International Journal of Radiation Oncology*Biology*Physics
Clinical investigation: soft tissue sarcomaPreoperative vs. postoperative radiation therapy for soft tissue sarcoma: A retrospective comparative evaluation of disease outcome☆
Introduction
Debate on the relative virtues and limitations of pre- vs. postoperative radiation therapy (XRT) for soft tissue sarcoma (STS) has continued for at least two decades. Much of this discussion has been theoretical and has tended to favor the use of preoperative XRT 1, 2, 3, 4, 5, 6. Data ostensibly supporting the use preoperative XRT include noncomparative reports of apparently favorable outcome following such treatment 1, 3, 6, 7, occasional favorable comparative reports (8), and reports that smaller, hence likely less toxic, XRT fields and doses can be used with preoperative XRT (9). Such data provide little concrete evidence for resolving the debate. There is at least one retrospective comparative report that found no significant difference in disease outcome between the two treatment sequences (10). Recently, a prospective randomized trial on pre- vs. postoperative XRT has been concluded, but it was designed to answer a toxicity question and as yet has insufficient follow-up for meaningful outcome comparisons (11). That study reported a significantly higher incidence of postsurgical wound complications in patients treated with preoperative XRT, compared with those treated with postoperative XRT—an observation also made in numerous retrospective reports 4, 5, 10, 12. It would seem to be established that such complications are significantly higher in the preoperative XRT setting. The issue of disease control remains unclear. To address this question, we retrospectively reviewed the relatively large experience at The University of Texas M. D. Anderson Cancer Center (MDACC) with these two strategies of XRT sequence.
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Methods and materials
A total of 1225 patients with nonmetastatic STS were treated with conservation surgery (SRG) and XRT at MDACC between 1960 and 1999. Desmoids, cystosarcomas, angiosarcomas, dermatofibrosarcomas, and Kaposi’s sarcoma were not included. The overall outcome and prognostic factors for this cohort have been reported (13). The sequencing of SRG and XRT was determined by the surgical procedure immediately preceding referral and by preferences among the sarcoma treatment team. During the 1960s and
Patient and tumor characteristics
There were 293 females and 224 males. Age ranged 2–85 years with a median of 49 years. Twenty-seven patients were ≤17 years old. Histopathologic subtypes were: MFH, 194 (38%); liposarcoma, 75 (15%); synovial sarcoma, 45 (9%); leiomyosarcoma, 32 (6%); neurogenic sarcoma, 30 (6%); rhabdomyosarcoma, 30 (6%); fibrosarcoma, 15 (3%); unclassified sarcoma, 69 (13%); and other, 27 (5%). Tumors in the “other” category were epithelioid sarcoma (8), chondrosarcoma (5), clear cell sarcoma (3),
Discussion
Although our study is open to all the criticisms appropriate of a retrospective review, we took into consideration a large number of well-documented prognostic factors for various endpoints in STS 13, 23, 24, 25, 26, 27. Moreover, we excluded patients who presented to our institution with grossly resected tumor, because the use of reexcision was not uniform and may have biased the results. Failure to use all available prognostic factors in multivariate analysis might well have resulted in
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This study was supported in part by grant CA 06294 awarded by the National Cancer Institute, U.S. Department of Health and Human Services.