High dose hyperfractionated radiotherapy in the treatment of extremity soft tissue sarcomas

Non Conventional Fractionation in Radiotherapy of the Musculo-Skeletal Sarcomas

In 1989 we started an accelerated hyperfractionated schedule of radiotherapy (two 1.6 Gy daily fractions) in standard risk localized Ewing's sarcoma of bone, with the aim at reducing late effects in young patients and at improving disease control through a better integration of treatment modalities. From 1991, the same schedule was used in preoperative radiotherapy of adult soft tissue sarcomas of the extremities: the main purpose was to reduce the time to surgery and to evaluate surgical complications in comparison with a previous experience of hypofractionated radiotherapy (one 3 Gy daily fraction). From 1991 to 1997, 76 patients with Ewing's sarcoma and 24 patients with soft tissue sarcoma were treated at our Institution. Results and complication rates are analyzed in comparison with historical data. In Ewing's sarcoma, a correct evaluation of improvement in local control was difficult because of changing treatment policy (bulky disease was not included in the present series). Late effects, as evaluated in patients with a minimum follow-up of 3 years, occurred with similar incidence, but at higher total dose levels in patients treated with accelerated hyperfractionation. In patients with soft tissue sarcomas, incidence of surgical complications is reduced as compared to historical experience. Major problems of wound healing were seen in association with intraoperative brachitherapy boost.

Soft tissue sarcoma of the hand or foot: conservative surgery and radiotherapy

Purpose. Conservative treatment in the form of limited surgery and post-operative radiotherapy is controversial in hand and foot sarcomas, both due to poor radiation tolerance of the palm and sole, and due to technical difficulties in achieving adequate margins.This paper describes the local control and survival of 41 patients with soft tissue sarcoma of the hand or foot treated with conservative surgery and radiotherapy. The acute and late toxicity of megavoltage radiotherapy to the hand and foot are described. The technical issues and details of treatment delivery are discussed. The factors influencing local control after radiotherapy are analysed.

Subjects . Eighteen patients had sarcomas of the hand and 23 of the foot. All patients received post-operative radiotherapy, the majority receiving a dose of 60 Gy in 2-Gy daily fractions using a two-phase treatment.

Results . The acute and late toxicity of treatment were within acceptable limits. The actuarial 5-year overall survival of the whole patient group was 67.6% and the local relapse-free survival was 44%.The local control was similar in tumours of hand and foot, and in patients treated at first presentation or relapse.

Discussion. Post-operative radiotherapy to the hand or foot appears to be a well tolerated treatment resulting in long-term local control in a significant proportion of patients. The increased frequency of recurrence within the high-dose volume suggests the need for the use of higher total doses of radiotherapy.

Hyper-fractionated radiotherapy for soft tissue sarcoma: results of the second study of hyper-fractionated radiotherapy

Purpose and Method. Hyper-fractionated radiotherapy for treatment of soft tissue sarcomas is designed to deliver a higher total dose of radiation without an increase in late normal tissue damage. In a previous study at the Royal Marsden Hospital, a total dose of 75 Gy using twice daily 1.25 Gy fractions resulted in a higher incidence of late damage than conventional radiotherapy using 2 Gy daily fractions treating to a total of 60 Gy. The current trial therefore used a lower dose per fraction of 1.2 Gy and lower total dose of 72 Gy, with 60 fractions given over a period of 6 weeks.

Subjects. A total of 37 patients (22 males and 15 females) with a median age of 56 years (range 19–88 years) were treated.

Results. Of eight patients treated pre-operatively, six showed a partial response and in two the tumour was static. The maximum acute toxicities were grade 1 in eight, grade 2 in 14 and grade 3 in 15 patients. Late toxicities of the skin were graded 1 in 10 and grade 2 in nine patients. Five patients complained of pain in the irradiated bone and soft tissues, which was of moderate severity (grade 2). Stiffness was graded 2 in three patients and severe (grade 3) in one.Three patients had moderate and one patient had severe lymphoedema following treatment. The 5-year recurrence-free survival probability of patients treated radically was 76%. Following excision of local recurrences the study group had a disease-free survival probability of 86% at 5 years.

Discussion. The regime is well tolerated with comparable local control and late complication rates to standard daily fractionated therapy.The potential benefit of this regime needs to be defined in a prospective randomized trial.

[Late outcome of 89 patients with soft-tissue sarcomas treated by surgery and three different radiotherapy schedules]

PURPOSE

To evaluate the outcome of patients treated for soft tissue sarcoma using three different post-operative radiotherapy schedules.

METHODS AND MATERIALS

Between 1990 and 2003, 89 patients (median age 50.8 years) presenting with soft tissue sarcoma (located to the limbs for 66 of them) underwent post-conservative-surgery radiotherapy. Pathology was liposarcoma in 35 cases and 54 others tumors. Tumors grades (FNCLCC classification) were 1, 2, 3 or unknown in 29, 32, 19 and 9 cases, respectively. Surgery was considered as complete in 68 patients. Irradiation was normofractionated (NF) in 62 cases, hyperfractionated (BF) in 19 cases and hypofractionated (HF) in 8 cases. For all the patients, median delivered dose was 61 Gy [34-76 Gy].

RESULTS

Median follow-up of alive patients was 73,8 months [3-184]. Five-year local control (LC) and overall survival (OS) rates were 85.5 and 71.2% respectively. According to multifactorial analysis, favourable prognostic factors were for local control, complete surgery (P=0.0075) and for overall survival, complete surgery (P=0.0267), grade 1 tumor (P=0.012) and absence of distant recurrence (P=0.0488). There was no statistical evidence of difference for the five-year LC and OS rates between the patients who received NF, BF or HF. There were few complications and there were comparable in the three groups.

CONCLUSIONS

This retrospective serie showed similar results for all the schedules. There is no evidence to recommend bifractionation. Hypofractionation should be used only in selected patients with poor performans status.

The local management of soft tissue sarcoma

Soft tissue sarcomas (STS) are rare tumors arising from the connective tissues. STS can arise at any anatomic site, can demonstrate varied behavior and prognosis, and therefore present a formidable challenge in management. The local treatment of STS demands technical complexity in the application of diagnostic tools, including pathology and imaging, as well as treatment approaches, including surgical ablation and reconstruction, radiotherapy, and, in defined cases, chemotherapy. The understanding of the management of these lesions is profoundly dependent on the multidisciplinary setting, where experience has been gained and skills are available to increase the likelihood of a successful result. Several proven options are available for optimal local management, and the choice of approach depends on the prevailing practice and resource profile of the treating center. With modern approaches, the local control rate can be expected to be at least 90% for extremity lesions, which constitute the most common STS. The experience in other anatomic sites is less favorable as a result of a combination of late diagnosis, technically difficult access sites, and possibly less familiarity with these less common presentations. The disappointing results make it all the more important for patients to be referred to a multidisciplinary setting with experience in sarcoma management to maximize the chance of successful local outcome.

Contemporary radiotherapy for soft tissue sarcoma

This review will detail the role of radiotherapy in the management of soft tissue sarcoma. Particular emphasis will be given to its role as an adjuvant to surgical excision for local curative management. The addition of radiotherapy permits a tissue-conserving operation to be performed, which has functional and cosmetic advantages yet produces local control equivalent to more radical surgery alone. The review will consider the historical evolution of treatment up through recent and contemporary practice. The principles of use will be outlined using available evidence and, where this is lacking, it will be acknowledged with suggestions for improvement. Finally, a brief overview of some technical issues about radiotherapy will be provided.

Postoperative radiotherapy in the management of adult soft tissue sarcoma of the extremities: results with two different total dose, fractionation, and overall treatment time schedules

PURPOSE

This retrospective study was performed to evaluate two postoperative radiotherapy schedules in terms of dose, fractionation, and overall treatment time in soft tissue sarcoma (STS) of the extremities.

METHODS AND MATERIALS

Between January 1984 and December 1993, 62 patients with newly diagnosed localized STS of the extremities were treated with maximal conservative surgery and postoperative radiotherapy (RT). Forty-five patients received 50 Gy with conventional fractionation plus a boost dose (5 to 20 Gy). Seventeen patients had hyperfractionated accelerated radiotherapy (HFART) up to a dose of 45 Gy in 3 weeks.

RESULTS

With a median follow-up of 72 months, the 5-year local failure rate was 25%, the 5-year disease-free and overall survival rates were respectively 42% and 62%. The 3-year local relapse, disease-free, and overall survival rates were respectively 16%, 44%, and 70% in the conventional radiotherapy group, and 36%, 47%, and 82% in the HFART group (NS). No factor significantly influenced local control with a trend, however, in favor of conventional RT (p = 0.10).

CONCLUSION

HFART at the dose of 45 Gy does not seem to be superior to the standard RT schedule, neither in terms of local control, survival, nor in terms of long-term side effects. However this dose could be considered too low as well as the power of comparison between the two groups to draw definitive conclusions.

Hyperfractionation: where do we stand?

Hyperfractionation is generally expected to allow an escalation of total dose, thereby increasing tumour control rate, without increasing the risk of late complications. The purpose of this review is to assess the empirical evidence for this therapeutic gain from hyperfractionated radiotherapy. Although extensive clinical data have been accumulated until now, especially on treatment of head and neck cancer, the line of evidence is not consistent. The present analysis indicates that the dose per fraction generally used in standard radiotherapy is already a good choice.

Radiation therapy in Ewing's sarcoma: an update of the CESS 86 trial

PURPOSE

We present an update analysis of the multiinstitutional Ewing's sarcoma study CESS 86.

METHODS AND MATERIALS

From January 1986 through June 1991, 177 patients with localized Ewing's sarcoma of bone, aged 25 years or less, were recruited. Chemotherapy consisted of four 9-week courses of vincristine, actinomycin D, cyclophosphamide, and adriamycin (VACA) in low-risk (extremity tumors < 100 cm3), or vincristine, actinomycin D, ifosfamide, and adriamycin (VAIA) in high-risk tumors (central tumors and extremity tumors > or = 100 cm3). Local therapy was an individual decision in each patient and was either radical surgery (amputation, wide resection) or resection plus postoperative irradiation with 45 Gy or definitive radiotherapy with 60 Gy (45 Gy plus boost). Irradiated patients were randomized concerning the type of fractionation in either conventional fractionation (once daily 1.8-2.0 Gy, break of chemotherapy) or hyperfractionated split-course irradiation simultaneously with the VACA/VAIA chemotherapy (twice daily 1.6 Gy, break of 12 days after 22.4 Gy and 44.8 Gy, total dose and treatment time as for conventional fractionation). For quality assurance in radiotherapy, a central treatment planning program was part of the protocol.

RESULTS

Forty-four patients (25%) received definitive radiotherapy; 39 (22%) had surgery, and 93 (53%) had resection plus postoperative irradiation. The overall 5-year survival was 69%. Thirty-one percent of the patients relapsed, 30% after radiotherapy, 26% after radical surgery, and 34% after combined local treatment. The better local control after radical surgery (100%) and resection plus radiotherapy (95%) as compared to definitive radiotherapy (86%) was not associated with an improvement in relapse-free or overall survival because of a higher frequency of distant metastases after surgery (26% vs. 29% vs. 16%). In irradiated patients, hyperfractionated split-course irradiation and conventional fractionation yielded the same results (5-year overall survival of definitively irradiated patients 63% after conventional fractionation and 65% after hyperfractionation; relapse-free survival 53% vs. 58%; local control 76% vs. 86%, not significant). The six local failures after radiotherapy did not correlate with tumor size or response to chemotherapy. Radiation treatment quality (target volume, technique, dosage) was evaluated retrospectively and was scored as unacceptable in only 1 out of 44 patients (2%) with definitive radiotherapy. Grade 3-4 complications developed in 4 out of 44 (9%) patients after definitive radiotherapy.

CONCLUSIONS

Under the given selection criteria for local therapy, radiation therapy yielded relapse-free and overall survival figures comparable to radical surgery. Hyperfractionated split-course irradiation simultaneously with multidrug chemotherapy did not significantly improve local control or survival.

Combined surgery and radiation therapy for limb preservation in soft tissue sarcoma of the extremity: the Massachusetts General Hospital experience

The results presented here indicate that excellent local control rates can be achieved using radiation in combination with limb-sparing surgery. At least three challenges remain and need to be addressed in future prospective trials. One is the need to reduce wound complications. In this regard, the influence of chemotherapy on the healing of the irradiated wound needs to be better defined as well as the role of recombinant growth factors and cytokines in tissue repair. Second is the need to better assess functional and psychological outcome in patients who are long-term survivors as well as in patients who succumb to distant disease. Despite the limited information on this end-point, it appears that strategies that reduce wound morbidity ultimately have a beneficial outcome with regard to functional and psychological status. Third, our greatest challenge is to improve the rates of distant disease control. Despite excellent local control rates following limb-sparing procedures, greater than 50% of patients will ultimately die of their disease. New systemic therapies must be developed to control systemic dissemination. The ultimate goal of combined surgery, radiation, and chemotherapy will be to preserve limb function in patients who are cured of their disease.