Phase 2 study of preoperative image‐guided intensity‐modulated radiation therapy to reduce wound and combined modality morbidities in lower extremity soft tissue sarcoma

Abstract

BACKGROUND: This study sought to determine if preoperative image‐guided intensity‐modulated radiotherapy (IG‐IMRT) can reduce morbidity, including wound complications, by minimizing dose to uninvolved tissues in adults with lower extremity soft tissue sarcoma. METHODS: The primary endpoint was the development of an acute wound complication (WC). IG‐IMRT was used to conform volumes to avoid normal tissues (skin flaps for wound closure, bone, or other uninvolved soft tissues). From July 2005 to June 2009, 70 adults were enrolled; 59 were evaluable for the primary endpoint. Median tumor size was 9.5 cm; 55 tumors (93%) were high‐grade and 58 (98%) were deep to fascia. RESULTS: Eighteen (30.5%) patients developed WCs. This was not statistically significantly different from the result of the National Cancer Institute of Canada SR2 trial (P = .2); however, primary closure technique was possible more often (55 of 59 patients [93.2%] versus 50 of 70 patients [71.4%]; P = .002), and secondary operations for WCs were somewhat reduced (6 of 18 patients [33%] versus 13 of 30 patients [43%]; P = .55). Moderate edema, skin, subcutaneous, and joint toxicity was present in 6 (11.1%), 1 (1.9%), 5 (9.3%), and 3 (5.6%) patients, respectively, but there were no bone fractures. Four local recurrences (6.8%, none near the flaps) occurred with median follow‐up of 49 months. CONCLUSIONS: The 30.5% incidence of WCs was numerically lower than the 43% risk derived from the National Cancer Institute of Canada SR2 trial, but did not reach statistical significance. Preoperative IG‐IMRT significantly diminished the need for tissue transfer. RT chronic morbidities and the need for subsequent secondary operations for WCs were lowered, although not significantly, whereas good limb function was maintained. Cancer 2013. © 2013 American Cancer Society.

Simultaneous Soft Tissue Sarcoma Excision and Prophylactic and Bony Fixation of the Upper Limb: Expediting Radiotherapy and Reducing Fracture Risk

“…Intensity Modulated Radiotherapy (IMRT) permits dose contouring to enable accurate targeting of tumor cells whilst minimizing dose to uninvolved tissues. A recent large prospective phase-II clinical trial demonstrated no difference in total wound complications as compared with EBRT but of interest it did show a 0% fracture rate in long bone STS [10]. As of yet, there have been no comparative studies of EBRT and IMRT; thus, the potential advantages of IMRT remain speculative.…”

Is there a role for intraoperative radiation therapy in resectable extremity soft tissue sarcoma beyond external beam radiation therapy?

“…More recently reported experiences with the use of preoperative EBRT with modern RT techniques show more favourable results in terms of complications, and IORT boost remains a very favourable option when critical, positive or close surgical margins are expected. Preoperative EBRT and IORT boost should be considered in particular when reconstructive surgery with flaps is needed, because of the possibility of sparing the vulnerable reconstruction and avoiding postoperative EBRT [14].…”

Sarcomas

“…If daily image guidance with cone beam or MV-CT is performed, a 0.5 cm CTV expansion for the PTV is permitted (O'Sullivan et al 2013 ).…”