Intraoperative interstitial iridium brachytherapy in the management of soft tissue sarcomas: preliminary results of a feasibility phase II study

Postradiation Fractures after Combined Modality Treatment in Extremity Soft Tissue Sarcomas

Soft tissue sarcoma (STS) of the extremities is typically treated with limb-sparing surgery and radiation therapy; with this treatment approach, high local control rates can be achieved. However, postradiation bone fractures, fractures occurring in the prior radiation field with minimal or no trauma, are a serious late complication that occurs in 2–22% of patients who receive surgery and radiation for STS. Multiple risk factors for sustaining a postradiation fracture exist, including high radiation dose, female sex, periosteal stripping, older age, femur location, and chemotherapy administration. The treatment of these pathological fractures can be difficult, with complications including delayed union, nonunion, and infection posing particular challenges. Here, we review the mechanisms, risk factors, and treatment challenges associated with postradiation fractures in STS patients.

[Radiotherapy for soft tissue sarcomas: Technical evolution and impact on clinical benefit]

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.

Prospective evaluation of quality of surgery in soft tissue sarcoma

BACKGROUND

Prospective application of the French Sarcoma Group (FSG) method of surgery reporting in soft tissue sarcoma (STS) in a single centre.

METHODS

Patients with primary STS of the extremities or trunk wall consecutively operated at the same institution from January 1996 to December 2002 were evaluated for local recurrence (LR). There were 205 patients, with AJCC/UICC stages III and IV in 51% of cases. Resection types according to FSG were R0 in 147, R1 in 53 and R2 in five cases. Radiotherapy was delivered in 163 patients and chemotherapy in 103. Multivariate analysis was performed. Overall five-year survival was 75%. Median follow-up for surviving patients was 53 months.

RESULTS

Actuarial five-year LR incidence was 13% in 200 patients with gross resection (R0+R1), it was 7% in R0 and 30% in R1 patients (p<0.0001). At univariate analysis, significant prognosticators for LR were age, histotype, tumour invasion, grade and resection type R. At multivariate analysis, resection R1 (relative risk (RR) 4.3, p=0.001) and grade 3 (RR 3.9, p=0.013) independently predicted LR. Combining these two variables produced three prognostic groups for LR: group 0 (no factor, n=70), group 1 (one factor, n=94) and group 2 (two factors, n=36) with five-year LR of 4%, 12% and 39%, respectively (p=6.4x10(-7)).

CONCLUSION

This first prospective evaluation of surgery reporting in STS evidences a fourfold, highly discriminating difference in LR between resections R0 and R1.

Place et techniques de radiothérapie dans le traitement des sarcomes des tissus mous de l'adulte

In soft tissue sarcoma, surgical resection remains the cornerstone of therapy for localized disease. Quality of margins is very important to evaluate. In case of marginal or incomplete resection, a new enlarged surgical resection should always be discussed before administration of any adjuvant treatments. Many retrospective studies and 2 randomized studies (one of adjuvant brachytherapy and one of external beam radiotherapy) have shown that adjuvant radiotherapy after complete surgery reduces significantly the risk of local recurrence in extremity soft tissue sarcomas. Combination of surgery and pre- or postoperative radiotherapy has therefore become the standard treatment with a local recurrence rate <or=25% and very few amputations. A recent randomized study has compared pre-op to postoperative radiotherapy. The results in terms of local control are similar in both arms (93 and 92% at 5 years) but the risk of early complications is higher in the preoperative arm and the risk of late sequela is higher in the postoperative arm. Surgical resection without radiotherapy may be considered after discussion at best within a multidisciplinary meeting, if surgical margins are considered satisfactory, in superficial, small tumours and low-grade. In retroperitoneal sarcomas, adjuvant radiotherapy is not a standard. It may decrease the risk of local recurrence but at the price of an increased gastro-intestinal toxicity. A randomized trial is warranted. Because of its rarity, and the risk of recurrence both local and metastatic, treatment should preferentially be discussed with a multimodality specialized approach.

[Brachytherapy for soft tissue sarcomas. Technique and therapeutic indications]

The role of brachytherapy in the therapeutic strategy of soft tissue sarcomas has been difficult to assess due to the fact it has been during a long time institution-specific. However, the experience gained specially with low dose-rate treatments has allowed formulating guidelines for technical rules and patient selection. Brachytherapy used as an isolated treatment combined with surgery has proven to be effective in high-grade sarcomas, compared to surgery alone, in a unique randomized trial. Beside, a number of data have shown that the combination of brachytherapy and external beam irradiation could be superior to brachytherapy or external beam irradiation alone in the treatment of tumors with high-grade, or central location, locally advanced or on contact with neurovascular structures. Brachytherapy alone, combined with surgery, is of interest for conservative treatment of recurrent sarcomas occurring in previously irradiated areas. The occurrence of side effects remains acceptable if technical guidelines are followed, for surgery as well as for brachytherapy, using the most modern available treatment techniques. Brachytherapy should be at the moment an integrated part of the multidisciplinary treatment of soft tissue sarcomas.

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.

Reconstruction after soft tissue sarcoma resection in the setting of brachytherapy: a 10-year experience

Management of recurrent soft tissue sarcomas often involves surgical resection and adjuvant brachytherapy. This study reviews our experience in the management of these patients and proposes a logical approach toward reconstruction. All patients who underwent soft tissue sarcoma resection, adjuvant brachytherapy, and soft tissue flap reconstruction (pedicled or free) during the 10-year period from 1991 to 2000 were included in this study. There were 17 patients (14 male, 3 female) with a mean age of 51 years (range, 16-80 years). Soft tissue sarcomas were distributed in the lower extremity (n = 9), upper extremity (n = 5), and trunk (n = 3). Reconstruction was accomplished by regional transposition flaps (n = 10) and free tissue transfer (n = 7). The average defect size was 143 cm. Patients received 5 to 12 (mean, 8) brachytherapy catheters. The brachytherapy dose delivered ranged from 1600 to 4500 cGy (mean, 3773 cGy). Brachytherapy catheters were loaded with radioactive sources between 5 and 7 days postoperatively. All flaps in this series survived. One patient required return to the operating room for revision of a venous thrombosis with flap salvage. Closed suction drainage tubes were left in place until after the brachytherapy catheters were removed to avoid dislodging the catheters. Two patients developed postradiation partial-thickness skin necrosis with delayed secondary wound healing. This study demonstrates that soft tissue reconstruction in the setting of sarcoma resection and brachytherapy catheter placement is safe and efficacious. Postoperative wound healing complications can be minimized through coordination among the ablative surgeon, reconstructive surgeon, and radiation oncologist. Specifically, placement of microvascular anastomoses well away from the radiation target area is indicated whenever possible. Finally, removal of closed suction drainage tubes should be deferred until after the brachytherapy catheters are removed to minimize complications resulting from catheter dislodgement.

Phantom study of radiation doses outside the target volume brachytherapy versus external radiotherapy of early breast cancer

BACKGROUND AND PURPOSE

Brachytherapy is sometimes suggested as an adjuvant treatment after surgery of some tumours. When introducing this, it would be useful to have an estimate of the dose distribution to different body sites, both near and distant to target, comparing conventional external irradiation to brachytherapy. The aim of the present study was to determine radiation doses with both methods at different body sites, near and distant to target, in an experimental situation on an operated left sided breast cancer on a female Alderson phantom.

METHODS

Five external beam treatments with isocentric tangential fields were given by a linear accelerator. A specified dose of 1.0 Gy was given to the whole left sided breast volume. Five interstitial brachytherapy treatments were given to the upper, lateral quadrant of the left breast by a two plane, 10 needles implant. A dose of 1.0 Gy specified according to the Paris system was administered by a pulsed dose rate afterloading machine. Absorbed dose in different fixed dose points were measured by thermoluminescence dosimeters.

RESULTS

Both methods yielded an absorbed dose of the same size to the bone marrow and internal organs distant to target, 1.0-1.4% of the prescribed dose. There was a trend of lower doses to the lower half of the trunk and higher doses to the upper half of the trunk, respectively, by brachytherapy. A 90% reduction of absorbed dose with brachytherapy compared to external irradiation was found in the near-target region within 5 cm from target boundary where parts of the left lung and the heart are situated. If an adjuvant dose of 50 Gy is given with the external radiotherapy and brachytherapy, the absorbed dose in a part of the myocardium could be reduced from 31.8 to 2.1 Gy.

CONCLUSIONS

Near target, brachytherapy yielded a considerably lower absorbed dose which is of special importance when considering radiation effects on the myocard and lungs. We could not demonstrate any difference of importance, in absorbed dose to dose points distant to target.

Current results of brachytherapy for soft tissue sarcoma

Perioperative brachytherapy results in a better local control rate than surgery alone for extremity soft tissue sarcoma. Brachytherapy enables the delivery of a high radiation dose to a limited volume of tissue, allows the reduction of radiation treatment time, enables direct visualization of the tumor bed and surrounding critical structures, and costs less than external beam radiotherapy. The literature seems to regard the effectiveness of brachytherapy as comparable to that of external beam radiotherapy, and the side effect profile is acceptable. Traditional low-dose-rate brachytherapy methods require extended periods of patient isolation, but recent technologic advances may obviate this necessity. Newer high-dose-rate (HDR) brachytherapy delivery methods allow for the fractionation of radiation delivery and outpatient treatment in some cases. Furthermore, with HDR brachytherapy, the radiation dose distribution can be tailored around critical anatomic structures. Although the application of HDR brachytherapy to soft tissue sarcoma is relatively new, it seems to result in a satisfactory local control rate and may replace traditional low-dose-rate techniques.

[Brachytherapy in soft tissue sarcomas]

Soft tissue sarcomas are rare tumors with a high risk or local recurrence and a risk of distant metastases. Standard treatment advocated is the combination of conservative resection and external radiotherapy. Brachytherapy is an integrated part of the multidisciplinary treatment. Brachytherapy can increase local control with good functional results. Primary exclusive brachytherapy has been used and is effective and safe in high grade sarcomas (randomized trial of MSKCC). Brachytherapy seems to be important as part of the treatment of central localization (shoulder, groin) and sarcomas with positive resection margins, but its relation with external radiotherapy has to be defined. Brachytherapy used with special guidelines allows to obtain an improved local control with an acceptable level of complication.

Intraoperative high-dose-rate brachytherapy for pediatric solid tumors: a 10-year experience

PURPOSE

To evaluate the efficacy and toxicity of intraoperative high-dose-rate brachytherapy (IOHDR) in the management of pediatric solid tumors.

METHODS AND MATERIALS

The records of 66 pediatric patients who underwent IOHDR for a solid tumor from February 1993 through December 2002 were retrospectively reviewed. The median age was 7 years (range 9 months to 24 years). Thirty-five patients (53%) were treated for recurrent disease and 24 (36%) had documented metastatic disease. Twenty-nine patients (44%) received both EBRT and IOHDR. The IOHDR dose was prescribed to a depth of 0.5 cm from the surface of a multichannel tissue-equivalent applicator. The median prescription dose was 12 Gy (range, 4-15 Gy).

RESULTS

After a median follow-up of 12 months, the 2-year actuarial rates of local control and overall survival were 56% and 54%, respectively, with a median survival of 29 months. Post-operative EBRT significantly improved (p=0.002) 2-year local control (83% v. 29%). Perioperative complications occurred in 8 of 66 patients while late complications occurred in only 3. The actuarial 2-year late complication rate was 12%. Late events that occurred in or near the IOHDR treatment site included small bowel obstruction, broncho-esophageal fistula, and bone growth retardation.

CONCLUSIONS

IOHDR is emerging as an integral part of multimodality therapy for pediatric solid tumors as an adjunct to EBRT for local control. IOHDR alone may not be appropriate in the majority of patients. Subacute toxicities occurred rarely and may be related to the combination of extensive surgery, EBRT, and multi-agent chemotherapy in this population.

Preoperative radiotherapy in the treatment of soft tissue sarcomas

The goal of the current study was to analyze the oncologic results and wound complications in patients with soft tissue sarcomas treated with preoperative radiation therapy and en bloc resection. A standard protocol of preoperative radiotherapy was administered followed by en bloc resection in 209 patients. The protocol included needle or incisional biopsy, prospective staging, a consistent dose of radiotherapy, standardized prospective evaluation of surgical margins, and long-term followup. The target radiotherapy dose was 50.4 cGy. Twenty-nine patients had low-grade lesions, and 180 had high-grade lesions. The mean followup was 55 months. The significant wound complication rate was 22% (moderate 14%, major 7%, and amputation 1%). Wound complications were significantly higher in patients with lower extremity lesions when compared with patients with upper extremity or axial lesions, and in patients with lesions larger than 5 cm. The local recurrence rate was 11% in patients who did not have prior surgery, and 37% in patients who had prior surgery at an outside institution (17% overall). Local recurrence was increased significantly in patients who had prior surgery. At latest followup, 78 patients (47%) were continuously disease-free, six (4%) were alive with no evidence of disease, nine (5%) were alive with disease, 63 (38%) died of disease, and 11 (7%) died of another cause. The 2- and 5-year disease-specific survival rates were 77% and 67%, respectively. Overall survival was 56%. A significant decrease in survival was seen in patients who had a local recurrence, and in patients with high-grade lesions. Preoperative radiotherapy can be given safely with a wound complication rate not significantly higher than that reported for other forms of radiotherapy delivery. Local recurrence tends to be higher if surgical intervention is done before tertiary center referral. Distant disease continues to be the cause of the high mortality in these patients.

Brachytherapy for locally recurrent soft-tissue sarcoma

Radiation is used to reduce potential risk of local recurrence from microscopic residual disease after surgical resection. Brachytherapy is a clinically established means of providing radiation for soft-tissue sarcomas that recur after surgical resection alone or surgical resection and radiation. Although the total dose of radiation that is prescribed is approximately the same for patients undergoing external beam radiation or brachytherapy, the radiobiologic characteristics of brachytherapy, based on the inverse-square law, provide higher doses of radiation to the surgical bed. This provides a theoretical advantage for the use of brachytherapy as compared with external beam radiation among patients with recurrence after surgical resection. When soft-tissue sarcomas recur in a previously irradiated area, further external beam radiation generally is not possible; therefore, brachytherapy allows a radiotherapeutic alternative in an attempt to reduce the risk of further local recurrence. Recommendations for patient selection, the total dose of radiation, and the radiation dose-rate are outlined. Standard grading systems for response, symptoms, and severity of complications should be used.

Adjuvant brachytherapy for primary high-grade soft tissue sarcoma of the extremity

BACKGROUND

We reviewed single-institution experience using brachytherapy alone for primary high-grade soft tissue sarcoma of the extremity.

METHODS

Between July 1982 and September 1997, 202 adult patients with primary high-grade soft tissue sarcoma of the extremity were treated with limb-sparing surgery and adjuvant brachytherapy. All patients underwent complete gross resection, but the margin of resection was microscopically positive in 18% of patients. The median dose of brachytherapy was 45 Gy delivered over 5 days. Tumors located in the shoulder or groin were defined as central location. Complications were assessed in terms of wound complications, bone fracture, and peripheral nerve damage.

RESULTS

With a median follow-up of 61 months, the 5-year local control, distant relapse-free survival, and overall survival rates were 84%, 63%, and 70%, respectively. On multivariate analysis, poor local control correlated with shoulder location, positive microscopic margins of resection, and nonshoulder upper extremity site. The 5-year actuarial rates of wound complications requiring reoperation, bone fracture, and grade > or = 3 nerve damage were 12%, 3%, and 5%, respectively.

CONCLUSIONS

Adjuvant brachytherapy provides adequate local control and acceptable morbidity that compares favorably with data reported for external beam radiation. Shoulder tumor location was identified as an independent prognostic factor for poor local control, mandating further improvement in the local management of these tumors.

[Definitions of target volumes in soft tissue sarcomas of the extremities]

Soft tissue sarcomas of the extremities are currently treated with more conservative and functional approaches, combining surgery, radiotherapy and chemotherapy. The role of external beam radiotherapy and brachytherapy has been defined through randomised studies performed in the 80's and 90's. However, the ubiquity of tumour location for these tumours makes difficult a systematic definition of local treatments. Tumour volume definition is based on pre and post surgical imaging (MRI) and on described pathological report. The clinical target volume will take into account quality of the resection and anatomical barriers and will be based on an anatomy and not only on safety margins around the tumour bed. General rules for this irradiation (doses, volumes) and principal results will be presented.

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.

Morbidity of adjuvant brachytherapy in soft tissue sarcoma of the extremity and superficial trunk

PURPOSE

We have previously shown that adjuvant brachytherapy (BRT) improves local control in soft tissue sarcoma (STS) of the extremity and superficial trunk. A detailed assessment of the morbidity of this approach has not been examined. The purpose of this study was to evaluate the toxicity associated with adjuvant BRT in terms of wound complications, bone fracture, and peripheral nerve damage.

METHODS AND MATERIALS

Between July 1982 and June 1992, 164 adult patients with STS of the extremity or superficial trunk were randomized intraoperatively to receive or not to receive BRT after complete resection. BRT was delivered with (192)Ir to a total dose of 42-45 Gy. The BRT and no-BRT arms were balanced with regard to age, sex, presentation (primary vs. recurrent), site, grade, size, and depth. Morbidity was assessed in terms of significant wound complication, bone fracture, and peripheral nerve damage (grade > or = 3). The significant wound complications were defined as those wound problems requiring operative revision for coverage or threatened limb loss, persistent seroma requiring repeated aspirations and/or drainage, wound separation > 2 cm, hematoma > 25 ml, and/or purulent wound discharge. The median follow-up was 100 months.

RESULTS

The significant wound complication rate was 24% in the BRT group and 14% in the no-BRT group, (p = 0.13). The rate of wound reoperation, however, was significantly higher in the BRT arm (10% vs. 0%; p = 0. 006). Examination of other covariables that may have contributed to wound reoperation revealed the width of the excised skin (WES) to be a significant factor [1% (WES < or = 4 cm) vs. 10% (WES > 4 cm), p = 0. 02]. Bone fracture only occurred in patients receiving BRT (n = 3, 4%), although this was not statistically significant (p = 0.2). The rate of peripheral nerve damage, however, was similar in both arms (7% vs. 7%).

CONCLUSION

The overall morbidity associated with adjuvant BRT was not significantly higher than that with surgery alone. However, BRT and WES > 4 cm were associated with significantly higher wound reoperation rate. This has significant implications for strategies designed to maximize wound coverage in patients who receive BRT.

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.

Postoperative radiotherapy in the management of adult soft tissue sarcoma of the extremities: results with two different total dose, fractionation, and overall treatment time schedules

PURPOSE

This retrospective study was performed to evaluate two postoperative radiotherapy schedules in terms of dose, fractionation, and overall treatment time in soft tissue sarcoma (STS) of the extremities.

METHODS AND MATERIALS

Between January 1984 and December 1993, 62 patients with newly diagnosed localized STS of the extremities were treated with maximal conservative surgery and postoperative radiotherapy (RT). Forty-five patients received 50 Gy with conventional fractionation plus a boost dose (5 to 20 Gy). Seventeen patients had hyperfractionated accelerated radiotherapy (HFART) up to a dose of 45 Gy in 3 weeks.

RESULTS

With a median follow-up of 72 months, the 5-year local failure rate was 25%, the 5-year disease-free and overall survival rates were respectively 42% and 62%. The 3-year local relapse, disease-free, and overall survival rates were respectively 16%, 44%, and 70% in the conventional radiotherapy group, and 36%, 47%, and 82% in the HFART group (NS). No factor significantly influenced local control with a trend, however, in favor of conventional RT (p = 0.10).

CONCLUSION

HFART at the dose of 45 Gy does not seem to be superior to the standard RT schedule, neither in terms of local control, survival, nor in terms of long-term side effects. However this dose could be considered too low as well as the power of comparison between the two groups to draw definitive conclusions.

[Treatment of soft tissue sarcomas of the extremities and the trunk by conservative surgery and postoperative irradiation. Apropos of a series of 96 patients]

AIM OF STUDY

Retrospective study of a series of 96 patients presenting with soft tissues sarcoma. Homogeneous treatment between 1980-1992 with conservative surgery and post operative irradiation.

PATIENTS AND METHODS

Median age of the 96 patients was 58 years. Tumor site was: upper limb 20, lower limb 46, trunk 30. In 35 cases largest diameter of the tumor was 5 cm or less (T1). All patients were M0. The most frequent pathological sub type was: malignant histiocytofibroma 28, liposarcoma 28. A gross complete surgery was performed in 89 cases. Radiotherapy was performed with cobalt or x 18 MV photons. The dose delivered was 50 Gy with a boost of 10 Gy. No adjuvant chemotherapy was given.

RESULTS

Mean follow up was 68 months. Local relapse was seen in 19 patients, six were salvaged by surgery, a limb amputation rates were necessary in 4 cases. The 5 and 10 year-overall survival was 70% and 64%. There was no severe radiation toxicity requiring surgery. A good function of the limb was preserved in all cases.

CONCLUSION

These results are in agreement with those of the literature and justify a conservative approach for these soft tissues sarcomas.

[Chemotherapy of soft tissue sarcoma in the adult]

The goal of postoperative treatment in adult soft tissue sarcoma is local control, and in high-risk patients prevention of distant failures. Radiation therapy is essential after non-radical surgery. The role of adjuvant chemotherapy on improvement of overall survival remains to be evidenced; however, recent meta-analysis data have confirmed its impact on both local and metastatic evolution of the disease. Because for both radiotherapy and chemotherapy, delay of treatment may be crucial for efficacy following tumor excision, concomitant radiochemotherapy should be considered. Review of the literature as well as personal results showed the feasibility of postoperative radiochemotherapy in adult soft tissue sarcoma, even when the chemotherapeutic associations used included an anthracycline. Prospective study of radiochemotherapy should be performed in order to assess its real impact in terms of efficacy and toxicity.

[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.

Intra-operative implant brachytherapy in the management of soft-tissue sarcomas

BACKGROUND

The management of localized soft-tissue sarcomas remains complex. This is a retrospective review of a single institution experience with manual afterloaded brachytherapy following intra-operative implantation of the tumour bed during surgery.

METHODS

Twelve patients over a 3-year period had resection for localized soft-tissue sarcomas and desmoids with insertion of intra-operative brachytherapy implants combined with resection for localized soft-tissue sarcomas. Manual afterloading of the implant with iridium wires was performed postoperatively in all patients. The low dose rate brachytherapy dose varied from 13 to 20 Gy. Supplementary external beam radiation was administered pre-operatively or postoperatively to bring the total dose of adjuvant irradiation to 60-65 Gy.

RESULTS

After a median follow-up period of 29 months, the 3-year local disease-free survival rate was 63%. The 3-year actuarial survival rate was 83%. There were no failures within the high-dose region of the implant, although two patients had locoregional failures adjacent to the tumour bed at the edge of the radiation field. Three patients developed distant metastases. Side effects were noted in five patients. Wound breakdown and delayed wound healing occurred in two patients. One patient required an amputation as a result of chronic non-healing and wound pain. Pathological fractures occurred in two patients. Those patients who did not develop wound breakdown had good cosmetic and functional outcomes.

CONCLUSION

Intra-operative implantation of the tumour bed in combination with tumour resection for soft-tissue sarcomas results in a high degree of local control with acceptable complications. This modality offers the patient a high chance of avoiding a more radical surgical procedure such as limb amputation.