Evidence-Based Recommendations for Local Therapy for Soft Tissue Sarcomas

Abstract

There has been a gradual migration in the local treatment of soft tissue sarcomas from amputation and similar radical resectional approaches to more conservative, function-preserving surgery combined with radiotherapy. This progress has been made possible by small, single-institution, randomized trials that demonstrated the superiority of this more conservative, combined-modality approach. In the new millennium, attention has shifted to defining subsets of patients who might be adequately treated by surgery alone and defining the optimal sequence of surgery and radiation for patients who require both types of local therapy. There remains considerable discussion and debate surrounding the issue of pre- and postoperative chemotherapy for patients with localized soft tissue sarcomas. Adjuvant chemotherapy is a standard of care for adults who have the subtypes of soft tissue sarcomas that typically occur in pediatric patients (Ewing sarcoma, rhabdomyosarcoma), and just as clearly, adjuvant chemotherapy is not warranted in patients with low- and intermediate-risk disease (stages I and II). For patients with higher risk disease (stage III), the available randomized trials do not convincingly demonstrate a clinical benefit to adjuvant chemotherapy. As such, a complete accounting of potential risks and benefits is appropriate when discussing adjuvant chemotherapy with patients who have stage III disease.

Soft-tissue Sarcomas in the Asia-Pacific Region: A Systematic Review

“…This finding aligns with current guidelines for STS treatment (Casali et al, 2010;National Comprehensive Cancer Network, 2012). Adjuvant radiotherapy has been shown to improve local control but not survival (Pisters et al, 2007), and its use depends on several factors, such as tumour size and location, the preferences of the treating physician and institution, and the resection margins (eg, involved, close, or clear). Adjuvant radiotherapy was administered to some patients, either preoperatively (1-100%) or postoperatively (6-88%), in 24 of the included studies.…”

“…Adjuvant radiotherapy was administered to some patients, either preoperatively (1-100%) or postoperatively (6-88%), in 24 of the included studies. Preoperative radiotherapy, which may allow for the use of smaller field sizes and lower radiation doses and have lower long-term morbidity than postoperative radiotherapy (Pisters et al, 2007), seemed to be the standard of care at an Australian study centre (Choong et al, 2003;Hui et al, 2006;Rudiger et al, 2009;Miki et al, 2010), despite the potential for acute postoperative wound complications (Hui et al, 2006;Rudiger et al, 2009). Although the use of adjuvant chemotherapy may help local control, its marginal, if any, survival benefit (Pervaiz et al, 2008;Woll et al, 2012) has generally restricted its use to treatment of metastatic disease (Casali et al, 2010;National Comprehensive Cancer Network, 2012).…”

Radiotherapy and surgery—An indispensable duo in the treatment of retroperitoneal sarcoma

“…44,47 The addition of IORT has been evaluated in multiple series and sometimes produces promising disease control rates, although high toxicity rates have been reported, with peripheral neuropathy the most frequent and severe. 1,11,44,45 Concerning postoperative RT, there may be a dose response and better local control rates with doses >55 Gy. 14 Modern technologies, such as IMRT, tomotherapy, and intensity-modulated arc therapy, should be the technologies of choice, because they combine dose escalation with sparing of the organs at risk and, consequently, are less toxic.…”

“…9 Unfortunately, obtaining a microscopically complete resection remains a heavy burden even in the hands of experienced surgeons. 8,[10][11][12][13] After undergoing macroscopically complete surgery alone, local recurrences develop in 20% to 75% of patients, and these can occur even after 5 years of follow-up. 1,8,10,[14][15][16][17][18][19] The estimated survival rate at 5 years varies between 12% and 75%, 6,13,20,21 and the cause of death for these patients usually is local recurrence, which is in sharp contrast to outcomes for patients with sarcoma of the extremities.…”

Fas Death Pathway in Sarcomas Correlates with Epidermal Growth Factor Transcription

“…Chemotherapy alone or in combination with radiotherapy is frequently employed against a variety of mesenchymal tumors to induce tumor shrinkage, thus facilitating surgical resection [5,7,8,29,36]. Most chemotherapeutic agents accomplish this task by inducing apoptosis [10,32] through the induction of a death receptor [35] or by activation of the endogenous mitochondrial death pathway [12,23].…”