Conservative surgery and adjuvant radiation therapy in the management of adult soft tissue sarcoma of the extremities: clinical and radiobiological results

[Role of radiotherapy in soft tissue sarcoma]

Radiation therapy is generally used as a surgical adjuvant in the treatment of soft tissue sarcomas. Postoperative external beam irradiation is the most commonly applied treatment. The majority of retrospective studies have suggested that radiation therapy could reduce the incidence of local recurrence. Radiation is recommended in case of deep tumor location, inadequate surgical margins and grade 3 tumor. A total dose of 55 to 65 Gy using large volume with initial field margin of 5 cm are recommended. Radiation therapy can also be delivered in preoperative fashion, but the majority of the studies have reported a higher wound complication rate. The value of brachytherapy for reducing the risk of local recurrence has been demonstrated in a randomized trial, especially for patients with high grade tumors. The combination of external radiation (40 to 45 Gy) and brachytherapy (15 to 20 Gy) seems to be the optimal adjuvant local strategy.

Survival in primary soft tissue sarcoma of the extremities and trunk

BACKGROUND

Soft tissue sarcomas (STS) of the extremities are rare. The purpose of this study was to identify prognostic risk factors associated with survival in patients with primary extremity and truncal STS.

METHODS

Patient, tumor, and pathologic data from 149 consecutive patients with localized primary STS of the extremities and trunk were analyzed using Kaplan-Meier and Cox regression techniques to identify univariate and multivariate risk factors. A subgroup analysis was performed to compare factors predictive of survival in patients who received treatment before (n = 50) and after (n = 99) treatment was standardized in 1988.

RESULTS

The 5-year survival rate was 76.5% with an average follow-up of 6 years. Local recurrence occurred in 23% of all patients, 40% before 1988 and 15% after 1988 (P < 0.0001). Risk factors associated with survival included resection quality (R0 vs. R1; P < 0.0001), era of operation (P = 0.002), local recurrence (P < 0.001), UICC stage (P < 0.0001), tumor size (P < 0.001), tumor depth (P = 0.002), regional lymph nodes (P < 0.0001), and histology (P < 0.0001). Multivariate analysis revealed that tumor size, tumor depth, and resection quality were independent risk factors of survival.

CONCLUSIONS

These results indicate that management of STS in a specialized institution improves overall survival. Resection quality is the most important risk factor of survival. Therefore, effort should be made during primary treatment of STS to achieve wide, tumor-free resection margins.

Radiotherapy in soft tissue sarcoma of the extremities

The local treatment of soft tissue sarcoma is evolving. Limb-sparing compartmentectomy offers local control but at the expense of function and a high amputation rate. The functional outcome is improved with combined wide excision and radiotherapy, at the same time achieving a similar local control rate. Future directions should include attempts to reduce toxicity and maximise the functional result. As the limb function is ultimately related to the aggressiveness of the local treatment, the optimum surgical margin, radiation volume and dose, require further investigation. The pursuit of local control should not be compromised in the quest for reducing morbidity, as the relationship between local control and survival remains unclear.