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Laughlin BS, Golafshar MA, Lin K, Goulding K, Roesler K, Vern-Gross T, Seetharam M, Zaniletti I, Ashman JB. Long-term experience with intraoperative electron radiation therapy boost in extremity sarcoma. J Surg Oncol 2022; 126:1279-1287. [PMID: 35856506 DOI: 10.1002/jso.27024] [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: 04/24/2022] [Revised: 06/17/2022] [Accepted: 07/12/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND In patients with extremity soft tissue sarcoma (eSTS), we describe outcomes of preoperative external beam radiation therapy (EBRT), limb-sparing surgery (LSS), and intraoperative electron radiation therapy (IOERT). METHODS One hundred and eighteen patients with eSTS treated between October 17, 2002 and July 28, 2021 were identified. EBRT was delivered preoperatively followed by LSS and IOERT. RESULTS The median follow-up was 24.9 months. The presentation was primary in 102 (94%) patients and recurrent in 6 (6%) patients. Tumor location was lower extremity in 82 (76%) patients and upper extremity in 26 (24%) patients. Stage distribution was as follows: 3 (3%) IA, 24 (22%) IB, 31 (29%) II, 24 (22%) IIIA, and 25 (23%) IIIB. Final surgical margins were negative in 96 (89%) patients. The 5-year local control, failure-free survival, and overall survival were 94%, 75%, and 64%, respectively. Univariate analysis identified age >50, lower extremity, and higher grade as significant negative prognostic factors for overall survival. Grade 3 fracture or osteoradionecrosis requiring surgical fixation, neuropathy, and lymphedema occurred in 7 (6%), 1 (1%), and 0 patients, respectively. CONCLUSIONS This study represents one of the largest series using preoperative EBRT, LSS, and IOERT for eSTS, with high local control and a low rate of late severe toxicity.
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Affiliation(s)
- Brady S Laughlin
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Michael A Golafshar
- Department of Qualitative Health Sciences, Mayo Clinic, Scottsdale, Arizona, USA
| | - Keldon Lin
- Mayo Clinic Alix School of Medicine, Scottsdale, Arizona, USA
| | - Krista Goulding
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | | | - Tamara Vern-Gross
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Mahesh Seetharam
- Department of Hematology and Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Isabella Zaniletti
- Department of Qualitative Health Sciences, Mayo Clinic, Scottsdale, Arizona, USA
| | - Jonathan B Ashman
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
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2
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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.
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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.
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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
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4
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Jentsch C, Hofbauer C, Makocki S, Troost E. [Late complications following neo-/adjuvant radiotherapy and surgery for sarcomas of the extremities or pelvis/retroperitoneum : Preventative measures]. DER ORTHOPADE 2020; 49:177-182. [PMID: 32052075 DOI: 10.1007/s00132-020-03881-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Radiotherapy is one of the pillars in the multimodal therapy of sarcomas of the extremities or pelvis/retroperitoneum. It can be delivered prior to or following surgery. Novel radiation techniques, such as intensity-modulated radiotherapy using high-energy photons or protons, contribute to the reduction of acute and late toxicities. This review article summarizes these concepts.
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Affiliation(s)
- C Jentsch
- Klinik und Poliklinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland. .,OncoRay - National Center for Radiation Research in Oncology, Dresden, Deutschland.
| | - C Hofbauer
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Deutschland
| | - S Makocki
- Klinik und Poliklinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland.,OncoRay - National Center for Radiation Research in Oncology, Dresden, Deutschland
| | - E Troost
- Klinik und Poliklinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland.,OncoRay - National Center for Radiation Research in Oncology, Dresden, Deutschland.,Institut für Radioonkologie - OncoRay, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Deutschland
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Iizumi T, Shimizu S, Numajiri H, Takei H, Yamada N, Mizumoto M, Ishikawa H, Okumura T, Sakurai H. Large Malignant Fibrous Histiocytoma Treated with Hypofractionated Proton Beam Therapy and Local Hyperthermia. Int J Part Ther 2019; 6:35-41. [PMID: 31773047 DOI: 10.14338/ijpt-18-00046.1] [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: 12/17/2018] [Accepted: 03/25/2019] [Indexed: 11/21/2022] Open
Abstract
Purpose Malignant fibrous histiocytoma (MFH) is one of the most common soft tissue sarcomas. The standard treatment is adequate surgical resection; in addition, radiation therapy plays a major role in perioperative treatment in most cases. Herein, we report the case of a patient with a large MFH who was successfully treated with combined proton beam therapy (PBT) and local hyperthermia (LH). Case Presentation A 60-year-old man presented with a 6×4-cm mass on his left thigh. Histopathology and immunohistochemistry indicated MFH, and he refused limb amputation. He received treatment with PBT at a dose at 72 GyE in 18 fractions. To cover the entire large target lesion, we used a patch-field protocol. He also concurrently received 7 courses of LH. The combination therapy achieved long-term local control without severe acute or late toxicity during the 7-year follow-up period. Conclusions This case suggests that the combination of PBT and LH may be an option as a limb-preserving treatment for large inoperable MFH in the extremities.
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Affiliation(s)
- Takashi Iizumi
- Department of Radiation Oncology and Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Shosei Shimizu
- Department of Radiation Oncology and Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Haruko Numajiri
- Department of Radiation Oncology and Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hideyuki Takei
- Department of Radiation Oncology and Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Noboru Yamada
- Department of Orthopedic Surgery, Fukushima Rosai Hospital, Iwaki, Fukushima, Japan
| | - Masashi Mizumoto
- Department of Radiation Oncology and Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hitoshi Ishikawa
- Department of Radiation Oncology and Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Toshiyuki Okumura
- Department of Radiation Oncology and Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hideyuki Sakurai
- Department of Radiation Oncology and Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
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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.
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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
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7
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Carbó-Laso E, Sanz-Ruiz P, Calvo-Haro JA, Cuervo-Dehesa M, Pérez-Mañanes R, Mediavilla-Santos L, Sánchez-Pérez C, Álvarez-González A, Vaquero-Martín J. Intraoperative radiotherapy for extremity soft-tissue sarcomas: can long-term local control be achieved? Int J Clin Oncol 2017; 22:1094-1102. [PMID: 28717856 DOI: 10.1007/s10147-017-1162-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 07/08/2017] [Indexed: 01/20/2023]
Abstract
BACKGROUND Intraoperative electron-beam radiation therapy (IOERT) during limb-sparing surgery has the advantage of delivering a single high boost dose to sarcoma residues and surgical bed area near to radiosensitive structures with limited toxicity. Retrospective studies have suggested that IOERT may improve local control compared to standard radiotherapy and we aimed to demonstrate this theory. Therefore, we performed an observational prospective study to determine (1) if it is possible to achieve high local control by adding IOERT to external-beam radiation therapy (EBRT) in extremity soft-tissue sarcomas (STS), (2) if it is possible to improve long-term survival rates, and (3) if toxicity could be reduced with IOERT MATERIALS AND METHODS: From 1995-2003, 39 patients with extremity STS were treated with IOERT and postoperative radiotherapy. The median follow-up time was 13.2 years (0.7-19). Complications, locoregional control and survival rates were collected. RESULTS Actuarial local control was attained in 32 of 39 patients (82%). Control was achieved in 88% of patients with primary disease and in 50% of those with recurrent tumors (p = 0.01). Local control was shown in 93% of patients with negative margins and in 50% of those with positive margins (p = 0.002). Limb-sparing was achieved in 32 patients (82%). The overall survival rate was 64%. 13% of patients had grade ≥3 acute toxicity, and 12% developed grade ≥3 chronic toxicity. CONCLUSION IOERT used as a boost to EBRT provides high local control and limb-sparing rates in patients with STS of the extremities, with less toxicity than EBRT alone.
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Affiliation(s)
- Esther Carbó-Laso
- Department of Traumatology and Orthopaedic Surgery, General Hospital Gregorio Marañón, Dr. Esquerdo, 46, 28007, Madrid, Spain.
| | - Pablo Sanz-Ruiz
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
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8
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Pilar A, Gupta M, Ghosh Laskar S, Laskar S. Intraoperative radiotherapy: review of techniques and results. Ecancermedicalscience 2017; 11:750. [PMID: 28717396 PMCID: PMC5493441 DOI: 10.3332/ecancer.2017.750] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Indexed: 12/14/2022] Open
Abstract
Intraoperative radiotherapy (IORT) is a technique that involves precise delivery of a large dose of ionising radiation to the tumour or tumour bed during surgery. Direct visualisation of the tumour bed and ability to space out the normal tissues from the tumour bed allows maximisation of the dose to the tumour while minimising the dose to normal tissues. This results in an improved therapeutic ratio with IORT. Although it was introduced in the 1960s, it has seen a resurgence of popularity with the introduction of self-shielding mobile linear accelerators and low-kV IORT devices, which by eliminating the logistical issues of transport of the patient during surgery for radiotherapy or building a shielded operating room, has enabled its wider use in the community. Electrons, low-kV X-rays and HDR brachytherapy are all different methods of IORT in current clinical use. Each method has its own unique set of advantages and disadvantages, its own set of indications where one may be better suited than the other, and each requires a specific kind of expertise. IORT has demonstrated its efficacy in a wide variety of intra-abdominal tumours, recurrent colorectal cancers, recurrent gynaecological cancers, and soft-tissue tumours. Recently, it has emerged as an attractive treatment option for selected, early-stage breast cancer, owing to the ability to complete the entire course of radiotherapy during surgery. IORT has been used in a multitude of roles across these sites, for dose escalation (retroperitoneal sarcoma), EBRT dose de-escalation (paediatric tumours), as sole radiation modality (early breast cancers) and as a re-irradiation modality (recurrent rectal and gynaecological cancers). This article aims to provide a review of the rationale, techniques, and outcomes for IORT across different sites relevant to current clinical practice.
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Affiliation(s)
- Avinash Pilar
- Department of Radiation Oncology, Tata Memorial Hospital, Dr Ernest Borges' Marg, Parel, Mumbai, MS, India 400012
| | - Meetakshi Gupta
- Department of Radiation Oncology, Tata Memorial Hospital, Dr Ernest Borges' Marg, Parel, Mumbai, MS, India 400012
| | - Sarbani Ghosh Laskar
- Department of Radiation Oncology, Tata Memorial Hospital, Dr Ernest Borges' Marg, Parel, Mumbai, MS, India 400012
| | - Siddhartha Laskar
- Department of Radiation Oncology, Tata Memorial Hospital, Dr Ernest Borges' Marg, Parel, Mumbai, MS, India 400012
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Abstract
The management of recurrent soft tissue sarcoma is a challenging problem for clinicians and has a significant physical, mental, emotional, and oncologic impact for the patient. Despite excellent limb-preservation therapies, approximately one-quarter of patients may eventually develop recurrence of disease. How to most appropriately manage these patients is a matter of debate. Several treatment options exist, including surgical resection, irradiation, systemic chemotherapy, amputation, and regional therapies. This article highlights the management of recurrent extremity soft tissue sarcoma.
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Affiliation(s)
- Whitney M Guerrero
- Department of Surgery, University of Tennessee Health Science Center, 910 Madison Ave, Suite 300, Memphis, TN 38163, USA
| | - Jeremiah L Deneve
- Department of Surgery, University of Tennessee Health Science Center, 910 Madison Ave, Suite 300, Memphis, TN 38163, USA; Division of Surgical Oncology, University of Tennessee Health Science Center, 910 Madison Avenue, Suite 300, Memphis, TN 38163, USA.
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10
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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.
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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
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Matsumine A, Tsujii M, Nakamura T, Asanuma K, Matsubara T, Kakimoto T, Yada Y, Takada A, Ii N, Nomoto Y, Sudo A. Minimally invasive surgery using intraoperative electron-beam radiotherapy for the treatment of soft tissue sarcoma of the extremities with tendon involvement. World J Surg Oncol 2016; 14:214. [PMID: 27514518 PMCID: PMC4982423 DOI: 10.1186/s12957-016-0968-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 08/02/2016] [Indexed: 11/21/2022] Open
Abstract
Background When a soft tissue sarcoma (STS) is located at the distal part of an extremity and involves the tendon, a wide excision usually causes severe functional disability. We therefore developed a minimally invasive surgical technique using intraoperative electron-beam radiotherapy (IOERT) to reduce the incidence of post-operative functional disability in patients with peri-/intra-tendinous STS. We assessed the clinical outcomes of the novel minimally invasive surgery. Methods The study population included five patients who received treatment for distal extremity STSs. After elevating the tumor mass, including the tendon and nerve from the tumor bed with a wide margin, a lead board was inserted beneath the tumor mass to shield the normal tissue. IOERT (25–50 Gy) was then applied, and the tumor excised with care taken to maintain the continuity of the tendon. Results In a desmoid patient, local recurrence was observed outside the irradiated field. No cases of neuropathy or bone necrosis were observed. The mean limb function score was excellent in all patients. None of the high-grade sarcoma patients had local recurrence or distant metastasis. Conclusions Although the current study is only a pilot study with a small number of patients, it shows that this minimally invasive procedure has the potential to become a standard treatment option for selected patients. Trial registration H17-250 (registered 2 November 2005) and H25-250 (modified from H17-250, registered 5 December 2013)
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Affiliation(s)
- Akihiko Matsumine
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan.
| | - Masaya Tsujii
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Tomoki Nakamura
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Kunihiro Asanuma
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Takao Matsubara
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Takuya Kakimoto
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Yuki Yada
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Akinori Takada
- Department of Radiology, Mie University School of Medicine, 2-174 Edobashi, Tsu city, Mie, 514-8507, Japan
| | - Noriko Ii
- Department of Radiology, Mie University School of Medicine, 2-174 Edobashi, Tsu city, Mie, 514-8507, Japan
| | - Yoshihito Nomoto
- Department of Radiology, Mie University School of Medicine, 2-174 Edobashi, Tsu city, Mie, 514-8507, Japan
| | - Akihiro Sudo
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
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12
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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]
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Intraoperative Radiotherapy in the Management of Locally Recurrent Extremity Soft Tissue Sarcoma. Sarcoma 2015; 2015:913565. [PMID: 26346118 PMCID: PMC4546758 DOI: 10.1155/2015/913565] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 06/26/2015] [Accepted: 07/14/2015] [Indexed: 11/18/2022] Open
Abstract
Purpose. To investigate the efficacy and morbidity of limb-sparing surgery with intraoperative radiotherapy (IORT) for patients with locally recurrent extremity soft tissue sarcoma (ESTS). Methods and Materials. Twenty-six consecutively treated patients were identified in a single institution retrospective analysis of patients with locally recurrent ESTS treated with IORT following salvage limb-sparing resection from May 2000 to July 2011. Fifteen (58%) patients received external beam radiotherapy (EBRT) prior to recurrence (median dose 63 Gy), while 11 (42%) patients received EBRT following IORT (median dose 52 Gy). The Kaplan-Meier product limit method was used to estimate disease control and survival and subsets were compared using a log rank statistic, Cox's regression model was used to determine independent predictors of disease outcome, and toxicity was reported according to CTCAE v4.0 guidelines. Results. With a median duration of follow-up from surgery and IORT of 34.9 months (range: 4 to 139 mos.), 10 patients developed a local recurrence with 4 subsequently undergoing amputation. The 5-year estimate for local control (LC) was 58% (95% CI: 36–75%), for amputation-free was 81% (95% CI: 57–93%), for metastasis-free control (MFC) was 56% (95% CI: 31–75%), for disease-free survival (DFS) was 35% (95% CI: 17–54%), and for overall survival (OS) was 50% (95% CI: 24–71%). Prior EBRT did not appear to influence disease control (LC, p = 0.74; MFC, p = 0.66) or survival (DFS, p = 0.16; OS, p = 0.58). Grade 3 or higher acute and late toxicities were reported for 6 (23%) and 8 (31%) patients, respectively. The frequency of both acute and late grade 3 or higher toxicities occurred equally between patients who received EBRT prior to or after IORT. Conclusions. IORT in combination with oncologic resection of recurrent ESTS yields good rates of local control and limb-salvage with acceptable morbidity. Within the limitations of small subsets, these data suggest that prior EBRT does not significantly influence disease control or toxicity.
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Jensen AD, Uhl M, Chaudhri N, Herfarth KK, Debus J, Roeder F. Carbon Ion irradiation in the treatment of grossly incomplete or unresectable malignant peripheral nerve sheaths tumors: acute toxicity and preliminary outcome. Radiat Oncol 2015; 10:109. [PMID: 25943106 PMCID: PMC4432820 DOI: 10.1186/s13014-015-0414-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 04/28/2015] [Indexed: 12/11/2022] Open
Abstract
Background To report our early experience with carbon ion irradiation in the treatment of gross residual or unresectable malignant peripheral nerve sheath tumors (MPNST). Methods We retrospectively analysed 11 patients (pts) with MPNST, who have been treated with carbon ion irradiation (C12) at our institution between 2010 and 2013. All pts had measurable gross disease at the initiation of radiation treatment. Median age was 47 years (29-79). Tumors were mainly located in the pelvic/sacral (5 pts) and sinunasal/orbital region (5 pts). 5 pts presented already in recurrent situation, 3 pts had been previously irradiated, and in 3 pts MPNST were neurofibromatosis type 1 (NF1) associated. Median cumulative dose was 60 GyE. Treatment was carried out either as a combination of IMRT plus C12 boost (4 pts) or C12 only (7 pts). Results Median follow-up was 17 months (3-31 months). We observed 3 local progressions, translating into estimated 1- and 2-year local control rates of 65%. One patient developed distant failure, resulting in estimated 1- and 2-year PFS rates of 56%. Two patients have died, therefore the estimated 1- and 2-year OS rates are 75%. Acute radiation related toxicities were generally mild, no grade 3 side effects were observed. Severe late toxicity (grade 3) was scored in 2 patients (trismus, wound healing delays). Conclusion Carbon ion irradiation yields very promising short term local control and overall survival rates with low morbidity in patients suffering from gross residual or unresectable malignant peripheral nerve sheath tumors and should be further investigated in a prospective trial.
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Affiliation(s)
- Alexandra D Jensen
- Department of Radiation Oncology, University of Heidelberg, INF 400, 69120, Heidelberg, Germany.
| | - Matthias Uhl
- Department of Radiation Oncology, University of Heidelberg, INF 400, 69120, Heidelberg, Germany.
| | - Naved Chaudhri
- Department of Medical Physics, Heidelberg Ion Beam Therapy Centre (HIT), Heidelberg, Germany.
| | - Klaus K Herfarth
- Department of Radiation Oncology, University of Heidelberg, INF 400, 69120, Heidelberg, Germany.
| | - Juergen Debus
- Department of Radiation Oncology, University of Heidelberg, INF 400, 69120, Heidelberg, Germany. .,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | - Falk Roeder
- Department of Radiation Oncology, University of Heidelberg, INF 400, 69120, Heidelberg, Germany. .,Department of Molecular and Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.
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Miller ED, Xu-Welliver M, Haglund KE. The role of modern radiation therapy in the management of extremity sarcomas. J Surg Oncol 2014; 111:599-603. [PMID: 25366825 DOI: 10.1002/jso.23823] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 09/24/2014] [Indexed: 11/11/2022]
Abstract
For nearly half a decade, surgery and radiation therapy have been used in combination to achieve the goal of limb preservation in extremity soft tissue sarcoma, with success rates in excess of 90%. Common decision points in therapeutic radiation delivery for sarcoma are discussed, including preoperative versus postoperative irradiation, the postoperative boost, and when irradiation might be unnecessary. We describe specialized techniques, such as brachytherapy and intraoperative irradiation. The data driving current practice is summarized.
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Affiliation(s)
- Eric D Miller
- Department of Radiation Oncology, Arthur G. James Cancer Hospital & Richard J. Solove Research Institute, Ohio State University Wexner Medical Center, Columbus, Ohio
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16
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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
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Affiliation(s)
- Falk Roeder
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.
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Calvo FA, Sole CV, Polo A, Cambeiro M, Montero A, Alvarez A, Cuervo M, Julian MS, Martinez-Monge R. Limb-sparing management with surgical resection, external-beam and intraoperative electron-beam radiation therapy boost for patients with primary soft tissue sarcoma of the extremity: a multicentric pooled analysis of long-term outcomes. Strahlenther Onkol 2014; 190:891-8. [PMID: 24715241 DOI: 10.1007/s00066-014-0640-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Accepted: 02/11/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND OR PURPOSE A joint analysis of data from three contributing centres within the intraoperative electron-beam radiation therapy (IOERT) Spanish program was performed to investigate the main contributions of IORT to the multidisciplinary treatment of high-risk extremity soft tissue sarcoma (STS). METHODS AND MATERIALS Patients with an histologic diagnosis of primary extremity STS, with absence of distant metastases, undergoing limb-sparing surgery with radical intent, external beam radiotherapy (median dose 45 Gy) and IOERT (median dose 12.5 Gy) were considered eligible for participation in this study. RESULTS From 1986-2012, a total of 159 patients were analysed in the study from three Spanish institutions. With a median follow-up time of 53 months (range 4-316 years), 5-year local control (LC) was 82 %. The 5-year IOERT in-field control, disease-free survival (DFS) and overall survival (OS) were 86, 62 and 72 %, respectively. On multivariate analysis, only microscopically involved margin (R1) resection status retained significance in relation to LC (HR 5.20, p < 0.001). With regard to IOERT in-field control, incomplete resection (HR 4.88, p = 0.001) and higher IOERT dose (≥ 12.5 Gy; HR 0.32, p = 0.02) retained a significant association in multivariate analysis. CONCLUSION From this joint analysis emerges the fact that an IOERT dose ≥ 12.5 Gy increases the rate of IOERT in-field control, but DFS remains modest, given the high risk of distant metastases. Intensified local treatment needs to be tested in the context of more efficient concurrent, neo- and adjuvant systemic therapy.
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Affiliation(s)
- Felipe A Calvo
- Department of Oncology, Hospital General Universitario Gregorio Marañón, C/Doctor Esquerdo, 46-28007, Madrid, Spain
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18
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Calvo FA, Sole CV, Cambeiro M, Montero A, Polo A, Gonzalez C, Cuervo M, San Julian M, Garcia-Sabrido JL, Martinez-Monge R. Prognostic value of external beam radiation therapy in patients treated with surgical resection and intraoperative electron beam radiation therapy for locally recurrent soft tissue sarcoma: a multicentric long-term outcome analysis. Int J Radiat Oncol Biol Phys 2014; 88:143-50. [PMID: 24331661 DOI: 10.1016/j.ijrobp.2013.10.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Revised: 09/02/2013] [Accepted: 10/15/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND A joint analysis of data from centers involved in the Spanish Cooperative Initiative for Intraoperative Electron Radiotherapy was performed to investigate long-term outcomes of locally recurrent soft tissue sarcoma (LR-STS) patients treated with a multidisciplinary approach. METHODS AND MATERIALS Patients with a histologic diagnosis of LR-STS (extremity, 43%; trunk wall, 24%; retroperitoneum, 33%) and no distant metastases who underwent radical surgery and intraoperative electron radiation therapy (IOERT; median dose, 12.5 Gy) were considered eligible for participation in this study. In addition, 62% received external beam radiation therapy (EBRT; median dose, 50 Gy). RESULTS From 1986 to 2012, a total of 103 patients from 3 Spanish expert IOERT institutions were analyzed. With a median follow-up of 57 months (range, 2-311 months), 5-year local control (LC) was 60%. The 5-year IORT in-field control, disease-free survival (DFS), and overall survival were 73%, 43%, and 52%, respectively. In the multivariate analysis, no EBRT to treat the LR-STS (P=.02) and microscopically involved margin resection status (P=.04) retained significance in relation to LC. With regard to IORT in-field control, only not delivering EBRT to the LR-STS retained significance in the multivariate analysis (P=.03). CONCLUSION This joint analysis revealed that surgical margin and EBRT affect LC but that, given the high risk of distant metastases, DFS remains modest. Intensified local treatment needs to be further tested in the context of more efficient concurrent, neoadjuvant, and adjuvant systemic therapy.
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Affiliation(s)
- Felipe A Calvo
- Department of Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; School of Medicine, Complutense University, Madrid, Spain
| | - Claudio V Sole
- Department of Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; School of Medicine, Complutense University, Madrid, Spain; Service of Radiation Oncology, Instituto de Radiomedicina, Santiago, Chile.
| | - Mauricio Cambeiro
- Service of Radiation Oncology, Clínica Universitaria, Universidad de Navarra, Pamplona, Spain
| | - Angel Montero
- Service of Radiation Oncology, Hospital Universitario Ramón y Cajal, Universidad de Alcala, Madrid, Spain
| | - Alfredo Polo
- Service of Radiation Oncology, Hospital Universitario Ramón y Cajal, Universidad de Alcala, Madrid, Spain
| | - Carmen Gonzalez
- School of Medicine, Complutense University, Madrid, Spain; Service of Radiation Oncology, Instituto de Radiomedicina, Santiago, Chile; Service of Radiation Oncology, Clínica Universitaria, Universidad de Navarra, Pamplona, Spain; Service of Radiation Oncology, Hospital Universitario Ramón y Cajal, Universidad de Alcala, Madrid, Spain; Service of Radiation Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Miguel Cuervo
- Service of Orthopedics and Traumatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Mikel San Julian
- Service of Orthopedics and Traumatology, Clínica Universitaria, Universidad de Navarra, Pamplona, Spain
| | - Jose L Garcia-Sabrido
- School of Medicine, Complutense University, Madrid, Spain; Service of General Surgery III, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Rafael Martinez-Monge
- Service of Radiation Oncology, Clínica Universitaria, Universidad de Navarra, Pamplona, Spain
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Debenham BJ, Hu KS, Harrison LB. Present status and future directions of intraoperative radiotherapy. Lancet Oncol 2013; 14:e457-e464. [PMID: 24079873 DOI: 10.1016/s1470-2045(13)70270-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In this Review, we summarise recent published work on the use of intraoperative radiotherapy to treat common tumour sites in the primary or recurrent setting. Techniques, radiobiology, and the physics of intraoperative radiotherapy are also explored. Disease sites discussed in this Review include head and neck cancer, breast cancer, sarcoma, gastrointestinal cancer, genitourinary cancer, gynaecological cancer, thoracic cancer, and palliative applications.
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Affiliation(s)
- Brock J Debenham
- Department of Radiation Oncology, Continuum Cancer Centers of New York-Beth Israel Medical Center, St Luke's and Roosevelt Hospitals, New York, NY 10003, USA
| | - Kenneth S Hu
- Department of Radiation Oncology, Continuum Cancer Centers of New York-Beth Israel Medical Center, St Luke's and Roosevelt Hospitals, New York, NY 10003, USA.
| | - Louis B Harrison
- Department of Radiation Oncology, Continuum Cancer Centers of New York-Beth Israel Medical Center, St Luke's and Roosevelt Hospitals, New York, NY 10003, USA
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Clinical and technical characteristics of intraoperative radiotherapy. Analysis of the ISIORT-Europe database. Strahlenther Onkol 2013; 189:729-37. [PMID: 23842635 DOI: 10.1007/s00066-013-0395-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 05/22/2013] [Indexed: 01/23/2023]
Abstract
BACKGROUND A joint analysis of clinical data from centres within the European section of the International Society of Intraoperative Radiation Therapy (ISIORT-Europe) was undertaken in order to define the range of intraoperative radiotherapy (IORT) techniques and indications encompassed by its member institutions. MATERIALS AND METHODS In 2007, the ISIORT-Europe centres were invited to record demographic, clinical and technical data relating to their IORT procedures in a joint online database. Retrospective data entry was possible. RESULTS The survey encompassed 21 centres and data from 3754 IORT procedures performed between 1992 and 2011. The average annual number of patients treated per institution was 42, with three centres treating more than 100 patients per year. The most frequent tumour was breast cancer with 2395 cases (63.8 %), followed by rectal cancer (598 cases, 15.9 %), sarcoma (221 cases, 5.9 %), prostate cancer (108 cases, 2.9 %) and pancreatic cancer (80 cases, 2.1 %). Clinical details and IORT technical data from these five tumour types are reported. CONCLUSION This is the first report on a large cohort of patients treated with IORT in Europe. It gives a picture of patient selection methods and treatment modalities, with emphasis on the main tumour types that are typically treated by this technique and may benefit from it.
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Sugahara S, Kamada T, Imai R, Tsuji H, Kameda N, Okada T, Tsujii H, Tatezaki S. Carbon ion radiotherapy for localized primary sarcoma of the extremities: results of a phase I/II trial. Radiother Oncol 2012; 105:226-31. [PMID: 23068710 DOI: 10.1016/j.radonc.2012.09.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Revised: 08/29/2012] [Accepted: 09/12/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE To determine the effectiveness of carbon ion radiotherapy (CIRT) for localized primary sarcomas of the extremities in a prospective study. PATIENTS AND MATERIALS From April 2000 to May 2010, 17 (male/female: 12/5) patients with localized primary sarcoma of the extremities received CIRT. The median age was 53 years (range: 14-87 years). Nine patients had primary diseases and eight had recurrent diseases. Of the 17 patients, eight refused amputation, and the remaining nine refused surgical resection. Tumors were located in the upper limbs in four patients and lower limbs in 13. Histological diagnosis was osteosarcoma in three patients, liposarcoma in two, synovial sarcoma in two, rhabdomyosarcoma in two, pleomorphic sarcoma in two, and miscellaneous in six. The CIRT dose to the limb was 52.8 GyE for one patient, 64 GyE for three, 70.4 GyE for 13 in 16 fixed fractions over 4 weeks. Records were reviewed and outcomes including radiologic response, local control (progression-free), and survival were analyzed. RESULTS The median follow-up was 37 months (range: 11-97 months). Radiological response rate was 65% (PR in 11, SD in 5, and PD in 1). The local control rate at 5 years was 76%. The overall survival rate at 5 years was 56%. Of the 17 patients, 10 survived without disease progression. Four patients had local recurrences, one was salvaged by repeated CIRT and the other three died due to systemic diseases. Distant failure was observed in six patients. One patient suffered from femoral fracture (grade 3) and received surgical fixation 27 months after CIRT. No other severe reactions (grade 3) were observed. CONCLUSIONS CIRT is suggested to be an effective and safe treatment for patients who refuse surgery for localized primary sarcomas of the extremities.
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Mahmoud O, Wolfson A. Perioperative irradiation in extremity soft tissue sarcoma. Expert Rev Anticancer Ther 2012; 11:1233-41. [PMID: 21916577 DOI: 10.1586/era.11.95] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Adjuvant radiotherapy constitutes an important component of the treatment of soft tissue sarcomas. Extremity soft tissue sarcomas constitute a large proportion of this rare mesenchymal tumor. Questions regarding timing, techniques and toxicity come into play about optimizing adjuvant radiotherapy. This article will discuss recent trends and outcomes of perioperative, that is, preoperative and postoperative, irradiation.
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Affiliation(s)
- Omar Mahmoud
- Department of Radiation Oncology, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
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Abstract
Musculoskeletal sarcomas are a heterogeneous group of malignant neoplasms derived from connective tissue. Sarcomas represent about 1% of cancer in adults. The annual incidence in adults in Europe is around 14,000 new cases of soft tissue sarcomas (STS) and 4,800 new cases of bone sarcomas. Musculoskeletal tumours arise anywhere in the body, although lower extremities are the most common site of appearance, followed by upper extremities, trunk, retroperitoneum and head and neck area. Adequate management of STS is a stimulating challenge for oncologists. The aim of treatment should be focused on four main aspects: improving survival, avoiding local recurrence, maximising organ function and, finally, minimising morbidity. Surgery, radiotherapy and, sometimes though increasingly, chemotherapy are the pillars on which rests the modern treatment of sarcomas. The optimal management of musculoskeletal tumour requires a multidisciplinary integration of these different approaches in treatment planning right from the initial diagnoses. Referring patients to qualified centres should be desirable to achieve the maximum probability of control and even cure for STS.
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Affiliation(s)
- Ángel Montero Luis
- FEA de Oncología Radioterápica, Hospital Universitario Ramón y Cajal, Madrid, Spain.
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Niewald M, Fleckenstein J, Licht N, Bleuzen C, Ruebe C. Intraoperative radiotherapy (IORT) combined with external beam radiotherapy (EBRT) for soft-tissue sarcomas--a retrospective evaluation of the Homburg experience in the years 1995-2007. Radiat Oncol 2009; 4:32. [PMID: 19709420 PMCID: PMC2739216 DOI: 10.1186/1748-717x-4-32] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2009] [Accepted: 08/26/2009] [Indexed: 11/13/2022] Open
Abstract
Purpose To retrospectively evaluate the results after a regimen of surgery, IORT (intraoperative radiotherapy), and EBRT (external beam radiotherapy) for soft-tissue sarcomas Methods 38 consecutive patients underwent IORT for soft-tissue sarcoma; 29 were treated for primary tumours, 9 for recurrences. There were 14 cases with liposarcomas, 8 with leiomyosarcomas, 7 with malignant fibrous histiocytomas. 27/38 tumours were located in the extremities, the remaining ones in the retroperitoneum or the chest. Radical resection was attempted in all patients; a R0-resection was achieved in 15/38 patients, R1 in 12/38 pats and R2 in 4/38 pats. IORT was performed using a J-125 source and a HDR (high dose rate) afterloading machine after suturing silicone flaps to the tumour bed. The total dose applied ranged from 8–15 Gy/0.5 cm tissue depth measured from the flap surface. After wound healing external beam radiotherapy (EBRT) was applied in 31/38 patients with total doses of 23–56 Gy dependent on resection status and wound situation. The mean duration of follow-up was 2.3 years. Results A local recurrence was found in 10/36 patients, lymph node metastases in 2/35, and distant metastases in 6/35 patients. The actuarial local control rate was 63%/5 years. The overall survival rate was 57%/5 years. There was no statistically significant difference between the results after treatment for primaries or for recurrences. Late toxicity to the skin was found in 13/31 patients, wound healing problems in 5/31 patients. A neuropathy was never seen. Conclusion The combination of surgery, IORT, and EBRT yields favourable local control and survival data which are well within the range of the results reported in the literature. The complication rates, however, are considerable although the complications are not severe, they should be taken into account when therapy decisions are made.
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Affiliation(s)
- Marcus Niewald
- Dept of Radiooncology, Saarland University Hospital, 66424 Homburg/Saar, Germany.
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Intraoperative electron radiotherapy for the management of aggressive fibromatosis. Int J Radiat Oncol Biol Phys 2009; 76:1154-60. [PMID: 19647952 DOI: 10.1016/j.ijrobp.2009.03.067] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2008] [Revised: 03/08/2009] [Accepted: 03/09/2009] [Indexed: 11/22/2022]
Abstract
PURPOSE We analyzed our experience with intraoperative electron radiotherapy (IOERT) followed by moderate doses of external beam radiotherapy (EBRT) after organ-sparing surgery in patients with primary or recurrent aggressive fibromatosis. METHODS AND MATERIALS Indication for IOERT and postoperative EBRT as an individual treatment approach to avoid mutilating surgical procedures was seen when complete surgical removal seemed to be unlikely or impossible. A total of 31 lesions in 30 patients were treated by surgery and IOERT with a median dose of 12 Gy. Median age was 31 years (range, 13-59 years). Resection status was close margin in six lesions, microscopically positive in 13, and macroscopically positive in 12. Median tumor size was 9 cm. In all, 25 patients received additional EBRT, with a median dose of 45 Gy (range, 36-54 Gy). RESULTS After a median follow-up of 32 months (range, 3-139 months), no disease-related deaths occurred. A total of five local recurrences were seen, resulting in actuarial 3-year local control rates of 82% overall and 91% inside the IOERT areas. Trends to improved local control were seen for older age (>31 years) and negative margins, but none of these factors reached significance. Perioperative complications were found in six patients, in particular as wound healing disturbances in five patients and venous thrombosis in one patient. Late toxicity was seen in five patients. CONCLUSION Introduction of IOERT into a multimodal treatment approach in patients with aggressive fibromatosis is feasible with low toxicity and yielded good local control rates even in patients with microscopical or gross residual disease.
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Stoeckle E, Coindre JM, Kind M, Kantor G, Bui BN. Evaluating surgery quality in soft tissue sarcoma. Recent Results Cancer Res 2009; 179:229-42. [PMID: 19230543 DOI: 10.1007/978-3-540-77960-5_14] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
To identify pertinent indicators for oncologic outcomes in assessing surgery in soft tissue sarcomas, only local recurrences are considered here. Functional outcomes and treatment morbidity, equally important end-points for evaluating surgery quality, are less frequently reported and are not taken into account in this review. Herein, we review recent publications reporting indicators of surgery quality in soft tissue sarcoma treatment. Local recurrence-free interval is the major end-point in evaluating the quality of surgery. Disease-free survival should not be used because the risk factors for metastases are different from those for local recurrence. Five-year local recurrence-free estimations for limb and trunk wall sarcoma should be below 20%, and best approach 10%. The risk of local recurrence depends on tumour biology (i.e. grade) and quality of surgery as defined by the quality of margins. Better than margin width as measured on the tumour specimen, margin quality determined consensually between surgeons and pathologists is the best indicator for local outcome. Quality of margin should be expressed according the UICC residual disease definitions (R0: in sano, R1: microscopic residual disease, R2: macroscopic residual disease). Other important indicators for surgery quality are treatment in specialised centres, a planned, organised surgery, and treatment within a multidisciplinary team. Soft tissue sarcoma should also be treated in specialised centres. Surgery quality depends on obtained margins that are determined best by close collaboration between the surgeon and the pathologist.
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Affiliation(s)
- Eberhard Stoeckle
- Department of Surgery, Institut Bergonie, Regional Cancer Centre, 229 Cours de I'Argonne, 33076 Bordeaux Cedex, France.
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Standardized approach to the treatment of adult soft tissue sarcoma of the extremities. Recent Results Cancer Res 2009; 179:211-28. [PMID: 19230542 DOI: 10.1007/978-3-540-77960-5_13] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
Soft tissue sarcomas are very rare tumors. Available data are based on only a few prospective randomized trials. Most studies are retrospective, reviewing the results of single institutions. Furthermore, universally accepted treatment protocols for adult patients are lacking. Several prognostic factors have been identified, including grading, tumor size and development of metastatic disease; however, the relevance of other important aspects in the treatment of patients with soft tissue sarcomas remains unknown or subject to controversy. The main issues concern: which surgical margin width is safe from an oncological perspective? Does local recurrence influence survival? Can systemic chemotherapy improve prognosis? Is radiotherapy necessary in every case? Should it be applied pre-, post- or intraoperatively? What is the value of assessing the response after neoadjuvant therapy? These topics are examined in this review.
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Janssen RWJ, Faddegon BA, Dries WJF. Prototyping a large field size IORT applicator for a mobile linear accelerator. Phys Med Biol 2008; 53:2089-102. [PMID: 18369280 DOI: 10.1088/0031-9155/53/8/006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The treatment of large tumors such as sarcomas with intra-operative radiotherapy using a Mobetron is often complicated because of the limited field size of the primary collimator and the available applicators (max Ø100 mm). To circumvent this limitation a prototype rectangular applicator of 80 x 150 mm(2) was designed and built featuring an additional scattering foil located at the top of the applicator. Because of its proven accuracy in modeling linear accelerator components the design was based on the EGSnrc Monte Carlo simulation code BEAMnrc. First, the Mobetron treatment head was simulated both without an applicator and with a standard 100 mm applicator. Next, this model was used to design an applicator foil consisting of a rectangular Al base plate covering the whole beam and a pyramid of four stacked cylindrical slabs of different diameters centered on top of it. This foil was mounted on top of a plain rectangular Al tube. A prototype was built and tested with diode dosimetry in a water tank. Here, the prototype showed clinically acceptable 80 x 150 mm(2) dose distributions for 4 MeV, 6 MeV and 9 MeV, obviating the use of complicated multiple irradiations with abutting field techniques. In addition, the measurements agreed well with the MC simulations, typically within 2%/1 mm.
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Affiliation(s)
- Rogier W J Janssen
- Catharina-Hospital Eindhoven, PO Box 1350, 5602 ZA, Eindhoven, The Netherlands.
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Affiliation(s)
- Valerae O Lewis
- MD Anderson Cancer Center, P.O. Box 301402, Unit 408, Houston, TX 77230-1402, USA
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Roeder F, Treiber M, Oertel S, Dinkel J, Timke C, Funk A, Garcia-Huttenlocher H, Bischof M, Weitz J, Harms W, Hensley FW, Buchler MW, Debus J, Krempien R. Patterns of failure and local control after intraoperative electron boost radiotherapy to the presacral space in combination with total mesorectal excision in patients with locally advanced rectal cancer. Int J Radiat Oncol Biol Phys 2007; 67:1381-8. [PMID: 17275208 DOI: 10.1016/j.ijrobp.2006.11.039] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2006] [Revised: 11/09/2006] [Accepted: 11/16/2006] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate local control and patterns of failure in patients treated with intraoperative electron beam radiotherapy (IOERT) after total mesorectal excision (TME), to appraise the effectiveness of intraoperative target definition. METHODS AND MATERIALS We analyzed the outcome of 243 patients with rectal cancer treated with IOERT (median dose, 10 Gy) after TME. Eighty-eight patients received neoadjuvant and 122 patients adjuvant external beam radiotherapy (EBRT) (median dose, 41.4 Gy), and in 88% simultaneous chemotherapy was applied. Median follow-up was 59 months. RESULTS Local failure was observed in 17 patients (7%), resulting in a 5-year local control rate of 92%. Only complete resection and absence of nodal involvement correlated positively with local control. Considering IOERT fields, seven infield recurrences were seen in the presacral space, resulting in a 5-year local control rate of 97%. The remaining local relapses were located as follows: retrovesical/retroprostatic (5), anastomotic site (2), promontorium (1), ileocecal (1), and perineal (1). CONCLUSION Intraoperative electron beam radiotherapy as part of a multimodal treatment approach including TME is a highly effective regimen to prevent local failure. The presacral space remains the site of highest risk for local failure, but IOERT can decrease the percentage of relapses in this area.
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Affiliation(s)
- Falk Roeder
- Department of Radiation Oncology, University of Heidelberg, Heidelberg, Germany
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Krempien R, Roeder F, Oertel S, Roebel M, Weitz J, Hensley FW, Timke C, Funk A, Bischof M, Zabel-Du Bois A, Niethammer AG, Eble MJ, Buchler MW, Treiber M, Debus J. Long-term results of intraoperative presacral electron boost radiotherapy (IOERT) in combination with total mesorectal excision (TME) and chemoradiation in patients with locally advanced rectal cancer. Int J Radiat Oncol Biol Phys 2006; 66:1143-51. [PMID: 16979835 DOI: 10.1016/j.ijrobp.2006.06.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2006] [Revised: 06/02/2006] [Accepted: 06/15/2006] [Indexed: 11/23/2022]
Abstract
BACKGROUND We analyzed the long-term results of patients with locally advanced rectal cancer using a multimodal approach consisting of total mesorectal excision (TME), intraoperative electron-beam radiation therapy (IOERT), and pre- or postoperative chemoradiation (CRT). PATIENTS AND METHODS Between 1991 and 2003, 210 patients with locally advanced rectal cancer (65 International Union Against Cancer [UICC] Stage II, 116 UICC Stage III, and 29 UICC Stage IV cancers) were treated with TME, IOERT, and preoperative or postoperative CHT. A total of 122 patients were treated postoperatively; 88 patients preoperatively. Preoperative or postoperative fluoropyrimidine-based CRT was applied in 93% of these patients. RESULTS Median age was 61 years (range, 26-81). Median follow-up was 61 months. The 5-year actuarial overall survival (OS), disease-free survival (DFS), local control rate (LC), and distant relapse free survival (DRS) of all patients was 69%, 66%, 93%, and 67%, respectively. Multivariate analysis revealed that UICC stage and resection status were the most important independent prognostic factors for OS, DFS, and DRS. The resection status was the only significant factor for local control. T-stage, tumor localization, type of resection, and type of chemotherapy had no significant impact on OS, DFS, DRS, and LC. Acute and late complications > or =Grade 3 were seen in 17% and 13% of patients, respectively. CONCLUSION Multimodality treatment with TME and IOERT boost in combination with moderate dose pre- or postoperative CRT is feasible and results in excellent long-term local control rates in patients with intermediate to high-risk locally advanced rectal cancer.
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Affiliation(s)
- Robert Krempien
- Department of Radiation Oncology, University of Heidelberg, Heidelberg, Germany.
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Krempien R, Roeder F, Oertel S, Weitz J, Hensley FW, Timke C, Funk A, Lindel K, Harms W, Buchler MW, Debus J, Treiber M. Intraoperative electron-beam therapy for primary and recurrent retroperitoneal soft-tissue sarcoma. Int J Radiat Oncol Biol Phys 2006; 65:773-9. [PMID: 16682152 DOI: 10.1016/j.ijrobp.2006.01.028] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2005] [Revised: 01/17/2006] [Accepted: 01/18/2006] [Indexed: 10/24/2022]
Abstract
PURPOSE This study assesses the long-term outcome of patients with retroperitoneal soft-tissue sarcomas treated by maximal resection in combination with intraoperative electron-beam therapy (IOERT) and postoperative external-beam radiotherapy. METHODS AND MATERIALS From 1991 to 2004, 67 patients were treated with curative intent for primary (n = 26) or recurrent (n = 41) retroperitoneal soft-tissue sarcoma. All patients underwent maximal resection in combination with IOERT (mean dose, 15 Gy), 45 patients underwent additional postoperative EBRT, and 20 patients were previously irradiated. RESULTS The 5-year actuarial overall survival (OS), disease-free survival, local control (LC), and freedom from metastatic disease of all patients was 64%, 28%, 40%, and 50%, respectively. The 5-year LC inside the IOERT field was 72%. For patients who completed IOERT and EBRT after R0-resection 5-year and 10-year OS was 80%, and 5-year and 10-year LC was 100%. Only 1 of the 21 patients after R0-resection and only 8 of 34 patients after R1-resection compared with 9 of 12 patients after R2-resection experienced inside IOERT-field relapse. Grade II or higher late complications were seen in 21% of the patients, but only 2 patients required surgical intervention because of late complications. CONCLUSION In selected patients, IOERT results in excellent local control and survival, with acceptable morbidity.
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Affiliation(s)
- Robert Krempien
- Department of Radiation Oncology, University of Heidelberg, Heidelberg, Germany.
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