Role of brachytherapy in recurrent extremity sarcoma in patients treated with prior surgery and irradiation

doi:10.1016/0360-3016(91)90232-S

International Journal of Radiation OncologyBiologyPhysics

Volume 20, Issue 6, June 1991, Pages 1229-1233

https://doi.org/10.1016/0360-3016(91)90232-S Get rights and content

Abstract

The treatment options for recurrent extremity sarcoma following conservative surgery and irradiation are limited. Amputation is the treatment of choice offered for the majority of these patients. In a selected group of patients with recurrent sarcoma, we have investigated the role of brachytherapy along with function-preserving resection. From 1979 to 1988, 40 patients underwent resection and brachytherapy for recurrent extremity sarcoma. There were 23 males and 17 females. All of the patients received function-preserving resection and an afterloading temporary tumor bed implant. A median dose of 4500 cGy was delivered with a range from 3000 to 4800 cGy. The median follow-up was 36 months with a range of 12 to 120 months. The actuarial local control at 5 years is 68%. Five patients (12.5%) developed complications such as wound ulceration (4) and femoral fracture (1) requiring surgery. Five patients developed local failure and an additional two patients had both local and distant failure. All of the failures occurred in patients with more than two prior recurrences. This review suggests that brachytherapy can be used as an effective treatment option in selected patients with recurrent extremity sarcoma following prior surgery and irradiation with satisfactory limb preservation. The data also suggest that higher local control rates can be achieved with early brachytherapeutic intervention.

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Dose volume histogram constraints in patients with soft tissue sarcomas of the extremities and the superficial trunk treated with surgery and perioperative HDR brachytherapy
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Wound healing complications (WHC), osteoradionecrosis (ORN), and nerve damage (ND) are common adverse effects in adult patients with soft tissue sarcomas of the extremities and the superficial trunk treated with surgery and perioperative high dose rate brachytherapy (PHDRB) alone or combined with external beam radiotherapy (EBRT).
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WHC in Previously Unirradiated patients can be minimized by using a more conservative CTV definition together with a meticulous implant technique and planning aimed to minimize hyperdose CTV_2cm3 areas. In Previously Irradiated patients WHC may be mimimized considering Lifetime EQD2 Skin_2cm3 doses. ORN can be reduced by using the Bone_2cm3 EQD2 constraint. ND occurs more frequently in patients with large tumors receiving high treated volume doses, but no specific constraints can be recommended due to the lack of peripheral nerve definition during brachytherapy planning.
American Brachytherapy Society (ABS) consensus statement for soft-tissue sarcoma brachytherapy
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Citation Excerpt :
Recurrent STS are often clinically challenging, especially in the setting of prior radiation as data suggests worse outcomes. Re-irradiation may reduce the risk of subsequent recurrence but is also associated with an increased toxicity, so an informed discussion is critical (63,99–104). As such, we evaluate the benefit of BT in recurrent STS (Table 5) (63,99–106).
Growing data supports the role of radiation therapy in the treatment of soft tissue sarcoma (STS). Brachytherapy has been used for decades in the management of STS and can be utilized as monotherapy or as a boost to external beam radiation. We present updated guidelines from the American Brachytherapy Society regarding the utilization of brachytherapy in the management of STS.
Members of the American Brachytherapy Society with expertise in STS and STS brachytherapy created an updated clinical practice guideline including step-by-step details for performing STS brachytherapy based on a literature review and clinical experience.
Brachytherapy monotherapy should be considered for lower-recurrence risk patients or after a local recurrence following previous external beam radiation; a brachytherapy boost can be considered in higher-risk patents meeting implant criteria. Multiple dose/fractionation regimens are available, with determination based on tumor location and treatment intent. Techniques to limit wound complications are based on the type of wound closure; wound complication can be mitigated with a delay in the start of brachytherapy with immediate wound closure or by utilizing a staged reconstruction technique, which allows an earlier treatment start with a delayed wound closure.
These updated guidelines provide clinicians with data on indications for STS brachytherapy as well as guidelines on how to perform and deliver high quality STS brachytherapy safely with minimal toxicity.
Sarcomas of Soft Tissue
2019, Abeloff’s Clinical Oncology
Soft tissue sarcomas (STS) comprise a group of relatively rare tumors with over 100 subtypes that have anatomically and histologically diverse properties. Molecularly, each subtype of sarcoma is distinct with individual subtypes, some of which contain translocations, while others demonstrate complex cytogenetics. There is an association between some sarcoma subtypes and genetic predisposition syndromes. The treatment of sarcomas requires multidisciplinary planning that not only is comprised of surgeons, radiotherapists and medical oncologists, but also a pathologist with extensive experience in the diagnosis of soft tissue tumors. This chapter will review management from diagnosis, to surgery and/or radiation, and the use of chemotherapy for the treatment of sarcoma. In addition, it will review the palliative use of chemotherapy and targeted agents in the metastatic setting with a focus on individual sarcoma subtypes. Finally, the data for the FDA approved agents for the treatment of sarcoma and their indications will be reviewed.
American Brachytherapy Society consensus statement for soft tissue sarcoma brachytherapy
2017, Brachytherapy
Radiation therapy represents an essential treatment option in the management of soft tissue sarcomas (STS). Brachytherapy represents an important subset of radiation therapy techniques used for STS, with evolving indications and applications. Therefore, the purpose of this guideline was to update clinicians regarding the data surrounding brachytherapy (BT) and provide recommendations for the utilization of BT in patients with STS.
Members of the American Brachytherapy Society with expertise in STS, and STS BT in particular, created an updated guideline for the use of BT in STS based on a literature review and clinical experience.
Guidelines are presented with respect to dose and fractionation and technical features to improve outcomes and potentially reduce the risk of toxicity. Brachytherapy as monotherapy can be considered in low-risk cases or in situations where re-irradiation is being considered. Brachytherapy boost can be considered in cases at higher risk of recurrence or where BT alone cannot adequately cover the target volume. To limit wound complications, the start of BT delivery should be delayed until final wound closure, or if after immediate reconstruction, started after postoperative Day 5.
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2016, Cancer/Radiotherapie
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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.

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Original contributionRole of brachytherapy in recurrent extremity sarcoma in patients treated with prior surgery and irradiation

Abstract

The principles and techniques of resection of soft part sarcomas

Surgery

The management of soft tissue sarcomas

Br. J. Surg.

Extremity soft tissue sarcomas

Pathology of soft tissue tumors

Brachytherapy treatment planning

Non-parametric observation from incomplete observation

J. Am. Stat. Assoc.

Original contribution
Role of brachytherapy in recurrent extremity sarcoma in patients treated with prior surgery and irradiation