% vs 12.3%; P = 0.041) and ≥Grade 3 fractures (0.0% vs 3.4%; P = 0.25) than those in 2D-RT group. ≥Grade 2 Edema was similar between these two groups (4.8% vs 9.2%; P = 0.183). CONCLUSIONS When compared with conventional techniques, postoperative IMRT seems to provide better LRFS, DMFS, DFS, and OS and less late toxicities in patients with STS of extremities and trunk, which should be offered as a preferred treatment.
Collapse
Affiliation(s)
- Jianyang Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yongwen Song
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xinfan Liu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jing Jin
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Weihu Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Zihao Yu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yueping Liu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ning Li
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Hui Fang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Hua Ren
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yuan Tang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yu Tang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Bo Chen
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ningning Lu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Shunan Qi
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Shulian Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yexiong Li
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| |
Collapse
|
17
|
Kawanami K, Matsuo T, Yuki S, Shimose S, Takahashi R, Deie M. Clinical outcomes of limb salvage surgery with postoperative intensity-modulated radiation therapy for soft-tissue sarcoma and metastasis. Indian J Cancer 2019; 55:176-178. [PMID: 30604732 DOI: 10.4103/ijc.ijc_618_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The primary aim of intensity-modulated radiation therapy (IMRT) for treating soft tissue sarcoma of an extremity is the reduction of morbidity and maintenance of local control. METHODS We evaluated the outcomes and toxicity of adjuvant IMRT following function-preserving surgery to treat patients with soft tissue sarcoma and metastasis of the extremities. We retrospectively reviewed prospective databases at Kure Medical Center and Aichi Medical University between 2013 and 2016 and identified 10 patients with lower extremity soft tissue sarcoma who underwent both limb-sparing surgery and postoperative IMRT at one of our institutions. RESULTS There were 7 men and 3 women (mean age, 67.2 years; range, 48-87 years) included in the study. Of these, four patients were continuously disease-free, two showed no evidence of disease, and four died due to disease. The average functional score was 82% (range, 53-100%). Among the 10 patients, 2 (22%) had grade 1-2 edema and 1 (11%) had grade 2 joint stiffness. Another patient developed grade 2 acute dermatitis. There were no severe complications such as infection, tissue necrosis, fracture, or nerve palsy. CONCLUSION Although the number of patients in this study was small, our results show that adjuvant IMRT following function-preserving surgery for soft tissue sarcoma of the extremity can be valuable for treating unmanageable tumors.
Collapse
Affiliation(s)
- Katsuhisa Kawanami
- Department of Orthopaedic Surgery, Aichi Medical University, Nagakute, Aichi 480-1195, Japan
| | - Toshihiro Matsuo
- Department of Orthopaedic Surgery, Aichi Medical University, Nagakute, Aichi 480-1195, Japan
| | - Shintaro Yuki
- Department of Orthopaedic Surgery, Kure Medical, Kure, Hiroshima 737-0023, Japan
| | - Shoji Shimose
- Department of Orthopaedic Surgery, Aichi Medical University, Nagakute, Aichi 480-1195, Japan
| | - Ryosuke Takahashi
- Department of Orthopaedic Surgery, Aichi Medical University, Nagakute, Aichi 480-1195, Japan
| | - Masataka Deie
- Department of Orthopaedic Surgery, Aichi Medical University, Nagakute, Aichi 480-1195, Japan
| |
Collapse
|
18
|
Sari SY, Yazici G, Gultekin M, Hurmuz P, Gurkaynak M, Ozyigit G. Sarcoma. Radiat Oncol 2019. [DOI: 10.1007/978-3-319-97145-2_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
|
19
|
Roeder F, de Paoli A, Saleh-Ebrahimi L, Alldinger I, Bertola G, Boz G, Navarria F, Cuervo M, Uhl M, Alvarez A, Buechler M, Lehner B, Debus J, Calvo FA, Krempien R. Intraoperative Electron Radiation Therapy Combined with External Beam Radiation Therapy after Gross Total Resection in Extremity Soft Tissue Sarcoma: A European Pooled Analysis. Ann Surg Oncol 2018; 25:3833-3842. [PMID: 30276647 DOI: 10.1245/s10434-018-6787-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Indexed: 12/17/2022]
Abstract
INTRODUCTION We report a pooled analysis evaluating the combination of gross complete limb-sparing surgery, intraoperative electron radiation therapy (IOERT), and external beam radiation therapy (EBRT) in patients with extremity soft tissue sarcoma (STS). METHODS Individual data of 259 patients (median follow-up 63 months) with extremity STS from three European expert centers were pooled. Median age was 55 years and median tumor size was 8 cm. Eighty percent of patients presented with primary disease, mainly located in the lower limb (81%). Union for International Cancer Control 7th edition stage at presentation was as follows: stage I: 9%; stage II: 47%; stage III: 39%; stage IV: 5%. Most patients showed high-grade lesions (91%), predominantly liposarcoma (31%). Median IOERT dose was 12 Gy, preceeded (17%) or followed (83%) by EBRT, with a median dose of 45 Gy. RESULTS Surgery resulted in R0 resections in 71% of patients and R1 resections in 29% of patients. The 5-year local control (LC) rate was 86%, and significant factors in univariate analysis were disease status and resection margin. Only margin remained significant in multivariate analysis. The 5-year distant control rate was 69%, and significant factors in univariate analysis were histology, grading, resection margin, and metastases prior to/at IOERT. Only grading and metastases remained significant in multivariate analysis. Actuarial 5-year rates of freedom from treatment failure and OS were 61% and 78%, respectively. Significant factors for OS were grading and metastases prior to/at IOERT (univariate, multivariate). Limb preservation and good functional outcome were achieved in 95% and 81% of patients. CONCLUSIONS Our pooled analysis confirmed prior reports of encouraging LC and survival, with excellent rates of preserved limb function with this treatment approach. Resection margin remained the most important factor for LC, while grading and metastases prior to/at IOERT mainly predicted survival.
Collapse
Affiliation(s)
- Falk Roeder
- Department of Radiation Oncology, University Hospital LMU Munich, Munich, Germany. .,CCU Molecular and Radiation Oncology, German Cancer Research Center, Heidelberg, Germany.
| | - Antonino de Paoli
- Department of Radiation Oncology, National Cancer Institute, CRO, Aviano, Italy
| | | | | | - Giulio Bertola
- Department of Surgical Oncology, National Cancer Institute, CRO, Aviano, Italy
| | - Giovanni Boz
- Department of Radiation Oncology, National Cancer Institute, CRO, Aviano, Italy
| | - Federico Navarria
- Department of Radiation Oncology, National Cancer Institute, CRO, Aviano, Italy
| | - Miguel Cuervo
- Musculoskeletal Tumor Unit, University Hospital Gregorio Maranon, Complutense University, Madrid, Spain
| | - Matthias Uhl
- Department of Radiation Oncology, University of Heidelberg, Heidelberg, Germany
| | - Ana Alvarez
- Department of Radiation Oncology, University Hospital Gregorio Maranon, Complutense University, Madrid, Spain
| | - Markus Buechler
- Department of Surgery, University of Heidelberg, Heidelberg, Germany
| | - Burkhard Lehner
- Department of Orthopedics and Traumatology, University of Heidelberg, Heidelberg, Germany
| | - Juergen Debus
- Department of Radiation Oncology, University of Heidelberg, Heidelberg, Germany.,CCU Radiation Oncology, German Cancer Research Center, Heidelberg, Germany
| | - Felipe A Calvo
- Department of Radiation Oncology, University Hospital Gregorio Maranon, Complutense University, Madrid, Spain
| | - Robert Krempien
- Department of Radiotherapy, Helios Hospital Berlin-Buch, Berlin, Germany
| |
Collapse
|
20
|
Radiotherapy in soft-tissue sarcoma of the extremities. Clin Transl Oncol 2018; 20:1127-1135. [PMID: 29476322 DOI: 10.1007/s12094-018-1848-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 02/15/2018] [Indexed: 10/18/2022]
Abstract
Sarcomas are an infrequent and heterogeneous group of neoplasia. Surgery with or without associated radiotherapy (RT) is the basic treatment for this type of tumour. To increase the therapeutic ratio (the index between cytotoxic effects in tumours and normal tissue complications with a certain dose of radiation), new advances are being investigated to increase local and distant control and to decrease the morbidity of the treatment. The aim of this review was to analyse the different strategies, based on technology and biology, which are being investigated to increase the therapeutic ratio of this disease.
Collapse
|
21
|
Antbring R, Parker SG, Lordan JT, Windsor AC. High-grade myxofibrosarcoma of the abdominal wall. BMJ Case Rep 2017; 2017:bcr-2017-219643. [PMID: 28576911 DOI: 10.1136/bcr-2017-219643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The authors present a case of a 57-year-old man, who presented to the surgical clinic with a mass in the suprapubic region. A CT scan revealed a well-circumscribed lobular, heterogeneous soft tissue mass measuring 12×8.6×7.8 cm. The final histopathological diagnosis from the resection of the lesion was a myxofibrosarcoma (MFS), grade 3. The management of MFS includes surgical and oncological options which are reviewed here. These are aimed at complete excision and reducing the risk of local occurrence.
Collapse
Affiliation(s)
- Richard Antbring
- Oncology Department, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Sam G Parker
- Colorectal Department, University College London Hospitals NHS Foundation Trust, London, UK
| | - Jeffrey T Lordan
- Sarcoma Department, Royal Free London NHS Foundation Trust, London, UK
| | - Alastair Cj Windsor
- Colorectal Department, University College London Hospitals NHS Foundation Trust, London, UK
| |
Collapse
|
22
|
Malignant soft tissue sarcoma of the shoulder treated by surface mould brachytherapy boost in an adjuvant setting. J Contemp Brachytherapy 2017; 9:167-173. [PMID: 28533807 PMCID: PMC5437085 DOI: 10.5114/jcb.2017.67392] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 03/18/2017] [Indexed: 11/25/2022] Open
Abstract
Purpose Soft tissue sarcomas of the extremities account for half of all soft tissue sarcomas. Radiotherapy and surgery have been the standard modalities in the treatment of this type of cancer. Brachytherapy can be used as the sole therapy, if the target volume is localized and easily accessible. This work reports three cases of shoulder soft tissue sarcomas with positive deep resected margins, treated with a combination of external beam radiotherapy and surface mould brachytherapy boost technique. Material and methods Between January and June 2014, three patients received brachytherapy with sites close to the shoulder, and post-surgery involved deep resected margins. Each mould was made on a base of thermoplastic, over which dental wax was coated and catheters implanted. The target volume was defined as the tissue covering the tumor bed with lateral margins of 2-2.5 cm and depth of 1-1.5 cm. Treatment planning was computed tomography-based and dose prescribed was 85-100% isodose. Treatments has been delivered twice daily, six hours interval, and a review of reactions evaluated. Results Volume receiving more than 150% of the prescribed dose has been limited to less than 2%, and that above 200% to be inside the mould. Brachytherapy equivalent dose at 2 Gy per fraction (EQD2) of these patients was 24 and 28.6 Gy. Maximum dose to organ at risk (OAR) (2 cc of OAR) ranged between 55-87% of prescribed dose, with a median dose being 80%. All cases had only grade 1 post-radiotherapy skin immediate reactions, which resolved within four weeks. In all patients, no treatment failures were noted at nearly 2-years post-irradiation. Conclusions Surface mould brachytherapy in soft tissue sarcomas could be a useful alternative to interstitial brachytherapy, especially where the target volume is superficially extensive with underlying critical structures, and where catheter placement may be difficult, such as the shoulder.
Collapse
|
23
|
Roeder F, Krempien R. Intraoperative radiation therapy (IORT) in soft-tissue sarcoma. Radiat Oncol 2017; 12:20. [PMID: 28100249 PMCID: PMC5244699 DOI: 10.1186/s13014-016-0751-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 12/21/2016] [Indexed: 12/18/2022] Open
Abstract
Soft-tissue sarcoma (STS) represent a rare tumor entity, accounting for less than 1% of adult malignancies. The cornerstone of curative intent treatment is surgery with free margins, although the extent of the surgical approach has been subject to change in the last decades. Multimodal approaches usually including radiation therapy have replaced extensive surgical procedures in order to preserve functionality while maintaining adequate local control. However, the possibility to apply adequate radiation doses by external beam radiation therapy (EBRT) can be limited in some situation especially in case of directly adjacent organs at risk with low radiation tolerance. Application of at least a part of the total dose via intraoperative radiation therapy (IORT) with a single fraction during the surgical procedure may overcome those limitations, because radiosensitive structures can be moved out of the radiation field resulting in reduced toxicity while the enhanced biological effectivity of the high single dose improves local control. The current review summarizes rationale, techniques, oncological and functional outcomes including possible pitfalls and associated toxicities based on the published literature for IORT focusing on extremity and retroperitoneal STS. In extremity STS, combination of limb-sparing surgery, IORT and pre- or postoperative EBRT with moderate doses consistently achieved excellent local control rates at least comparable to approaches using EBRT alone but usually including patient cohorts with higher proportions of unfavourable prognostic factors. Further on, IORT containing approaches resulted in very high limb preservation rates and good functional outcome, probably related to the smaller high dose volume. In retroperitoneal STS, the combination of preoperative EBRT, surgery and IORT consistently achieved high local control rates which seem superior to surgery alone or surgery with EBRT at least with regard to local control and in some reports even to overall survival. Further on, preoperative EBRT in combination with IORT seems to be superior to the opposite combination with regard to local control and toxicity. No major differences in wound healing disturbances or postoperative complication rates can be observed with IORT compared to non-IORT containing approaches. Neuropathy of major nerves remains a dose limiting toxicity requiring dose restrictions or exclusion from target volume. Gastrointestinal structures and ureters should be excluded from the IORT area whenever possible and the IORT volume should be restricted to the available minimum. Nevertheless, IORT represents an ideal boosting method if combined with EBRT and properly executed by experiences users which should be further evaluated preferably in prospective randomized trials.
Collapse
Affiliation(s)
- Falk Roeder
- Department of Radiation Oncology, University Hospital of Munich (LMU), Marchioninistr. 15, 81377, Munich, Germany. .,Clinical Cooperation Unit Molecular Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | - Robert Krempien
- Department of Radiation Oncology, Helios Clinic Berlin-Buch, Berlin-Buch, Germany
| |
Collapse
|
24
|
Radiation Therapy for Sarcomas. Sarcoma 2017. [DOI: 10.1007/978-3-319-43121-5_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
|
25
|
[Radiotherapy for soft tissue sarcomas: Technical evolution and impact on clinical benefit]. Cancer Radiother 2016; 20:666-76. [PMID: 27614501 DOI: 10.1016/j.canrad.2016.07.074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 07/11/2016] [Accepted: 07/18/2016] [Indexed: 12/21/2022]
Abstract
The standard treatment for extremity soft tissue sarcomas is based on the association of surgery and radiotherapy. This strategy allows local control improvement with the risk of increased toxicity. There is therefore a growing interest to identify those patients who will benefit from radiotherapy and those who will have the same local control with surgery alone. Furthermore, the development of toxicity has been correlated with the extension of the irradiated volume and the volume receiving high doses. Technological development as intensity modulated radiotherapy and image-guided radiotherapy allows limited irradiated volume improving the protection of the organs at risk leading to clinical benefit improvement. Moreover, efforts are being done to improve local control for the patients at high risk of local relapse. In this paper, we discuss all these mentioned aspects.
Collapse
|
26
|
Blumenfeld P, Sen N, Abrams R, Wang D. Advances in Radiation Therapy for Primary and Metastatic Adult Soft Tissue Sarcomas. Curr Oncol Rep 2016; 18:36. [DOI: 10.1007/s11912-016-0523-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
27
|
Intraoperative electron radiation therapy combined with external beam radiation therapy and limb sparing surgery in extremity soft tissue sarcoma: a retrospective single center analysis of 183 cases. Radiother Oncol 2016; 119:22-9. [DOI: 10.1016/j.radonc.2015.11.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 11/10/2015] [Accepted: 11/18/2015] [Indexed: 01/22/2023]
|
28
|
Tiong SS, Dickie C, Haas RL, O'Sullivan B. The role of radiotherapy in the management of localized soft tissue sarcomas. Cancer Biol Med 2016; 13:373-383. [PMID: 27807504 PMCID: PMC5069839 DOI: 10.20892/j.issn.2095-3941.2016.0028] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
The combination of radiotherapy (RT) and function-preserving surgery is the most usual contemporary approach in the management of soft tissue sarcomas (STS). Pre- and postoperative RT result in similar local control rates, as shown by a landmark trial in extremity STS. In this review, the role of RT in the management of extremity STS will be discussed, but STS in other sites, including retroperitoneal STS, will also be addressed. The focus will consider various aspects of RT including strategies to reduce the volume of tissue being irradiated, dose, scheduling, and the possible of omission of RT in selected cases. Finally, technology advances through the use of intensity-modulated radiotherapy (IMRT), image-guided IMRT, intraoperative radiotherapy (IORT) and particle therapy will also be discussed.
Collapse
Affiliation(s)
- Siaw Sze Tiong
- Department of Radiation Oncology, Princess Margaret Cancer Center, University of Toronto, Toronto M5G 2M9, ON, Canada
| | - Colleen Dickie
- Department of Radiation Oncology, Princess Margaret Cancer Center, University of Toronto, Toronto M5G 2M9, ON, Canada
| | - Rick L Haas
- Department of Radiotherapy, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam 1066, CX, The Netherlands
| | - Brian O'Sullivan
- Department of Radiation Oncology, Princess Margaret Cancer Center, University of Toronto, Toronto M5G 2M9, ON, Canada
| |
Collapse
|
29
|
Wang J, Wang S, Song Y, Liu X, Jin J, Wang W, Yu Z, Liu Y, Li Y. Postoperative intensity-modulated radiation therapy provides favorable local control and low toxicities in patients with soft tissue sarcomas in the extremities and trunk wall. Onco Targets Ther 2015; 8:2843-7. [PMID: 26491357 PMCID: PMC4608545 DOI: 10.2147/ott.s88227] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose To investigate the efficacy and toxicity of postoperative intensity-modulated radiation therapy (IMRT) for patients with soft tissue sarcomas (STSs) in the extremities and trunk wall. Patients and methods Eighty patients with localized STSs in the extremities and trunk wall treated with function-conserving surgery and postoperative IMRT were analyzed. The primary locations were in the extremities in 51 patients and in the trunk wall in 29 patients. The margins were positive in nine patients and negative in 71 patients. The median dose of IMRT was 64 Gy. Results At a median follow-up time of 38 months, eight patients developed local recurrences. The 5-year local control (LC) rate was 88.1%. The patients with negative margins exhibited much better LC than did those with positive margins (90% vs 64.8%, P=0.023). Multivariate analysis revealed that positive margin was an independent risk factor for LC. The 5-year distant metastasis-free survival, disease-free survival, and overall survival rates were 75.2%, 72.6%, and 83.6%, respectively. Large tumor size (>5 cm) was significantly associated with poor overall survival. Edema and joint stiffness were observed in 17.6% and 9.8% of patients with extremity STSs, respectively. Conclusion IMRT provides excellent LC and low toxicity for patients with STSs in the extremities and trunk wall.
Collapse
Affiliation(s)
- Jianyang Wang
- Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Shulian Wang
- Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yongwen Song
- Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Xinfan Liu
- Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Jing Jin
- Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Weihu Wang
- Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Zihao Yu
- Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yueping Liu
- Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yexiong Li
- Department of Radiation Oncology, Cancer Hospital and Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| |
Collapse
|
30
|
Perioperative high-dose-rate interstitial brachytherapy combined with external beam radiation therapy for soft tissue sarcoma. Brachytherapy 2015; 14:571-7. [DOI: 10.1016/j.brachy.2015.03.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Revised: 03/05/2015] [Accepted: 03/06/2015] [Indexed: 11/16/2022]
|
31
|
Griffin AM, Dickie CI, Catton CN, Chung PWM, Ferguson PC, Wunder JS, O'Sullivan B. The influence of time interval between preoperative radiation and surgical resection on the development of wound healing complications in extremity soft tissue sarcoma. Ann Surg Oncol 2015; 22:2824-30. [PMID: 26018726 DOI: 10.1245/s10434-015-4631-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The aim of this study was to determine the relationship of the time interval between completion of preoperative radiation therapy (RT) and surgical resection on wound complications (WCs) in extremity soft tissue sarcoma (STS). METHODS Overall, 798 extremity STS patients were managed with preoperative RT and surgery from 1989 to 2013. WCs were defined as requiring secondary operations/invasive procedures for wound care, use of vacuum-assisted closure, prolonged dressing changes, or infection within 120 days of surgery. RESULTS Mean tumor size was 8.8 cm. A total of 743 (93 %) tumors were primary presentations, 565 (71 %) patients had lower extremity tumors, and 238 patients (30 %) had a prior unplanned excision. Of 242 patients (30 %) who developed a WC, 206 (37 %) had lower extremity tumors and 36 (15 %) had upper extremity tumors. Mean time from RT completion to surgery was 41.3 (range 4-470) days; 42.0 (range 4-470) days for upper extremity cases, and 41.1 (range 4-109) days for lower extremity cases. Similarly, mean time interval for patients who developed a WC was 40.9 (range 4-100) days, and 41.5 (range 4-470) days for those who did not develop a WC (p = 0.69). Thirty-nine cases (5 %) had surgery within 3 weeks of RT; 15 (38 %) patients developed WCs versus 227 (30 %) patients who had their tumors excised after 3 weeks (p = 0.28). One hundred and twenty-nine (16 %) patients had surgery within 4 weeks, and 39 (30 %) patients developed WCs versus 203 (30 %) patients who had their tumors excised after 4 weeks (p = 1.0). A trend towards a higher rate of WCs was seen for those patients who had surgery after 6 weeks (28 % prior vs. 34 % after; p = 0.08). There was no difference in WCs with intensity-modulated RT (IMRT) versus non-IMRT cases (p = 0.6). CONCLUSION The time interval between preoperative RT and surgical excision in extremity STS had minimal influence on the development of WCs. Four- or 5-week intervals showed equivalent complication rates between the two groups, suggesting an optimal interval to reduce potential WCs.
Collapse
Affiliation(s)
- Anthony M Griffin
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, ON, Canada,
| | | | | | | | | | | | | |
Collapse
|
32
|
Überlegenheit der IMRT gegenüber der konventionellen 3D-EBRT auch bei der lokalen Kontrolle von Extremitätensarkomen. Strahlenther Onkol 2015; 191:382-3. [DOI: 10.1007/s00066-015-0813-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
33
|
Abstract
Over recent decades, limb-preservation surgery in combination with radiotherapy achieves local control rates exceeding 90% for extremity soft tissue sarcoma (STS). Local control is not as successful for retroperitoneal sarcoma (approximately 60%) despite aggressive surgical approaches including en bloc resection of uninvolved adjacent organs combined with intensity modulated radiotherapy (IMRT). This review will discuss the indications for adjuvant radiation therapy (RT) for primary presentation of soft tissue sarcoma: "What," referring to the type and manner of planning and delivery of RT; "When," referring to the timing and scheduling of RT; and "Why," referring to the rationale for the use of RT will be addressed. From a practical stand point, this Educational Chapter on "adjuvant RT" will focus on pre- and postoperative RT in the context of gross total resection for extremity and retroperitoneal soft tissue sarcoma, the two most frequent paradigms for the use of adjuvant RT.
Collapse
Affiliation(s)
- Colleen I Dickie
- From the Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada; Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada; Department of Radiotherapy, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Rick Haas
- From the Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada; Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada; Department of Radiotherapy, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Brian O'Sullivan
- From the Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada; Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada; Department of Radiotherapy, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| |
Collapse
|
34
|
Kahn J, Gillespie A, Tsokos M, Ondos J, Dombi E, Camphausen K, Widemann BC, Kaushal A. Radiation therapy in management of sporadic and neurofibromatosis type 1-associated malignant peripheral nerve sheath tumors. Front Oncol 2014; 4:324. [PMID: 25452937 PMCID: PMC4233912 DOI: 10.3389/fonc.2014.00324] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 10/28/2014] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Malignant peripheral nerve sheath tumors (MPNSTs) are highly aggressive soft tissue sarcomas in which complete surgical resection is the mainstay of therapy. However, the recurrence rate is high and few options remain for refractory or metastatic MPNST. This study examines the outcomes of adjuvant radiation therapy in MPNST in patients with and without neurofibromatosis type 1 (NF1) and reviews the literature on use of radiation for MPNST. METHODS A retrospective review of 33 MPNST patients between 1990 and 2012 evaluated at the NIH. All diagnoses were pathologically confirmed at the NCI. Clinical presentation, treatment, and survival were analyzed. RESULTS Thirty-three patients were included 18 NF1-associated, 15 sporadic tumors. Tumor location included extremity (58%), trunk (36%), and head/neck (6%). Histologic grade showed 25 high-grade tumors compared to 7 low-grade tumors. Twenty patients were treated with radiation therapy (median total dose of 58.5 Gy with 1.8 Gy/fraction). A median survival of all patients was 46.5 months and 43.7% overall 5-year survival. Prognostic factors include extent of resection, tumor location, and histology grade. Radiation was not found to be a prognostic factor for overall survival. CONCLUSION This study is consistent with previous studies regarding the role of radiation in the management of MPNST. Prospective evaluation of adjuvant radiation will allow to more fully define the role of radiation in MPNST.
Collapse
Affiliation(s)
- Jenna Kahn
- Radiation Oncology Branch, National Cancer Institute, National Institutes of Health , Bethesda, MD , USA ; Warren Alpert School of Medicine, Brown University , Providence, RI , USA
| | - Andy Gillespie
- Pediatric Oncology Branch, National Cancer Institute, National Institutes of Health , Bethesda, MD , USA
| | - Maria Tsokos
- Department of Pathology, National Institutes of Health , Bethesda, MD , USA
| | - John Ondos
- Radiation Oncology Branch, National Cancer Institute, National Institutes of Health , Bethesda, MD , USA
| | - Eva Dombi
- Pediatric Oncology Branch, National Cancer Institute, National Institutes of Health , Bethesda, MD , USA
| | - Kevin Camphausen
- Radiation Oncology Branch, National Cancer Institute, National Institutes of Health , Bethesda, MD , USA
| | - Brigitte C Widemann
- Pediatric Oncology Branch, National Cancer Institute, National Institutes of Health , Bethesda, MD , USA
| | - Aradhana Kaushal
- Radiation Oncology Branch, National Cancer Institute, National Institutes of Health , Bethesda, MD , USA
| |
Collapse
|
35
|
Folkert MR, Singer S, Brennan MF, Kuk D, Qin LX, Kobayashi WK, Crago AM, Alektiar KM. Comparison of local recurrence with conventional and intensity-modulated radiation therapy for primary soft-tissue sarcomas of the extremity. J Clin Oncol 2014; 32:3236-41. [PMID: 25185087 DOI: 10.1200/jco.2013.53.9452] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
PURPOSE The use of intensity-modulated radiation therapy (IMRT) in the treatment of soft tissue sarcoma (STS) of the extremity is increasing, but no large-scale direct comparison has been reported between conventional external-beam radiation therapy (EBRT) and IMRT. METHODS Between January 1996 and December 2010, 319 consecutive adult patients with primary nonmetastatic extremity STS were treated with limb-sparing surgery and adjuvant radiotherapy (RT) at a single institution. Conventional EBRT was used in 154 patients and IMRT in 165 with similar dosing schedules. Median follow-up time for the cohort was 58 months. RESULTS Treatment groups were comparable in terms of tumor location, histology, tumor size, depth, and use of chemotherapy. Patients treated with IMRT were older (P = .08), had more high-grade lesions (P = .05), close (< 1 mm) or positive margins (P = .04), preoperative radiation (P < .001), and nerve manipulation (P = .04). Median follow-up was 90 months for patients treated with conventional EBRT and 42 months for patients treated with IMRT. On multivariable analysis adjusting for patient age and tumor size, IMRT retained significance as an independent predictor of reduced LR (hazard ratio = 0.46; 95% CI, 0.24 to 0.89; P = .02). CONCLUSION Despite a preponderance of higher-risk features (especially close/positive margin) in the IMRT group, IMRT was associated with significantly reduced local recurrence compared with conventional EBRT for primary STS of the extremity.
Collapse
Affiliation(s)
| | - Samuel Singer
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Deborah Kuk
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Li-Xuan Qin
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Aimee M Crago
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | |
Collapse
|
36
|
Nguyen NP, Vock J, Vinh-Hung V, Khan R, Slane B, Sroka T, Jang S, Dias V, Vo RA, Karlsson U, Chi A. Feasibility of Tomotherapy for Postoperative Irradiation of Lower Extremity Sarcomas. TUMORI JOURNAL 2014. [DOI: 10.1177/1636.17914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Nam P Nguyen
- Department of Radiation Oncology, Howard University, Washington, DC, USA
| | - Jacqueline Vock
- Department of Radiation Oncology, Lindenhofspital, Bern, Switzerland
| | - Vincent Vinh-Hung
- Department of Radiation Oncology, University Hospital of Martinique, Fort de France, France
| | | | - Benjamin Slane
- Department of Radiation Oncology, University of Arizona, Tucson, AZ, USA
| | - Thomas Sroka
- Department of Radiation Oncology, Dartmouth College, Hanover, NH, USA
| | - Siyoung Jang
- Department of Radiation Oncology, University of Arizona, Tucson, AZ, USA
| | - Vigil Dias
- Department of Radiation Oncology, University of Arizona, Tucson, AZ, USA
| | - Richard A Vo
- Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
| | - Ulf Karlsson
- Department of Radiation Oncology, Marshfield Clinic, Marshfield, WI, USA
| | - Alexander Chi
- Department of Radiation Oncology, University of West Virginia, Morgantown, WV, USA
| |
Collapse
|
37
|
Roeder F, Lehner B, Schmitt T, Kasper B, Egerer G, Sedlaczek O, Grüllich C, Mechtersheimer G, Wuchter P, Hensley FW, Huber PE, Debus J, Bischof M. Excellent local control with IOERT and postoperative EBRT in high grade extremity sarcoma: results from a subgroup analysis of a prospective trial. BMC Cancer 2014; 14:350. [PMID: 24885755 PMCID: PMC4032585 DOI: 10.1186/1471-2407-14-350] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 05/13/2014] [Indexed: 12/31/2022] Open
Abstract
Background To report the results of a subgroup analysis of a prospective phase II trial focussing on radiation therapy and outcome in patients with extremity soft tissue sarcomas (STS). Methods Between 2005 and 2010, 50 patients (pts) with high risk STS (size ≥ 5 cm, deep/extracompartimental location, grade II-III (FNCLCC)) were enrolled. The protocol comprised 4 cycles of neoadjuvant chemotherapy with EIA (etoposide, ifosfamide and doxorubicin), definitive surgery with IOERT, postoperative EBRT and 4 adjuvant cycles of EIA. 34 pts, who suffered from extremity tumors and received radiation therapy after limb-sparing surgery, formed the basis of this subgroup analysis. Results Median follow-up from inclusion was 48 months in survivors. Margin status was R0 in 30 pts (88%) and R1 in 4 pts (12%). IOERT was performed as planned in 31 pts (91%) with a median dose of 15 Gy, a median electron energy of 6 MeV and a median cone size of 9 cm. All patients received postoperative EBRT with a median dose of 46 Gy after IOERT or 60 Gy without IOERT. Median time from surgery to EBRT and median EBRT duration was 36 days, respectively. One patient developed a local recurrence while 11 patients showed nodal or distant failures. The estimated 5-year rates of local control, distant control and overall survival were 97%, 66% and 79%, respectively. Postoperative wound complications were found in 7 pts (20%), resulting in delayed EBRT (>60 day interval) in 3 pts. Acute radiation toxicity mainly consisted of radiation dermatitis (grade II: 24%, no grade III reactions). 4 pts developed grade I/II radiation recall dermatitis during adjuvant chemotherapy, which resolved during the following cycles. Severe late toxicity was observed in 6 pts (18%). Long-term limb preservation was achieved in 32 pts (94%) with good functional outcome in 81%. Conclusion Multimodal therapy including IOERT and postoperative EBRT resulted in excellent local control and good overall survival in patients with high risk STS of the extremities with acceptable acute and late radiation side effects. Limb preservation with good functional outcome was achieved in the majority of patients. Trial registration ClinicalTrials.gov NCT01382030, EudraCT 2004-002501-72, 17.06.2011
Collapse
Affiliation(s)
- Falk Roeder
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Beane JD, Yang JC, White D, Steinberg SM, Rosenberg SA, Rudloff U. Efficacy of adjuvant radiation therapy in the treatment of soft tissue sarcoma of the extremity: 20-year follow-up of a randomized prospective trial. Ann Surg Oncol 2014; 21:2484-9. [PMID: 24756814 DOI: 10.1245/s10434-014-3732-4] [Citation(s) in RCA: 163] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND This update of a randomized, prospective study presents the effect of external beam radiation therapy (EBRT) on long-term overall survival, local control, and limb function following limb-sparing surgery (LSS) for the treatment extremity soft tissue sarcoma (STS). METHODS Following LSS, patients with extremity STS were randomized to receive EBRT or surgery alone. All patients with high-grade STS received adjuvant chemotherapy. Long-term follow-up was obtained through telephone interviews using a questionnaire based on validated methods. Overall survival (OS) was determined by Kaplan-Meier method. RESULTS A total of 141 patients with extremity STS were randomized to receive adjuvant EBRT (n = 70) or LSS alone (n = 71). Median follow-up was 17.9 years. The 10- and 20-year survival was 77 % (95 % CI 66-85 %) and 64 % (95 % CI 52-75 %) for patients receiving LSS alone and 82 % (95 % CI 72-90 %) and 71 % (95 % CI 59-81 %) for patients receiving EBRT (p = 0.22). Of the 54 patients who completed telephone interviews, the incidence of local recurrence during the follow-up period was 4 % (1 of 24) in the LSS alone cohort compared with 0 % (0 of 30) in those who received EBRT (p = 0.44). Patients treated with EBRT tended to have more wound complications (17 vs. 12.5 %, p = 0.72), clinically significant edema (25 vs. 12 %, p = 0.31), and functional limb deficits (15 vs. 12 %, p = 0.84). CONCLUSIONS Adjuvant EBRT following surgery for STS of the extremity provides excellent local control with acceptable treatment-related morbidity and no statistically significant improvement in overall survival.
Collapse
Affiliation(s)
- Joal D Beane
- Surgery Branch, National Cancer Institute, Bethesda, MD, USA
| | | | | | | | | | | |
Collapse
|
39
|
Federico SM, Gilpin D, Samant S, Billups CA, Spunt SL. Clinical features and outcomes of young patients with head and neck non-rhabdomyosarcoma soft tissue sarcomas. Head Neck 2014; 37:76-83. [DOI: 10.1002/hed.23564] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Revised: 09/10/2013] [Accepted: 12/05/2013] [Indexed: 11/12/2022] Open
Affiliation(s)
- Sara M. Federico
- Department of Oncology; St. Jude Children's Research Hospital; Memphis Tennessee
- Department of Pediatrics University of Tennessee; College of Medicine; Memphis Tennessee
| | - David Gilpin
- Department of Oncology; St. Jude Children's Research Hospital; Memphis Tennessee
| | - Sandeep Samant
- Department of Otolaryngology Head and Neck Surgery; University of Tennessee Health Science Center; Memphis Tennessee
| | - Catherine A. Billups
- Department of Biostatistics; St. Jude Children's Research Hospital; Memphis Tennessee
| | - Sheri L. Spunt
- Department of Oncology; St. Jude Children's Research Hospital; Memphis Tennessee
- Department of Pediatrics University of Tennessee; College of Medicine; Memphis Tennessee
| |
Collapse
|
40
|
Combined management of retroperitoneal sarcoma with dose intensification radiotherapy and resection: Long-term results of a prospective trial. Radiother Oncol 2014; 110:165-71. [DOI: 10.1016/j.radonc.2013.10.041] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Revised: 10/29/2013] [Accepted: 10/31/2013] [Indexed: 11/21/2022]
|
41
|
Holloway CL, Delaney TF, Alektiar KM, Devlin PM, O'Farrell DA, Demanes DJ. American Brachytherapy Society (ABS) consensus statement for sarcoma brachytherapy. Brachytherapy 2013; 12:179-90. [PMID: 23434220 DOI: 10.1016/j.brachy.2012.12.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Revised: 12/02/2012] [Accepted: 12/31/2012] [Indexed: 12/23/2022]
Abstract
PURPOSE To present recommendations for the use of brachytherapy (BT) in patients with soft tissue sarcoma (STS). METHODS A group of practitioners with expertise and experience in sarcoma BT formulated recommendations for BT in STS based on clinical experience and literature review. RESULTS The indications for adjuvant BT are discussed. There is no consensus on the use of BT alone or in combination with external beam radiation therapy (EBRT), but factors that influence the selection of this modality include tumor grade and size, prior surgeries, and tumor recurrence. Low-dose-rate, high-dose-rate, and pulsed-dose-rate radiation are all acceptable BT modalities to use for STS. Recommendations are made for patient selection, techniques, dose rates, and dosages. Outcome data and toxicity data are reviewed. CONCLUSIONS BT is a useful component of the treatment of STS. The advantages of BT are the targeted dose distribution, low integral dose, and short treatment times. Ultimately the clinician should select the modality or combination of modalities that are most familiar to the treatment team and suitable to the patient.
Collapse
Affiliation(s)
- Caroline L Holloway
- Department of Radiation Oncology, BC Cancer Agency, Vancouver Island Centre, Victoria, BC, Canada.
| | | | | | | | | | | |
Collapse
|
42
|
O'Sullivan B, Griffin AM, Dickie CI, Sharpe MB, Chung PWM, Catton CN, Ferguson PC, Wunder JS, Deheshi BM, White LM, Kandel RA, Jaffray DA, Bell RS. Phase 2 study of preoperative image-guided intensity-modulated radiation therapy to reduce wound and combined modality morbidities in lower extremity soft tissue sarcoma. Cancer 2013; 119:1878-84. [PMID: 23423841 DOI: 10.1002/cncr.27951] [Citation(s) in RCA: 154] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Revised: 11/30/2012] [Accepted: 12/04/2012] [Indexed: 11/07/2022]
Abstract
BACKGROUND This study sought to determine if preoperative image-guided intensity-modulated radiotherapy (IG-IMRT) can reduce morbidity, including wound complications, by minimizing dose to uninvolved tissues in adults with lower extremity soft tissue sarcoma. METHODS The primary endpoint was the development of an acute wound complication (WC). IG-IMRT was used to conform volumes to avoid normal tissues (skin flaps for wound closure, bone, or other uninvolved soft tissues). From July 2005 to June 2009, 70 adults were enrolled; 59 were evaluable for the primary endpoint. Median tumor size was 9.5 cm; 55 tumors (93%) were high-grade and 58 (98%) were deep to fascia. RESULTS Eighteen (30.5%) patients developed WCs. This was not statistically significantly different from the result of the National Cancer Institute of Canada SR2 trial (P = .2); however, primary closure technique was possible more often (55 of 59 patients [93.2%] versus 50 of 70 patients [71.4%]; P = .002), and secondary operations for WCs were somewhat reduced (6 of 18 patients [33%] versus 13 of 30 patients [43%]; P = .55). Moderate edema, skin, subcutaneous, and joint toxicity was present in 6 (11.1%), 1 (1.9%), 5 (9.3%), and 3 (5.6%) patients, respectively, but there were no bone fractures. Four local recurrences (6.8%, none near the flaps) occurred with median follow-up of 49 months. CONCLUSIONS The 30.5% incidence of WCs was numerically lower than the 43% risk derived from the National Cancer Institute of Canada SR2 trial, but did not reach statistical significance. Preoperative IG-IMRT significantly diminished the need for tissue transfer. RT chronic morbidities and the need for subsequent secondary operations for WCs were lowered, although not significantly, whereas good limb function was maintained.
Collapse
Affiliation(s)
- Brian O'Sullivan
- Department of Radiation Oncology, Princess Margaret Hospital, Toronto, Ontario, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Saba SC, Shaterian A, Tokin C, Dobke MK, Wallace AM. The pedicled myocutaneous flap as a choice reconstructive technique for immediate adjuvant brachytherapy in sarcoma treatment. ACTA ACUST UNITED AC 2013; 19:e491-5. [PMID: 23300372 DOI: 10.3747/co.19.1141] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Successful treatment of soft-tissue sarcomas is highly dependent on total tumour resection coupled with adjuvant radiation therapy to achieve local control and decrease recurrence. Reconstruction of soft-tissue defects after resection aims to cover vital structures, while providing enough stable tissue to withstand adjuvant brachytherapy treatment. In the present study, pedicled myocutaneous flaps were used as a vital adjunct in the treatment of soft-tissue sarcoma, and our experience with 2 such patients is described. The flaps served to reconstruct large three-dimensional defects while providing stable coverage over brachytherapy hardware to allow for delivery of radiation in the immediate postoperative period. Pedicled locoregional myocutaneous flaps provide a safe, easy, and reliable reconstructive technique in the treatment of soft-tissue sarcoma.
Collapse
Affiliation(s)
- S C Saba
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of California-San Diego, CA, U.S.A
| | | | | | | | | |
Collapse
|
44
|
Current World Literature. Curr Opin Oncol 2012; 24:454-60. [DOI: 10.1097/cco.0b013e328355876c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
45
|
|