Limb-sparing management with surgical resection, external-beam and intraoperative electron-beam radiation therapy boost for patients with primary soft tissue sarcoma of the extremity

Abstract

From this joint analysis emerges the fact that an IOERT dose ≥ 12.5 Gy increases the rate of IOERT in-field control, but DFS remains modest, given the high risk of distant metastases. Intensified local treatment needs to be tested in the context of more efficient concurrent, neo- and adjuvant systemic therapy.

Intraoperative radiation therapy (IORT) in soft-tissue sarcoma

“…However Roeder et al [29] observed 12% neuropathy of all grades (CTCAE 3.0) including only 3% grade 3 in their prospective subgroup analysis. Azinovic et al [34] found 11% neuropathy in total in their series and Calvo et al [40] reported a 3% RTOG grade 3 neuropathy rate in their pooled analysis. These neuropathy rates seem lower than historical reports from other body regions which might be attributed to the fact that most of the expert centers try to exclude major nerves from the IORT area in extremity sarcoma whenever possible.…”

“…In summary, the combination of limb-sparing surgery, IORT and EBRT resulted consistently in excellent 5-year LC rates of 82–97% [5, 6, 29, 30, 35, 36, 39, 40] in patients with extremity STS. Those results are at least equal to major Non-IORT series, which consistently report 5-year LC rates of 83–93% [15, 42–50], especially if the higher proportions of patients with unfavourable prognostic factors in the IORT series are taken into account.…”

“…Two groups have performed pooled data analyses so far [39, 40]. The first one, recently published by Calvo et al [40], included 159 patients from three Spanish expert centers. All presented in primary situation without distant spread.…”

“…Those results are at least equal to major Non-IORT series, which consistently report 5-year LC rates of 83–93% [15, 42–50], especially if the higher proportions of patients with unfavourable prognostic factors in the IORT series are taken into account. Beside from oncological outcome, IORT containing approaches resulted consistently in very high limb preservation rates (83–100%) [5, 6, 29, 30, 33–36, 39, 40] with good functional outcome (59–86%) [5, 6, 29, 30, 34, 36, 39]. This might be attributed to the smaller high dose volume compared to an EBRT boost as treatment volume was clearly associated with increased late toxicity in a randomized trial using EBRT alone [28].…”

“…In the prospective trial, postoperative complications of all grades (CTCAE 3.0) were found in 20% of whom only 9% were grade 3 using a similar approach [29]. Calvo et al [40] observed an even lower rate of 5% wound complications in their pooled analysis and Kunos et al [51] found a 15% rate if IOERT was combined with postoperative RT and 36% if IOERT was combined with preoperative IOERT. Those figures almost exactly equal the numbers from the NCIC trial comparing preoperative and postoperative EBRT without IORT, which reported 35% in the preoperative and 17% in the postoperative arm [26] using almost identical definitions of wound complications.…”