Early post-operative brachytherapy and free flap reconstruction in the management of sarcomas

Brachytherapy in the Treatment of Soft-Tissue Sarcomas of the Extremities-A Current Concept and Systematic Review of the Literature

INTRODUCTION

Evidence on the use of brachytherapy in soft-tissue sarcoma (STS) is sparse. Therapy regimens are determined more by local interdisciplinary tumor conferences than by standardized protocols. Patient-specific factors complicate the standardized application of therapy protocols. The individuality of the treatment makes it difficult to compare results.

MATERIALS AND METHODS

A comprehensive literature search was conducted, whereby the literature from a period of almost 44 years (1977-2021) was graded and included in this systematic review. For this purpose, PubMed was used as the primary database. Search string included "soft-tissue sarcoma", "brachytherapy", and "extremity." Four independent researchers reviewed the literature. Only full-text articles written in English or German were included.

RESULTS

Of the 175 identified studies, 70 were eligible for analysis based on the inclusion and exclusion criteria. The key points to compare were local complications, recurrence rate and correlation with margins of resection, and the use of brachytherapy regarding tumor grading.

CONCLUSION

Brachytherapy represents an important subset of radiotherapy techniques used in STSs, whose indications and applications are constantly evolving, and for which a local control rate of 50% to 96% has been reported as monotherapy, depending on risk factors. However, the best benefit is seen in the combination of further resection and brachytherapy, and most authors at many other centers agree with this treatment strategy.

Perioperative high-dose-rate brachytherapy in soft tissue sarcomas of the extremity and superficial trunk in adults: initial results of a pilot study

PURPOSE

This study was undertaken to determine the feasibility of perioperative high-dose-rate brachytherapy (PHDRB) as an alternative to standard low-dose-rate brachytherapy in adult patients with soft tissue sarcomas.

METHODS AND MATERIALS

Twenty-five adult patients with soft tissue sarcomas of the extremities or the superficial trunk were treated with surgical resection and PHDRB (16, 24, or 32Gy) for negative, close/microscopically positive, or grossly involved surgical resection margins, respectively. External beam radiation therapy (45Gy) was added postoperatively. Adjuvant chemotherapy with ifosfamide and doxorubicin was given to patients with high-grade tumors.

RESULTS

Resection margins were negative in 6 patients (24.0%), close/microscopically positive in 18 (72.0%), and grossly involved in 1 (4.0%). One patient (4.0%) with wound dehiscence needed reoperation. Three patients failed in the anatomical region treated, but relapse sites were not adjacent to the area treated with PHDRB. After a median followup of 23.2 months (range 2.8-48.0), the 4-year local and regional control rates were 100% and 80.5%, respectively. Four-year overall survival was 78.2%.

CONCLUSIONS

Locoregional control and survival results are encouraging for this high-risk patient population. PHDRB results seem to be similar to those obtained with low-dose-rate brachytherapy.

Optimizing radiation therapy and post-treatment function in the management of extremity soft tissue sarcoma

When treating soft tissue sarcomas (STS) of the extremities, the major therapeutic goals are survival, local tumor control, optimal function, and minimal morbidity. Surgical resection of the primary tumor is the essential component of treatment for virtually all patients. However, local control by surgery alone is poor for the majority of patients with extremity lesions unless the procedure removes large volumes of grossly normal tissue (ie, widely negative margins are attained, because sarcomas tend to infiltrate normal tissue adjacent to the evident lesion). Thus, removal of the gross lesion by a simple excision alone is followed by local recurrence in 60% to 90% of patients. Radical resections reduce the local recurrence rate to 10% to 30%, but may compromise limb function. The combination of function-sparing surgery and radiation achieves better outcomes than either treatment alone for nearly all patients with STS. Because both surgical and radiation technique are critically important for optimizing local control of tumor and functional outcome, it is important to manage these patients in dedicated multispecialty clinics comprised of physicians with expertise in sarcomas, including orthopedic and general oncologic surgeons, radiation oncologists, medical oncologists, sarcoma pathologists, and bone and soft tissue diagnostic radiologists. Radiation therapy can be given by external beam radiation therapy (EBRT) or brachytherapy (BRT) or combination thereof. External beam radiation can be given either preoperatively or postoperatively. The clinical considerations and the outcome data that must be considered in choosing the most appropriate treatment technique for the individual patient are discussed.

Management of soft tissue sarcomas (STS) in first isolated local recurrence: a retrospective study of 83 cases

PURPOSE

To analyze the management and clinical outcome of patients treated for a first isolated local recurrence of soft tissue sarcomas (trunk or extremities) and to identify prognosis factors.

METHODS AND MATERIAL

Between 1980 and 1999, 83 adult patients were included in the study. Mean age was 61 years. Mean tumor size was 6 cm. Most sarcomas were located in extremities (n=74), were deep (n=60), and proximal (n=53); 30 involved nerves or vessels. Histologic subtypes were mainly grade 2 (42%) or 3 (36%) histiocytofibrosarcomas (49%) and liposarcomas (20%). Surgical treatment of recurrences consisted in wide excision (29 cases), marginal resection (43 cases), 5 patients requiring amputation. Final results were R0 (n=33), R1 (n=47) or R2 (n=3) resection. Besides surgery, 6 patients received neo-adjuvant and 7 others adjuvant chemotherapy. Twenty three patients received post-operative external beam radiotherapy (EBRT) (mean dose 55 Gy) and 26 interstitial 192Ir low dose rate brachytherapy (BCT) (mean dose 45 Gy for BCT alone, 22 Gy when associated with EBRT), 19 patients being re-irradiated.

RESULTS

Mean follow up was 13 years. Thirty-seven (45%) patients relapsed, 62% of whom presenting an isolated local recurrence. Nineteen patients developed distant metastases. Multivariate analysis showed only tumor depth (P=0.05) and re-resection for primary R1 resection (P=0.018) being independent prognosis factors for tumor control, radiotherapy (EBRT and/or BCT) being significant in univariate analysis (P=0.05). Overall survival rate was 73%, 54%, and 47% at, respectively, 3.5 and 10 years, and was 65%, 35% and 32% after a further local recurrence. Multivariate analysis showed trunk (P=0.0001) or inferior extremity locations (P=0.023), symptomatic (P=0.001), high grade (P=0.01), deep (P=0.01) tumors, and the occurrence of a further local failure (P=0.004) as unfavorable characteristics for overall survival.

CONCLUSIONS

A first isolated local recurrence of STS increases mainly the risk of a subsequent local relapse. Quality of local treatment is decisive. When a conservative treatment is feasible, it should combine surgical resection and radiotherapy, BCT being the best suited in previously irradiated patients. Efforts have to be pursued to increase quality of the treatment of primary tumors, at best performed in centers that have expertise in this field.

Prise en charge des sarcomes des tissus mous en première rechute locale isolée : étude rétrospective de 83 cas

PURPOSE

To analyse the management and clinical outcome of patients treated for a first isolated local recurrence of soft tissue sarcoma (trunk or extremities) and to identify prognosis factors.

PATIENTS AND MATERIAL

This is a retrospective study of 83 adult patients treated between 1980 and 1999. Mean tumor size was 6 cm. Most sarcomas were located in extremities (N =74), were deep (N =60), and proximal (N =53). Thirty involved nerves or vessels. Histologic subtypes were mainly grade 2 (42%) or 3 (36%) histocytofibrosarcomas (49%) and liposarcomas (20%). Surgical treatment of recurrences consisted in wide excision (32 cases), marginal resection (46 cases), five patients requiring amputation. Final results were R0 (N =33), R1 (N =47) or R2 (N =3) resection. Beside surgery, six patients received neoadjuvant and seven others adjuvant chemotherapy. Twenty-three patients received postoperative external beam radiotherapy (EBRT) (mean dose 55 Gy) and 26 interstitial (192)Ir low dose rate brachytherapy (BCT) (mean dose 45 Gy for BCT alone, 22 Gy when associated with EBRT), 19 patients being re-irradiated.

RESULTS

Mean follow up was 59 months. Thirty-seven (45%) tumors relapsed, 62% locally as first event. Nineteen patients developed secondary distant metastases. Multivariate analysis showed only tumour depth (P =0.05) and re-resection for primary R1 resection for the recurrence (P =0.018) being independent prognosis factors for tumour control, radiotherapy (EBRT and/or BCT) being significant in univariate analysis (P =0.05). Overall survival rate was 73, 54, and 47% at respectively 3, 5 and 10 years, and was 65, 35 and 32% after a further local recurrence. Multivariate analysis showed trunk (P =0.0001) or inferior extremity locations (P =0.023), symptomatic (P =0.001), high grade (P =0.01), deep (P = 0.01) tumours, and the occurrence of a further local failure (P =0.004) as unfavourable characteristics for overall survival.

CONCLUSION

Because of the high relapse rate in this series, a first isolated local recurrence of STS increases mainly the risk of a subsequent local relapse. Quality of local treatment for the first local relapse is decisive. When a conservative treatment is feasible, it should combine surgical resection and radiotherapy, brachytherapy being the best suited in previously irradiated patients. Efforts have to be pursued to increase quality of the treatment of primary tumours, at best performed in centers that have expertise in this field.

The American Brachytherapy Society recommendations for brachytherapy of soft tissue sarcomas

PURPOSE

This report presents the American Brachytherapy Society (ABS) guidelines for the use of brachytherapy for patients with soft tissue sarcoma.

METHODS AND MATERIALS

Members of the ABS with expertise in soft tissue sarcoma formulated brachytherapy guidelines based upon their clinical experience and a review of the literature. The Board of Directors of the ABS approved the final report.

RESULTS

Brachytherapy used alone or in combination with external beam irradiation is an established means of safely providing adjuvant local treatment after resection for soft tissue sarcomas in adults and in children. Brachytherapy options include low dose rate techniques with iridium 192 or iodine 125, fractionated high dose rate brachytherapy, or intraoperative high dose rate therapy. Recommendations are made for patient selection, techniques, dose rates, and dosages. Complications and possible interventions to minimize their occurrence and severity are reviewed.

CONCLUSION

Brachytherapy represents an effective means of enhancing the therapeutic ratio, offering both biologic and dosimetric advantage in the treatment of patients with soft tissue sarcoma. The treatment approach used depends upon the institution, physician expertise, and the clinical situation. Guidelines are established for the use of brachytherapy in the treatment of soft tissue sarcomas in adults and in children. Practitioners and cooperative groups are encouraged to use these guidelines to formulate their treatment and dose-reporting policies. These guidelines will be modified, as further clinical results become available.

Low-dose-rate intraoperative brachytherapy combined with external beam irradiation in the conservative treatment of soft tissue sarcoma

PURPOSE

Conservative treatment of soft tissue sarcomas most often implies combination of surgical resection and irradiation. The aim of this study was to evaluate low-dose-rate intraoperative brachytherapy, delivered as a boost, in the local control of primary tumors, with special concern about treatment complications.

METHODS AND MATERIALS

Between 1986 and 1995, 112 patients underwent intraoperative implant. This report focuses on the group of 58 patients with primary sarcomas treated by combination of conservative surgery, intraoperative brachytherapy, and external irradiation. Most of the tumors were located in the lower limbs (46/58-79%). Median size of the tumor was 10 cm, most of the lesions being T2-T3 (51/58-88%), Grade 2 or 3 (48/58-83%). The mean brachytherapy dose was 20 Gy and external beam irradiation dose 45 Gy. In 36/58 cases, iridium wires had to be placed on contact with neurovascular structures.

RESULTS

With a median follow-up of 54 months, the 5-year actuarial survival was 64.9%, with a 5-year actuarial local control of 89%. Of the 6 patients with local relapse, 3 were salvaged. Acute side effects, essentially wound healing problems, occurred in 20/58 patients, late side effects in 16/58 patients (7 neuropathies G2 to G4). No amputation was required. The only significant factor correlated with early side effects was the location of the tumor in the lower limb (p = 0.003), and with late side effects the vicinity of the tumor with neurovascular structures (p = 0.009).

CONCLUSION

Brachytherapy allows early delivery of a boost dose in a reduced volume of tissue, precisely mapped by the intraoperative procedure. Combined with external beam irradiation, it is a safe and efficient treatment technique leading to high local control rates and limited functional impairment.

Large, deep high-grade extremity sarcomas: when is a myocutaneous flap reconstruction necessary?

The surgical treatment of large, deep high-grade extremity soft tissue sarcomas frequently produces a significant tissue defect. In addition, the management of the surgical wound is often further complicated by preoperative radiation or adjuvant therapies. The use of either pedicled or free myocutaneous flaps allows for more rapid and predictable wound healing in this situation. Myocutaneous flaps provide well-vascularized coverage of lost tissue volume, exposed vital structures, and prosthetic reconstruction materials. When harvested from unirradiated sites, flap coverage can overcome the detrimental effects of radiation therapy and chemotherapy on postoperative wound healing. Reconstruction of the soft tissue defect may also improve patient satisfaction with aesthetic issues. The use of innervated myocutaneous flaps can even address the functionality of the extremity following resection of major muscle groups. Myocutaneous flaps are an extremely versatile option for reconstruction in the treatment of large, deep high-grade extremity soft tissue sarcomas.

Adjuvant brachytherapy in the treatment of soft-tissue sarcomas

For many patients with STS, administering adjuvant radiation treatments in the form of interstitial brachytherapy provides an excellent alternative to a protracted course of EBRT. Ideal patients are those with intermediate- or high-grade tumors amenable to en bloc resection. Attractive features of this approach include an untainted pathologic specimen, expeditious completion of treatment, reduction in wound complications, and improved functional outcome. Brachytherapy can permit definitive reirradiation by tightly localizing the high dose radiation exposure. It is also useful in patients who are known to have or be at high risk of metastatic disease, for whom the rapid completion of local treatment allows systemic therapy to begin quickly. Introduction of HDR techniques has shifted the delivery of brachytherapy from inpatient solitary confinement to an outpatient setting. Early reports using HDR brachytherapy for treatment of adult and pediatric STS are quite encouraging. The clinical equivalence between hyperfractionated HDR schedules and traditional LDR techniques is gaining acceptance.