Clinical investigation: soft tissue sarcoma
Preoperative vs. postoperative radiation therapy for soft tissue sarcoma: A retrospective comparative evaluation of disease outcome

https://doi.org/10.1016/S0360-3016(02)04510-8Get rights and content

Abstract

Purpose

Radiation (XRT) is a proven component in the treatment of soft tissue sarcoma. However, there is little evidence regarding the relative effectiveness of preoperative vs. postoperative XRT. This retrospective study addresses the relative effectiveness of disease control by these two treatment sequences.

Methods and materials

A total of 517 patients (246 treated with postoperative XRT, and 271 treated with preoperative XRT) with nonmetastatic sarcoma were evaluated for disease outcome and late complications using univariate and multivariate techniques.

Results

With a median follow-up of 6 years, overall local control was 81% and 78% at 5 and 10 years, respectively. Although local control appeared superior with preoperative XRT (83% at 10 years) compared with postoperative XRT (72%), multivariate analysis revealed that this difference could be entirely explained by the unequal distribution of prognostic factors between the two groups, and there was no evidence that treatment sequence independently determined local control. There were no differences in nodal or metastatic relapse between the two treatments, and disease-specific survival was not significantly different. There was a slightly higher incidence of late XRT-related complications among those treated with postoperative XRT (10-year incidence of 9% vs. 5%, p = 0.03).

Conclusions

This study found no evidence for differences in disease outcome attributable to the use of either pre- or postoperative XRT. There was a slight increase in long-term complications with postoperative XRT, likely due to the higher doses used in this sequence.

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.

Section snippets

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

References (28)

  • P.D Stefanovski et al.

    Prognostic factors in soft tissue sarcomasA study of 359 patients

    EJSO

    (2002)
  • H.D Suit et al.

    Treatment of the patient with stage M0 soft tissue sarcoma

    J Clin Oncol

    (1988)
  • H Suit et al.

    Preoperative radiation therapy for patients with sarcoma of the soft tissues

    Cancer Treat Res

    (1993)
  • H.D Suit et al.

    Role of radiation in the management of adult patient with sarcoma of soft tissue

    Semin Surg Oncol

    (1994)
  • Cited by (0)

    This study was supported in part by grant CA 06294 awarded by the National Cancer Institute, U.S. Department of Health and Human Services.

    View full text