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Roohani S, Wiltink LM, Kaul D, Spałek MJ, Haas RL. Update on Dosing and Fractionation for Neoadjuvant Radiotherapy for Localized Soft Tissue Sarcoma. Curr Treat Options Oncol 2024; 25:543-555. [PMID: 38478330 PMCID: PMC10997691 DOI: 10.1007/s11864-024-01188-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2024] [Indexed: 04/06/2024]
Abstract
OPINION STATEMENT Neoadjuvant radiotherapy (RT) over 5-6 weeks with daily doses of 1.8-2.0 Gy to a total dose of 50-50.4 Gy is standard of care for localized high-grade soft tissue sarcomas (STS) of the extremities and trunk wall. One exception is myxoid liposarcomas where the phase II DOREMY trial applying a preoperative dose of 36 Gy in 2 Gy fractions (3-4 weeks treatment) has achieved excellent local control rates of 100% after a median follow-up of 25 months.Hypofractionated preoperative RT has been investigated in a number of phase II single-arm studies suggesting that daily doses of 2.75-8 Gy over 1-3 weeks can achieve similar oncological outcomes to conventional neoadjuvant RT. Prospective data with direct head-to-head comparison to conventional neoadjuvant RT investigating oncological outcomes and toxicity profiles is eagerly awaited.For the entire group of retroperitoneal sarcomas, RT is not the standard of care. The randomized multi-center STRASS trial did not find a benefit in abdominal recurrence-free survival by the addition of preoperative RT. However, for the largest histological subgroup of well-differentiated and grades I and II dedifferentiated liposarcomas, the STRASS trial and the post-hoc propensity-matched STREXIT analysis have identified a possible benefit in survival by preoperative RT. These patients deserve to be informed about the pros and cons of preoperative RT while the longer follow-up data from the STRASS trial is awaited.
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Affiliation(s)
- Siyer Roohani
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
- BIH Charité Junior Clinician Scientist Program, BIH Biomedical Innovation Academy, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
- German Cancer Consortium (DKTK), Partner site Berlin, and German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | - Lisette M Wiltink
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - David Kaul
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- German Cancer Consortium (DKTK), Partner site Berlin, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Mateusz Jacek Spałek
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
- Department of Radiotherapy I, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Rick L Haas
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
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Ewongwo A, Oladipo ED, Hui C, Avedian RS, Steffner RJ, Mohler DG, Kalbasi A, Chin AL, Million L, Hiniker SM, Moding EJ. Patterns of Local Recurrence and Risk of Skin Recurrence in Soft Tissue Sarcomas After Surgical Resection. Pract Radiat Oncol 2024; 14:e62-e67. [PMID: 37804883 DOI: 10.1016/j.prro.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 09/13/2023] [Accepted: 09/22/2023] [Indexed: 10/09/2023]
Abstract
PURPOSE Although there is a theoretical risk of skin seeding during surgical resection of soft tissue sarcomas (STSs), current consensus guidelines recommend against routine use of bolus during radiation therapy (RT). However, the risk of skin recurrence has not been systematically assessed. We aimed to assess the patterns of local recurrence (LR) in patients with STS treated with surgery with or without RT. METHODS AND MATERIALS We performed a retrospective analysis of adults with STSs evaluated at our institution between 2007 and 2021. For patients who developed LR, the depth was evaluated. Progression-free survival and overall survival were analyzed from time of first LR using the Kaplan-Meier method. Cumulative incidence of distant metastasis was calculated with competing risk analysis from date of LR. RESULTS Of the 206 patients evaluated, 20 had LR (9.7%). Among patients with LR, 5 patients (25.0%) were treated with surgery alone and 15 patients (75.0%) with surgery and RT. In patients treated with RT, 46.7% had preoperative RT, 53.3% had postoperative RT, and bolus was used in 46.7%. Surgical margins were close (<1 mm) in 4 patients (20.0%) and positive in 10 patients (50.0%). LR occurred in the deep subfascial tissue in 9 patients (45%), subcutaneous tissue in 10 patients (50.0%), and skin in 1 patient (5.0%). The patient with a skin recurrence was treated with surgery alone, and the tumor involved the skin at presentation. In patients treated with RT, LR occurred within the RT field in 13 patients (86.7%). At 1 year after LR, progression-free survival was 70.3%, overall survival was 81.7%, and cumulative incidence of distant metastasis was 5.9%. CONCLUSIONS Skin recurrences were rare after surgical resection of STSs and only occurred in a tumor that involved the skin at initial presentation. These findings support current recommendations against routine use of bolus in STSs not involving the skin at presentation.
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Affiliation(s)
- Agnes Ewongwo
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Eniola D Oladipo
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Caressa Hui
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Raffi S Avedian
- Department of Orthopedic Surgery, Stanford University, Stanford, California
| | - Robert J Steffner
- Department of Orthopedic Surgery, Stanford University, Stanford, California
| | - David G Mohler
- Department of Orthopedic Surgery, Stanford University, Stanford, California
| | - Anusha Kalbasi
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Alexander L Chin
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Lynn Million
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Susan M Hiniker
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Everett J Moding
- Department of Radiation Oncology, Stanford University, Stanford, California; Stanford Cancer Institute, Stanford University, Stanford, California.
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Farzaliyev F, Touma A, Taeger G, Steinau HU, Hardes J, Streitbürger A, Podleska LE. Efficacy of hyperthermic isolated limb perfusion in the treatment of locally recurrent high-grade soft tissue sarcoma of the extremities. World J Surg Oncol 2020; 18:332. [PMID: 33349267 PMCID: PMC7754588 DOI: 10.1186/s12957-020-02110-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 12/08/2020] [Indexed: 11/23/2022] Open
Abstract
Background This novel study compared the use of tumor necrosis factor (TNF)-alpha and melphalan-based isolated limb perfusion (TM-ILP) to the standard treatment of locally recurrent soft tissue extremity sarcoma. The aim was to assess whether TM-ILP positively influences the recurrence-free survival of locally recurrent high-grade soft tissue sarcoma (STS) of the extremities. Methods We retrospectively analyzed our clinical database for patients with STS. Variables were analyzed using chi-square test or Mann-Whitney rank-sum test. Furthermore, Kaplan-Meier survival plots were calculated and a proportional hazard regression model was developed. Results Out of 448 patients with extraabdominal STS treated between August 2012 and December 2015, 52 cases involving 47 patients had locally recurrent STS. Twenty-eight of these patients were treated with TM-ILP prior to surgical resection (TM-ILP-group), and 24 were treated with standard therapy (without TM-ILP). The 3-year recurrence-free survival for the TM-ILP-group was estimated at 75% (95% confidence interval (CI), 71.5–78.5). Local recurrence-free survival in the standard group was significantly lower (LRFS: 43.4%, 95% CI 38.7–48.1, p = 0.026). Multivariable analysis revealed resection with negative margins, lower number of previous recurrences, and TM-ILP as positive predictors for recurrence-free survival. Conclusions TM-ILP and consecutive resection of residual tumor with negative resection margins significantly improves local recurrence-free survival for patients with a first local recurrence of high-grade STS in the extremities.
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Affiliation(s)
- Farhad Farzaliyev
- Department of General, Visceral and Transplantation Surgery, Division of Plastic and Reconstructive Surgery, University Hospital Essen, University Essen-Duisburg, Hufelandstr.55, 45147, Essen, Germany.
| | - Alexander Touma
- Department of General, Visceral and Transplantation Surgery, Division of Plastic and Reconstructive Surgery, University Hospital Essen, University Essen-Duisburg, Hufelandstr.55, 45147, Essen, Germany
| | - Georg Taeger
- Department of Tumor Orthopedics and Sarcoma Surgery, University Hospital Essen, Essen, Germany
| | - Hans-Ulrich Steinau
- Department of General, Visceral and Transplantation Surgery, Division of Plastic and Reconstructive Surgery, University Hospital Essen, University Essen-Duisburg, Hufelandstr.55, 45147, Essen, Germany
| | - Jendrik Hardes
- Department of Tumor Orthopedics and Sarcoma Surgery, University Hospital Essen, Essen, Germany
| | - Arne Streitbürger
- Department of Tumor Orthopedics and Sarcoma Surgery, University Hospital Essen, Essen, Germany
| | - Lars Erik Podleska
- Department of Tumor Orthopedics and Sarcoma Surgery, University Hospital Essen, Essen, Germany
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Weigl H, Janssen S, Vassos N, Hohenberger P, Simeonova-Chergou A, Wenz F, Haubenreisser H, Jakob J. Fusion imaging to evaluate the radiographic anatomical relationship between primary tumors and local recurrences in retroperitoneal soft tissue sarcoma. Surg Oncol 2020; 34:109-112. [PMID: 32891314 DOI: 10.1016/j.suronc.2020.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 04/02/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Local recurrence (LR) of retroperitoneal soft tissue sarcoma (RPS) is a common and life-threatening event. The evaluation of the exact anatomical patterns of local recurrence might help to improve local treatment in RPS. METHODS Of our local database we extracted ten patients with LR of RPS with axial MRI and/or CT datasets of the primary tumor (PT) and the LR. Using the Osirix DICOM viewer Version v.3.9.4 64-bit (Pixmeo, Geneva, Switzerland) we performed a three-step fusion algorithm consisting of: a) 3-point co-registration of the axial datasets depicting the PT and the LR using three abdominal landmarks b) re-orientation of the datasets and c) image fusion. We evaluated the feasibility of this technique with regard to categorizing the localization of LR as within or distant from the PT. RESULTS Fusion imaging was feasible in seven out of ten patients. In the other three patients anatomical shifting of organs after surgery led to a relevant mismatch of anatomical landmarks and impeded interpretation of the fused images. In five of seven patients with successful fusion imaging, local recurrences were located within the anatomical borders of the primary tumor, in two out of seven patients local recurrences were distant to the primary. CONCLUSIONS Fusion imaging of primary tumors and local recurrences is feasible in most patients with RPS. Most local recurrences occurred within the anatomical localization of the primary tumor. For further investigations validation of the technique in larger patient cohorts is required.
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Affiliation(s)
- Helene Weigl
- Department of Surgery, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Sonja Janssen
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Mannheim, Germany
| | - Nikolaos Vassos
- Department of Surgery, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany; Division of Surgical Oncology & Thoracic Surgery, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Peter Hohenberger
- Division of Surgical Oncology & Thoracic Surgery, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Anna Simeonova-Chergou
- Department of Radiotherapy and Oncology, University Medical Center Mannheim, Mannheim, Germany
| | - Frederik Wenz
- University Medical Center Freiburg, Freiburg, Germany
| | - Holger Haubenreisser
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Mannheim, Germany
| | - Jens Jakob
- Department of General, Visceral and Pediatric Surgery, University Medical Center Göttingen, Göttingen, Germany.
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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
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Eloy G, Daveau C, Kreps S, Boudou-Rouquette P, Anract P, Biau D. Higher complications after previous external beam radiation for extremity soft-tissue sarcoma in the surgical treatment of a local recurrence: a comparative retrospective study of one hundred and three patients. INTERNATIONAL ORTHOPAEDICS 2018; 43:727-733. [PMID: 30046861 DOI: 10.1007/s00264-018-4064-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 07/16/2018] [Indexed: 01/13/2023]
Abstract
PURPOSE The use of adjuvant radiation in the treatment of soft-tissue sarcoma (STS) is equivocal in selected cases. Our objective was to compare the short-term outcomes in patients operated on for a local recurrence who had radiation for the primary tumour to those who were spared radiation. METHODS This was a retrospective study of 103 patients treated for a local recurrence: 48 (47%) with previous radiation and 55 (53%) without. Our primary outcome criterion was to identify the differences in the local treatment provided. Secondary outcomes were the cumulative incidence of a surgical site infection/wound complication (SSI/WC), variables associated with SSI/WC, and local recurrence. RESULTS Amputation and the incidence of re-operation were significantly more frequent in patients who received previous radiation compared to patients without previous radiation (27% vs 9%, p = 0.02, for amputation; 26% vs 36% at 2 years for SSI/WC, p = 0.049). Multivariable regression models found previous radiation (p = 0.049), arteriopathy (p = 0.012), location at lower limb (p = 0.09), and use of a flap (0.0048) associated with the risk of SSI/WC. CONCLUSIONS Previous radiation is associated with an increased risk of amputation and reoperation for SSI/WC when treating a local recurrence. This information should be accounted for when deciding for the use of radiation.
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Affiliation(s)
- Gauthier Eloy
- Orthopedic Surgery, Hopital Cochin, Paris, Île-de-France, France.
| | - Caroline Daveau
- Radiotherapy, Hopital Europeen Georges Pompidou, Paris, Île-de-France, France
| | - Sarah Kreps
- Radiotherapy, Hopital Europeen Georges Pompidou, Paris, Île-de-France, France
| | | | - Philippe Anract
- Orthopedic Surgery, Hopital Cochin, Paris, Île-de-France, France
| | - David Biau
- Orthopedic Surgery, Hopital Cochin, Paris, Île-de-France, France
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Sargos P, Charleux T, Haas R, Michot A, Llacer C, Moureau-Zabotto L, Vogin G, Le Péchoux C, Verry C, Ducassou A, Delannes M, Mervoyer A, Wiazzane N, Thariat J, Sunyach M, Benchalal M, Laredo J, Kind M, Gillon P, Kantor G. Pre- and postoperative radiotherapy for extremity soft tissue sarcoma: Evaluation of inter-observer target volume contouring variability among French sarcoma group radiation oncologists. Cancer Radiother 2018; 22:131-139. [DOI: 10.1016/j.canrad.2017.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 08/24/2017] [Accepted: 09/07/2017] [Indexed: 01/08/2023]
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Levy A, Bonvalot S, Bellefqih S, Terrier P, Le Cesne A, Le Péchoux C. Is dose de-escalation possible in sarcoma patients treated with enlarged limb sparing resection? Radiother Oncol 2018; 126:493-498. [DOI: 10.1016/j.radonc.2017.10.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 09/04/2017] [Accepted: 10/20/2017] [Indexed: 12/11/2022]
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9
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Li W, Appiah S, Hill C, Becker N, Catton C, Chung P, Shultz D, Ferguson P, O'Sullivan B, Dickie C. Evidence-based region of interest matching guidelines for sarcoma volumetric image-guided radiation therapy. Tech Innov Patient Support Radiat Oncol 2018; 5:3-8. [PMID: 32095568 PMCID: PMC7033805 DOI: 10.1016/j.tipsro.2018.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 12/20/2017] [Accepted: 01/08/2018] [Indexed: 12/26/2022] Open
Abstract
Region-of-interest (ROI) guidelines for soft tissue sarcoma CBCT-guidance were developed. ROI guidelines were developed for four anatomic sites using the PDSA cycle. ROI guidelines are intended to increase image registration reproducibility. Results include improved image guidance decision making and workflow efficiencies.
Purpose Region-of-interest (ROI) guidelines for online cone-beam computed tomography (CBCT) radiotherapy may improve matching reproducibility and reduce inter-user variability of soft tissue sarcoma (STS) image guidance. The purpose of this work is to standardize ROI STS CBCT image registration guidelines using the plan-do-study-act (PDSA) cycle for the lower extremity, retroperitoneal, pelvis, and thorax. Methods Based on anatomic bony surrogates, initial ROI matching guidelines for STS were developed by a team of radiation therapists, physicists and oncologists (Plan). Retrospective, qualitative evaluation of the guidelines was completed by the designated sarcoma lead therapist to determine clinical feasibility (Do). Validation of the ROI guidelines was performed through independent evaluation by radiation therapy CBCT imaging experts on a cohort of 10 patients per anatomic region (Study). Results Draft ROI guidelines were evaluated by 2 independent observers who registered weekly CBCT images to test their validity. Each observer assessed 5 patients per anatomic site, testing ROI options for accuracy of image registration and feasibility, while some ROI borders were adjusted based on algorithm matching performance. Validated ROI guidelines were presented to the sarcoma multidisciplinary site group, and an inter-professional committee of imaging experts for approval prior to clinical implementation (Act). Conclusion ROI matching guidelines for STS IGRT were standardized for 4 anatomic sites using the PDSA cycle for change testing and implementation. IGRT guidelines are intended to improve STS image registration reproducibility, and in turn, are expected to improve the confidence of IGRT decision making and workflow efficiencies for a rare disease with diverse presentation.
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Affiliation(s)
- Winnie Li
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Samuel Appiah
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Christine Hill
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Nathan Becker
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Charles Catton
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Peter Chung
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - David Shultz
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Peter Ferguson
- Division of Orthopedic Surgery, Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, ON, Canada
| | - Brian O'Sullivan
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Colleen Dickie
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
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Swinscoe JA, Dickie CI, Ireland RH. Immobilization and image-guidance methods for radiation therapy of limb extremity soft tissue sarcomas: Results of a multi-institutional survey. Med Dosim 2018; 43:377-382. [DOI: 10.1016/j.meddos.2017.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 10/21/2017] [Accepted: 12/15/2017] [Indexed: 01/22/2023]
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Abstract
Although there is no consensus regarding the optimal sequencing of external beam radiotherapy and surgery for extremity soft tissue sarcoma, radiation therapy delivered before or after limb-sparing surgery significantly improves local control, particularly for high-grade tumors. Large database analyses suggest that improved local control may translate into an overall survival benefit. Best practices require ample communication between the radiation and surgical teams to ensure appropriate tissues are targeted, unnecessary radiation is avoided, and patients are afforded the best opportunity for cure while maintaining function. Modern experiences with intensity-modulated radiotherapy/image-guided radiation therapy suggest toxicity is reduced through field size reduction and precise targeting, improving the therapeutic ratio.
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Affiliation(s)
- Brooke K Leachman
- Department of Radiation Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111, USA
| | - Thomas J Galloway
- Department of Radiation Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111, USA.
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[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.
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Moureau-Zabotto L, Delannes M, Le Péchoux C, Sunyach M, Kantor G, Sargos P, Thariat J, Llacer-Moscardo C. Prise en charge des sarcomes des tissus mous des membres par radiothérapie externe. Cancer Radiother 2016; 20:133-40. [DOI: 10.1016/j.canrad.2015.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 09/25/2015] [Accepted: 10/13/2015] [Indexed: 01/15/2023]
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Arthurs M, Gillham C, O'Shea E, McCrickard E, Leech M. Dosimetric comparison of 3-dimensional conformal radiation therapy and intensity modulated radiation therapy and impact of setup errors in lower limb sarcoma radiation therapy. Pract Radiat Oncol 2016; 6:119-25. [PMID: 26932232 DOI: 10.1016/j.prro.2015.03.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 03/19/2015] [Accepted: 03/30/2015] [Indexed: 11/30/2022]
Abstract
PURPOSE This study compared dosimetric data between 3-dimensional conformal radiation therapy (3DCRT) and intensity modulated radiation therapy (IMRT) plans in a population of patients with lower limb sarcoma immobilized with an in-house device and quantified the impact of systematic and random errors on these techniques. The dosimetric effects of displacements on target coverage and organs at risk (OARs) were considered. METHODS AND MATERIALS Plans were created for 11 postoperative patients using both 3DCRT and IMRT. The techniques were compared dosimetrically. Population-based systematic and random errors were applied and the results compared with the initial plans. RESULTS Higher target D95, D2, D98, and D50 and the best homogeneity index resulted with IMRT compared with 3DCRT. Systematic errors increased target D2 in IMRT. Random errors decreased target homogeneity in IMRT. Maximum bone dose was higher in IMRT than in 3DCRT. Neither error type increased OAR dose for either technique. CONCLUSIONS IMRT could become the favored lower limb sarcoma radiation therapy technique because of superior target coverage and homogeneity. Offline imaging can adequately correct for systematic errors in these patients when an in-house immobilization device is used.
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Affiliation(s)
- Meadhbh Arthurs
- Applied Radiation Therapy Trinity Research Group, Discipline of Radiation Therapy, School of Medicine, Trinity College Dublin, Ireland
| | | | - Evelyn O'Shea
- St. Luke's Radiation Oncology Network, Dublin, Ireland
| | | | - Michelle Leech
- Applied Radiation Therapy Trinity Research Group, Discipline of Radiation Therapy, School of Medicine, Trinity College Dublin, Ireland.
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Haas RLM, Miah AB, LePechoux C, DeLaney TF, Baldini EH, Alektiar K, O'Sullivan B. Preoperative radiotherapy for extremity soft tissue sarcoma; past, present and future perspectives on dose fractionation regimens and combined modality strategies. Radiother Oncol 2015; 119:14-21. [PMID: 26718153 DOI: 10.1016/j.radonc.2015.12.002] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 12/07/2015] [Accepted: 12/13/2015] [Indexed: 01/12/2023]
Abstract
INTRODUCTION This critical review aims to summarize published data on limb sparing surgery for extremity soft tissue sarcoma in combination with pre-operative radiotherapy (RT). METHODS This review is based on peer-reviewed publications using a PubMed search on the MeSH headings "soft tissue sarcoma" AND "preoperative radiotherapy". Titles and abstracts screened for data including "fraction size AND/OR total dose AND/OR overall treatment time", "chemotherapy", "targeted agents AND/OR tyrosine kinase inhibitors", are collated. Reference lists from some articles have been studied to obtain other pertinent articles. Additional abstracts presented at international sarcoma meetings have been included as well as information on relevant clinical trials available at the ClinicalTrials.gov website. RESULTS Data are presented for the conventional regimen of 50-50.4Gy in 25-28 fractions in 5-6 of weeks preoperative external beam RT with respect to the regimen's local control probability compared to surgery alone, as well as acute and late toxicities. The rationale and outcome data for hypofractionated and/or reduced dose regimens are discussed. Finally, combination schedules with conventional chemotherapy and/or targeted agents are summarized. CONCLUSION Outside the setting of well-designed prospective clinical trials, the conventional 50Gy in 5-6week schedule should be considered as standard. However, current and future studies addressing alternative fraction size, total dose, overall treatment time and/or combination with chemotherapy or targeted agents may reveal regimens of equal or increased efficacy with reduced late morbidities.
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Affiliation(s)
- Rick L M Haas
- Department of Radiotherapy, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
| | - Aisha B Miah
- Department of Radiotherapy and Physics, Sarcoma Unit, The Royal Marsden Hospital, London, UK
| | | | - Thomas F DeLaney
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, USA
| | - Elizabeth H Baldini
- Department of Radiation Oncology, Dana Farber Cancer Institute and Brigham and Women's Hospital, Boston, USA
| | - Kaled Alektiar
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, USA
| | - Brian O'Sullivan
- Department of Radiation Oncology, Princess Margaret Hospital, University of Toronto, Canada
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Cipriano CA, Wunder JS, Ferguson PC. Surgical Management of Soft Tissue Sarcomas of the Extremities. ACTA ACUST UNITED AC 2014. [DOI: 10.1053/j.oto.2014.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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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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Sampo MM, Tuomikoski L, Tarkkanen M, Jääskeläinen AS, Tukiainen EJ, Beule A, Tenhunen M, Böhling TO, Blomqvist CP. Marginal miss or radioresistance? The pattern of local recurrence after operation and 3D planned radiation treatment in soft tissue sarcoma of the extremities and the limb girdles; an analysis based on image fusion. Acta Oncol 2014; 53:557-62. [PMID: 24199624 DOI: 10.3109/0284186x.2013.844355] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Most local recurrences have developed in the clinical target volume in previously published series after combined modality treatment for soft tissue sarcoma. However, marginal misses were seen in almost 20% of the patients. The aim of the present study was to determine the location of the recurrence and the total dose at the centre point of the local recurrence for future radiation therapy planning. MATERIAL AND METHODS We included only patients with images in digital form, during 1999-2006 (n = 17), treated for soft tissue sarcoma with combined surgical therapy and radiotherapy at Helsinki University Central Hospital. Image fusion was used to determine the location of the recurrence in relation to radiation therapy target. RESULTS In the present study utilising digital image fusion, in patients with 3D CT-based radiation treatment planning the risk of marginal miss was low as only one patient of 17 relapsed outside the target. Estimated mean radiation dose at the site of local recurrence was 49.1 Gy in patients with positive margins and 48.1 Gy in patients with negative margins. CONCLUSION The risk of marginal miss in soft tissue sarcoma is low after modern 3D planned radiation treatment combined with surgery. More generous use of boost might improve in-target local control.
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Affiliation(s)
- Mika M. Sampo
- Department of Oncology, Helsinki University Central Hospital (HUCH), Finland
| | - Laura Tuomikoski
- Department of Oncology, Helsinki University Central Hospital (HUCH), Finland
| | - Maija Tarkkanen
- Department of Oncology, Helsinki University Central Hospital (HUCH), Finland
| | | | | | - Annette Beule
- Department of Oncology, Helsinki University Central Hospital (HUCH), Finland
| | - Mikko Tenhunen
- Department of Oncology, Helsinki University Central Hospital (HUCH), Finland
| | - Tom O. Böhling
- Department of Pathology, HUSLAB and University of Helsinki, Finland
| | - Carl P. Blomqvist
- Department of Oncology, Helsinki University Central Hospital (HUCH), Finland
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19
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Jebsen NL, Engellau J, Engström K, Bauer HC, Monge OR, Muren LP, Eide GE, Trovik CS, Bruland OS. Patterns of local recurrence and dose fractionation of adjuvant radiation therapy in 462 patients with soft tissue sarcoma of extremity and trunk wall. Int J Radiat Oncol Biol Phys 2013; 86:949-55. [PMID: 23725998 DOI: 10.1016/j.ijrobp.2013.04.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 04/08/2013] [Accepted: 04/10/2013] [Indexed: 01/29/2023]
Abstract
PURPOSE To study the impact of dose fractionation of adjuvant radiation therapy (RT) on local recurrence (LR) and the relation of LR to radiation fields. METHODS AND MATERIALS LR rates were analyzed in 462 adult patients with soft tissue sarcoma who underwent surgical excision and adjuvant RT at five Scandinavian sarcoma centers from 1998 to 2009. Medical records were reviewed for dose fractionation parameters and to determine the location of the LR relative to the radiation portals. RESULTS Fifty-five of 462 patients developed a LR (11.9%). Negative prognostic factors included intralesional surgical margin (hazard ratio [HR]: 7.83, 95% confidence interval [CI]: 3.08-20.0), high malignancy grade (HR: 5.82, 95% CI: 1.31-25.8), age at diagnosis (HR per 10 years: 1.27, 95% CI: 1.03-1.56), and malignant peripheral nerve sheath tumor histological subtype (HR: 6.66, 95% CI: 2.56-17.3). RT dose was tailored to margin status. No correlation between RT dose and LR rate was found in multiple Cox regression analysis. The majority (65%) of LRs occurred within the primary RT volume. CONCLUSIONS No significant dose-response effect of adjuvant RT was demonstrated. Interestingly, patients given 45-Gy accelerated RT (1.8 Gy twice daily/2.5 weeks) had the best local outcome. A total dose of 50 Gy in 25 fractions seemed adequate following wide margin surgery. The risk of LR was associated with histopathologic subtype, which should be included in the treatment algorithm of adjuvant RT in soft tissue sarcoma.
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Affiliation(s)
- Nina L Jebsen
- Department of Clinical Medicine, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway.
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Lee J, Park YJ, Yang DS, Yoon WS, Lee JA, Rim CH, Kim CY. Treatment outcome of conservative surgery plus postoperative radiotherapy for extremity soft tissue sarcoma. Radiat Oncol J 2012; 30:62-9. [PMID: 22984684 PMCID: PMC3429890 DOI: 10.3857/roj.2012.30.2.62] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Revised: 06/01/2012] [Accepted: 06/14/2012] [Indexed: 11/03/2022] Open
Abstract
PURPOSE To evaluate the treatment outcome and prognostic factor of postoperative radiotherapy for extremity soft tissue sarcoma (STS). MATERIALS AND METHODS Forty three patients with extremity STS were treated with conservative surgery and postoperative radiotherapy from January 1981 to December 2010 at Korea University Medical Center. Median total 60 Gy (range, 50 to 74.4 Gy) of radiation was delivered and 7 patients were treated with chemotherapy. RESULTS The median follow-up period was 70 months (range, 5 to 302 months). Twelve patients (27.9%) sustained relapse of their disease. Local recurrence occurred in 3 patients (7.0%) and distant metastases developed in 10 patients (23.3%). The 5-year overall survival (OS) was 69.2% and disease free survival was 67.9%. The 5-year local relapse-free survival was 90.7% and distant relapse-free survival was 73.3%. On univariate analysis, no significant prognostic factors were associated with development of local recurrence. Histologic grade (p = 0.005) and stage (p = 0.02) influenced the development of distant metastases. Histologic grade was unique significant prognostic factor for the OS on univariate and multivariate analysis. Severe acute treatment-related complications, Common Terminology Criteria for Adverse Events (CTCAE) grade 3 or 4, developed in 6 patients (14.0%) and severe late complications in 2 patients (4.7%). CONCLUSION Conservative surgery with postoperative radiotherapy achieved a satisfactory rate of local control with acceptable complication rate in extremity STS. Most failures were distant metastases that correlate with tumor grade and stage. The majority of local recurrences developed within the field. Selective dose escalation of radiotherapy or development of effective systemic treatment might be considered.
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Affiliation(s)
- Jieun Lee
- Department of Radiation Oncology, Korea University Medical Center, Seoul, Korea
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O'Sullivan B, Dickie C, Catton C, Chung P, Wong P, Griffin A, Wunder J, Ferguson P, Bell R. In regard to RTOG sarcoma radiation oncologists reach consensus on gross tumor volume and clinical target volume on computed tomographic images for preoperative radiotherapy of primary soft tissue sarcoma of extremity in Radiation Therapy Oncology Group studies: in regard to Wang et al (Int J Radiat Oncol Biol Phys 2011;81:e525-e528). Int J Radiat Oncol Biol Phys 2012; 83:483. [PMID: 22579375 DOI: 10.1016/j.ijrobp.2012.01.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Revised: 01/17/2012] [Accepted: 01/18/2012] [Indexed: 10/24/2022]
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