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Mayo ZS, Fan C, Jia X, Parker SM, Kocsis J, Shah CS, Scott JG, Campbell SR. Meta-Analysis of 5-Fraction Preoperative Radiotherapy for Soft Tissue Sarcoma. Am J Clin Oncol 2024:00000421-990000000-00195. [PMID: 38764405 DOI: 10.1097/coc.0000000000001110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2024]
Abstract
OBJECTIVES Studies investigating preoperative 5-fraction radiation therapy (RT) for soft tissue sarcoma (STS) are limited. We performed a meta-analysis to determine the efficacy and safety of this treatment paradigm. METHODS This study-level meta-analysis was conducted using Bayesian methods. Statistical estimation for risk of outcome rates was conducted by posterior mean and 95% highest posterior density (HPD) intervals. Studies with 2-year local control (LC) and description of major wound complications (MWC) per the CAN-NCIC-SR2 study were included and served as the primary endpoints. Secondary endpoints included rates of acute and late toxicity. A total of 10 studies were identified and 7 met the inclusion criteria. Subgroup analyses were performed for ≥30 Gy vs <30 Gy. RESULTS A total of 209 patients from 7 studies were included. Five studies used ≥30 Gy (n=144), and 2 studies <30 Gy (n=64). Median follow-up was 29 months (range: 21 to 57 mo). Primary tumor location was lower extremity in 68% and upper extremity in 22%. Most tumors were intermediate or high grade (95%, 160/169), and 50% (79/158) were >10 cm. The two-year LC for the entire cohort was 96.9%, and the rate of MWC was 30.6%. There was a trend toward improved LC with ≥ 30 Gy (95% HPD: 0.95 to 0.99 vs 0.84 to 0.99). There was no difference in MWC (95% HPD: 0.18 to 0.42 vs 0.17 to 0.55) or late toxicity between the groups. CONCLUSION Preoperative 5-fraction RT for STS demonstrates excellent 2-year LC with MWC and toxicity similar to standard fractionation preoperative RT. Multi-institutional trials with a universal RT protocol are warranted.
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Affiliation(s)
- Zachary S Mayo
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH
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Campbell SR, Wooley JR, Nystrom LM. Modern Multidisciplinary Management of Soft Tissue Sarcoma of the Extremity and Trunk. JCO Oncol Pract 2024:OP2300050. [PMID: 38574314 DOI: 10.1200/op.23.00050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 02/20/2024] [Accepted: 03/06/2024] [Indexed: 04/06/2024] Open
Abstract
Soft tissue sarcomas (STS) of the extremity and trunk are heterogeneous and rare tumors that require coordinated multidisciplinary management. Surgical resection remains the backbone of treatment for localized tumors, with the addition of radiotherapy to surgery to achieve high rates of local control. Despite this, overall survival is limited because of significant distant metastatic risk and a lack of efficacious systemic therapies. Clinical trials have produced conflicting results on the impact of systemic therapy in the neoadjuvant and adjuvant settings for patients with localized disease, leaving systemic treatment decisions largely guided by shared decision making and prognostic prediction tools such as nomograms. This article will review the foundational data as well as latest developments in surgical, radiotherapy, and systemic management supporting current practice guidelines for localized STS of the extremity and trunk.
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Affiliation(s)
| | - Joseph R Wooley
- Department of Hematology and Oncology, Cleveland Clinic, Cleveland, OH
| | - Lukas M Nystrom
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
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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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Guadagnolo BA, Baldini EH. Are We Ready for Life in the Fast Lane? A Critical Review of Preoperative Hypofractionated Radiotherapy for Localized Soft Tissue Sarcoma. Semin Radiat Oncol 2024; 34:180-194. [PMID: 38508783 DOI: 10.1016/j.semradonc.2023.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
This critical review aims to summarize the relevant published data regarding hypofractionation regimens for preoperative radiation therapy (RT) prior to surgery for soft tissue sarcoma (STS) of the extremity or superficial trunk. We identified peer-reviewed publications using a PubMed search on the MeSH headings of "soft tissue sarcoma" AND "hypofractionated radiation therapy." To obtain complication data on similar anatomical radiotherapeutic scenarios we also searched "hypofractionated radiation therapy" AND "melanoma" as well as "hypofractionated radiation therapy" AND "breast cancer." We then used reference lists from relevant articles to obtain additional pertinent publications. We also incorporated relevant abstracts presented at international sarcoma meetings and relevant clinical trials as listed on the ClinicalTrials.gov website. Detailed data are presented and contextualized for ultra-hypofractionated and moderately hypofractionated regimens with respect to local control, wound complications, and amputation rates. Comparative data are also presented for late toxicities including: fibrosis, joint limitation, edema, skin integrity, and bone fracture or necrosis. These data are compared to a standard regimen of 50 Gy in 25 daily fractions delivered over 5 weeks. This analysis supports the continued use of a standard regimen for preoperative RT for STS of 25 × 2 Gy over 5 weeks without concurrent chemotherapy. Use of concurrent chemotherapy with preoperative RT for STS should be reserved for well-designed clinical trials. A randomized trial of ultra-hypofractionated and moderately hypofractionated pre op RT for STS is warranted, but it is critical for the primary endpoint (or co-primary endpoint) to be late toxicity to: bone, soft tissue, joint, and skin.
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Affiliation(s)
| | - Elizabeth H Baldini
- Department of Radiation Oncology, Dana Farber/Brigham Women's Hospital, Boston, MA
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5
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Montero A, Chen-Zhao X, Ciérvide R, Álvarez B, Prado A, López M, Sánchez E, Hernando O, de la Casa MA, García-Aranda M, Valero J, Alonso R, Fernández-Letón P, Rubio C. Moderate hypofractionated radiation therapy and pathologic response for soft tissue sarcomas (STS) of limbs and trunk: experience from a tertiary cancer center. Clin Transl Oncol 2024; 26:204-213. [PMID: 37277526 DOI: 10.1007/s12094-023-03237-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 05/28/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND Preoperative radiation therapy following by limb-sparing or conservative surgery is a standard approach for limb and trunk STS. Data supporting hypofractionated radiotherapy schedules are scarce albeit biological sensitivity of STS to radiation would justify it. We sought to evaluate the impact of moderate hypofractionation on pathologic response and its influence on oncologic outcomes. MATERIAL AND METHODS From October 2018 to January 2023, 18 patients with limb or trunk STS underwent preoperative radiotherapy at a median dose of 52.5 Gy (range 49.5-60 Gy) in 15 fractions of 3.5 Gy (3.3-4 Gy) with or without neoadjuvant chemotherapy. A favorable pathologic response (fPR) was considered as ≥ 90% tumor necrosis on specimen examination. RESULTS All patients completed planned preoperative radiotherapy. Eleven patients (61.1%) achieved a fPR, and 7 patients (36.8%) a complete pathologic response with total disappearance of tumor cells. Nine patients (47%) developed grade 1-2 acute skin toxicity, and 7 patients (38.8%) had wound complications on follow-up. With a median follow-up of 14 months (range 1-40), no cases of local relapse were observed, and actuarial 3-year overall survival (OS) and distant metastases-free survival (DMFS) are 87% and 76.4%, respectively. In the univariate analysis, the presence of a favorable pathologic response (fPR) was associated with improved 3-year OS (100% vs. 56.03%, p = 0.058) and 3-year DMFS (86.91% vs. 31.46%, p = 0.002). Moreover, both complete or partial RECIST response and radiological stabilization of the tumor lesion showed a significant association with higher rates of 3-year distant metastasis-free survival (DMFS) (83% vs. 83% vs. 56%, p < 0.001) and 3-year overall survival (OS) (100% vs. 80% vs. 0, p = 0.002). CONCLUSIONS Preoperative moderate hypofractionated radiation treatment for STS is feasible and well tolerated and associates encouraging rates of pathologic response that could have a favorable impact on final outcomes.
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Affiliation(s)
- Angel Montero
- Department of Radiation Oncology, Centro Integral Oncológico Clara Campal (C.I.O.C.C.), HM Hospitales, Calle Oña 10, 28050, Madrid, Spain.
- Facultad de Ciencias de la Salud, Universidad Camilo José Cela, Madrid, Spain.
| | - Xin Chen-Zhao
- Department of Radiation Oncology, Centro Integral Oncológico Clara Campal (C.I.O.C.C.), HM Hospitales, Calle Oña 10, 28050, Madrid, Spain
| | - Raquel Ciérvide
- Department of Radiation Oncology, Centro Integral Oncológico Clara Campal (C.I.O.C.C.), HM Hospitales, Calle Oña 10, 28050, Madrid, Spain
| | - Beatriz Álvarez
- Department of Radiation Oncology, Centro Integral Oncológico Clara Campal (C.I.O.C.C.), HM Hospitales, Calle Oña 10, 28050, Madrid, Spain
| | - Alejandro Prado
- Department of Medical Physics, Centro Integral Oncológico Clara Campal (C.I.O.C.C.), HM Hospitales, Madrid, Spain
| | - Mercedes López
- Department of Radiation Oncology, Centro Integral Oncológico Clara Campal (C.I.O.C.C.), HM Hospitales, Calle Oña 10, 28050, Madrid, Spain
| | - Emilio Sánchez
- Department of Radiation Oncology, Centro Integral Oncológico Clara Campal (C.I.O.C.C.), HM Hospitales, Calle Oña 10, 28050, Madrid, Spain
| | - Ovidio Hernando
- Department of Radiation Oncology, Centro Integral Oncológico Clara Campal (C.I.O.C.C.), HM Hospitales, Calle Oña 10, 28050, Madrid, Spain
| | - Miguel Angel de la Casa
- Department of Medical Physics, Centro Integral Oncológico Clara Campal (C.I.O.C.C.), HM Hospitales, Madrid, Spain
| | - Mariola García-Aranda
- Department of Radiation Oncology, Centro Integral Oncológico Clara Campal (C.I.O.C.C.), HM Hospitales, Calle Oña 10, 28050, Madrid, Spain
| | - Jeannette Valero
- Department of Radiation Oncology, Centro Integral Oncológico Clara Campal (C.I.O.C.C.), HM Hospitales, Calle Oña 10, 28050, Madrid, Spain
| | - Rosa Alonso
- Department of Radiation Oncology, Centro Integral Oncológico Clara Campal (C.I.O.C.C.), HM Hospitales, Calle Oña 10, 28050, Madrid, Spain
| | - Pedro Fernández-Letón
- Department of Medical Physics, Centro Integral Oncológico Clara Campal (C.I.O.C.C.), HM Hospitales, Madrid, Spain
| | - Carmen Rubio
- Department of Radiation Oncology, Centro Integral Oncológico Clara Campal (C.I.O.C.C.), HM Hospitales, Calle Oña 10, 28050, Madrid, Spain
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Salerno KE, Das P, Yu JB. 2023 Radiation oncology highlights. J Surg Oncol 2024; 129:159-163. [PMID: 38044813 DOI: 10.1002/jso.27547] [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: 11/14/2023] [Accepted: 11/15/2023] [Indexed: 12/05/2023]
Abstract
Radiation oncology plays an important role in the local treatment of cancers. Understanding recent advances in the application of radiation therapy to solid tumors is important for all disciplines. The radiation oncology section editors for this journal have selected the following articles for their overall significance, relevance to surgical oncologists, and to illustrate important concepts within the practice of radiation oncology.
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Affiliation(s)
- Kilian E Salerno
- Radiation Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Prajnan Das
- Department of Gastrointestinal Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - James B Yu
- Department of Radiation Oncology, Saint Francis Hospital, Hartford, Connecticut, USA
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Cury FL, Viani GA, Gouveia AG, Freire CVS, Grisi GDA, Moraes FY. Meta-analysis of 5-day preoperative radiotherapy for soft tissue sarcoma (5D-PREORTS). Radiother Oncol 2024; 190:109935. [PMID: 37884194 DOI: 10.1016/j.radonc.2023.109935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 09/25/2023] [Accepted: 09/26/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND AND PURPOSE Although the role of conventionally fractionated radiotherapy (RT) in combination with surgery in the limb-sparing treatment of soft tissue sarcoma (STS) patients is well established, the effectiveness and safety of 5-day preoperative radiotherapy (RT) remain controversial. We performed a meta-analysis to evaluate the treatment outcomes of 5-day preoperative RT using ≥ 5 Gy per fraction with contemporary radiotherapy techniques. MATERIALS AND METHODS Medline, Embase, the Cochrane Library, and the proceedings of annual meetings through March 2022 were used to identify eligible studies. Following the PRISMA and MOOSE guidelines, a meta-regression analysis was performed to assess possible correlations between variables and outcomes. A p-value < 0.05 was considered significant. RESULTS Nine prospective studies with 786 patients (median follow-up 35 months, 20-60 months) treated with preoperative RT delivered a median total of 30 Gy (25-40 Gy) in 5 fractions. The local control (LC), R0 margins, overall survival (OS), and distant relapse (DR) rates were 92.3% (95% CI: 87---97%), 84.5% (95% CI: 78---90%), 78% (95% CI: 70---86%), and 36% (95% CI: 70---86%). The meta-regression analysis identified a significant relationship between biological equivalent dose (BED) and larger tumor size for LC and R0 margins (p < 0.05). The subgroup analysis reveals that patients receiving BED ≥ 90 (equivalent to 30 Gy in 5 fractions) had a higher LC control rate than BED < 90 (p < 0.0001). The complete pathologic response and amputation rates were 19% (95% CI: 13-26%) and 8.3% (95% CI: 0.5-15%). Amputation rates were higher in studies using the lowest and highest doses and were related to salvage surgery after recurrence and complications, respectively. The rate of wound complication and fibrosis grade 2 or worse was 30% (95% CI 23-38%) and 6.4% (95% CI 1.9-11%). CONCLUSION A 5-day course of preoperative RT results in high LC and favorable R0 margins, with acceptable complication rates in most studies. Better local control and R0 margins were associated with regimens using higher BED, i.e., doses equal to or higher than 30 Gy when using 5 fractions.
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Affiliation(s)
- Fabio L Cury
- Department of Oncology, Division of Radiation Oncology, McGill University Health Centre, McGill University, Montreal, Canada.
| | - Gustavo A Viani
- Ribeirao Preto Medical School, Department of Medical Imagings, Hematology and Oncology of University of São Paulo (FMRP-USP), Ribeirão Preto, Brazil.
| | - Andre G Gouveia
- Department of Oncology - Division of Radiation Oncology, Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
| | | | | | - Fabio Y Moraes
- Department of Oncology, Division of Radiation Oncology, Kingston General Hospital, Queen's University, Kingston, Canada
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Walker K, Simister SK, Carr-Ascher J, Monument MJ, Thorpe SW, Randall RL. Emerging innovations and advancements in the treatment of extremity and truncal soft tissue sarcomas. J Surg Oncol 2024; 129:97-111. [PMID: 38010997 DOI: 10.1002/jso.27526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 11/29/2023]
Abstract
In this special edition update on soft tissue sarcomas (STS), we cover classifications, emerging technologies, prognostic tools, radiation schemas, and treatment disparities in extremity and truncal STS. We discuss the importance of enhancing local control and reducing complications, including the role of innovative imaging, surgical guidance, and hypofractionated radiation. We review advancements in systemic and immunotherapeutic treatments and introduce disparities seen in this vulnerable population that must be considered to improve overall patient care.
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Affiliation(s)
- Kyle Walker
- Department of Orthopaedics, University of California, Davis, Sacramento, California, USA
| | - Samuel K Simister
- Department of Orthopaedics, University of California, Davis, Sacramento, California, USA
| | - Janai Carr-Ascher
- Department of Hematology and Oncology, University of California, Davis, Sacramento, California, USA
| | - Michael J Monument
- Department of Surgery, The University of Calgary, Calgary, Alberta, Canada
| | - Steven W Thorpe
- Department of Orthopaedics, University of California, Davis, Sacramento, California, USA
| | - R Lor Randall
- Department of Orthopaedics, University of California, Davis, Sacramento, California, USA
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Mayo ZS, Mesko N, Nystrom L, Shah CS, Scott JG, Campbell SR. Radiotherapy Innovation in Rare Diseases- Focusing on the Value of Single Institutional Experiences for Hypofractionated Radiotherapy in Soft Tissue Sarcoma. Radiother Oncol 2023:109626. [PMID: 36963441 DOI: 10.1016/j.radonc.2023.109626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 03/13/2023] [Indexed: 03/26/2023]
Affiliation(s)
- Zachary S Mayo
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH
| | - Nathan Mesko
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Lukas Nystrom
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Chirag S Shah
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH
| | - Jacob G Scott
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH
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10
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Methodological concerns for ultra-hypofractionated neoadjuvant radiation therapy in soft tissue sarcoma. Radiother Oncol 2023; 183:109596. [PMID: 36870605 DOI: 10.1016/j.radonc.2023.109596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 02/26/2023] [Indexed: 03/06/2023]
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11
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Early outcomes of ultra-hypofractionated preoperative radiation therapy for soft tissue sarcoma followed by immediate surgical resection. Radiother Oncol 2023; 180:109439. [PMID: 36481382 DOI: 10.1016/j.radonc.2022.109439] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 12/10/2022]
Abstract
BACKGROUND There is increasing interest in shorter courses of radiation therapy (RT) in the management of soft tissue sarcoma (STS). We report our institutional experience for patients undergoing ultra-hypofractionated preoperative RT followed by immediate resection. METHODS An IRB approved review of patients treated with preoperative 5 fraction, once daily RT followed by immediate resection (within 7 days) for STS of the extremity or trunk was conducted. The primary endpoints are major wound complications and local control (LC). Secondary endpoints include grade ≥ 2 toxicity, metastasis free survival (MFS), and overall survival (OS). RESULTS Twenty-two patients with a median age of 67 years (range 30-87) and median follow-up of 24.5 months (IQR 17.0-35.7) met eligibility criteria; 18/22 patients (81.8 %) had ≥ 1 year follow-up. Primary tumor location was lower extremity in 15 patients (68.2 %), upper extremity in 5 (22.7 %), and trunk in 2 (9.1 %). All patients received 30 Gy in 5 fractions. The median time to resection following RT was 1 day (range 0-5). The median time from biopsy to resection was 34 days (range 20-69). Local control was 100 %; in patients with localized disease, 2-year MFS and OS were 71.3 % and 76.9 %, respectively. Major wound complications occurred in 9 patients (40.9 %), with wound complications requiring reoperation occurring in 8 patients (36.4 %). Other acute and late grade ≥ 2 toxicities were seen in 0 and 4 patients (18.2 %), respectively. CONCLUSION Ultra-hypofractionated preoperative RT followed by immediate resection permits expedited completion of oncologic therapy with early results demonstrating excellent local control and acceptable toxicity. Prospective data with long-term follow-up is needed.
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Roohani S, Ehret F, Kobus M, Flörcken A, Märdian S, Striefler JK, Rau D, Öllinger R, Jarosch A, Budach V, Kaul D. Preoperative hypofractionated radiotherapy for soft tissue sarcomas: a systematic review. Radiat Oncol 2022; 17:159. [PMID: 36104789 PMCID: PMC9472188 DOI: 10.1186/s13014-022-02072-9] [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: 04/26/2022] [Accepted: 05/24/2022] [Indexed: 12/04/2022] Open
Abstract
Background Soft tissue sarcomas (STS) represent a diverse group of rare malignant tumors. Currently, five to six weeks of preoperative radiotherapy (RT) combined with surgery constitute the mainstay of therapy for localized high-grade sarcomas (G2–G3). Growing evidence suggests that shortening preoperative RT courses by hypofractionation neither increases toxicity rates nor impairs oncological outcomes. Instead, shortening RT courses may improve therapy adherence, raise cost-effectiveness, and provide more treatment opportunities for a wider range of patients. Presumed higher rates of adverse effects and worse outcomes are concerns about hypofractionated RT (HFRT) for STS. This systematic review summarizes the current evidence on preoperative HFRT for the treatment of STS and discusses toxicity and oncological outcomes compared to normofractionated RT.
Methods We conducted a systematic review of clinical trials describing outcomes for preoperative HFRT in the management of STS using PubMed, the Cochrane library, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Embase, and Ovid Medline. We followed the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Trials on retroperitoneal sarcomas, postoperative RT, and hyperthermia were excluded. Articles published until November 30th, 2021, were included. Results Initial search yielded 94 articles. After removal of duplicate and ineligible articles, 13 articles qualified for analysis. Eight phase II trials and five retrospective analyses were reviewed. Most trials applied 5 × 5 Gy preoperatively in patients with high-grade STS. HFRT courses did not show increased rates of adverse events compared to historical trials of normofractionated RT. Toxicity rates were mostly comparable or lower than in trials of normofractionated RT. Moreover, HFRT achieved comparable local control rates with shorter duration of therapy. Currently, more than 15 prospective studies on HFRT + / − chemotherapy are ongoing. Conclusions Retrospective data and phase II trials suggest preoperative HFRT to be a reasonable treatment modality for STS. Oncological outcomes and toxicity profiles were favorable. To date, our knowledge is mostly derived from phase II data. No randomized phase III trial comparing normofractionated and HFRT in STS has been published yet. Multiple ongoing phase II trials applying HFRT to investigate acute and late toxicity will hopefully bring forth valuable findings. Supplementary Information The online version contains supplementary material available at 10.1186/s13014-022-02072-9.
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