PREOPERATIVE HYPOFRACTIONED RADIOTHERAPY IN LOCALIZED EXTREMITY/TRUNK WALL SOFT TISSUE SARCOMAS: EARLY STUDY RESULTS

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PREOPERATIVE HYPOFRACTIONED RADIOTHERAPY IN
LOCALIZED EXTREMITY/TRUNK WALLSOFT TISSUE
SARCOMASEARLY STUDY RESULTS
Hanna Kosela Milena Kolodziejczyk Tadeusz
Morysinski Wirginiusz Dziewirski
Marcin Zdzienicki Piotr Rutkowski Department of
Soft Tissue/Bone Sarcoma and Melanoma,
Department of Radiotherapy Maria
Sklodowska-Curie Memorial Cancer Center and
Institute of Oncology Warsaw, Poland
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Background

• Primary treatment of majority of localized soft
  tissue sarcoma is surgical resection of the tumor
  with adequate margins combined with radiotherapy
• Using radiotherapy in the local setting increases
  local control of the disease (with suggested
  survival benefit for patients with high grade
  tumors)
• Koshy M,  et al. . Improved survival with
  radiation therapy in high-grade soft tissue
  sarcomas of the extremities a SEER analysis. Int
  J Radiat Oncol Biol Phys. 2010 May 177(1)203-9

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Background preoperative radiotherapy vs
postoperative setting
Benefits Drawbacks
Lower doses and smaller treatment field size Possible improvement in tumor resectability Smaller incidence in long term radiation- related complications Increased risk of wound complications
No differences in local recurrence rate,
regional and distant failure rates O'Sullivan
B, et al. . Preoperative versus postoperative
radiotherapy in soft-tissue sarcoma of the limbs
a randomised trial.2002 Jun 29359(9325)2235-41.
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Background

• Can we shorten the overall treatment time by
  using hypofractionated radiotherapy and immediate
  surgery in STS as in rectal carcinoma?
• Potential benefits
• Lower risk of tumor clonogens repopulation
• Convenience
• Lower cost
• Radiobiological rationale low a/ß ratio -0,5-5
  Gy
• Gunderson LL, Tepper JE. Clinical Radiation
  Oncology. London, UK ChurchillLivingstone 2007

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AIM OF THIS PILOT STUDY

• Incidence of late complicatons and local
  recurrences compared to those observed after
  conventionally fractionated preoperative
  radiotherapy.
• Overall survival

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Patients and methods
In the years 2006-2010, 262 patients received 5x5
Gy according to uniform internal preoperative
protocol and underwent tumor resection within a
consecutive week. In our analysis we included
only patients with diagnosis of localized,
resectable soft tissue sarcoma of the extremities
or trunk wall (confirmed pathologically) primary
or recurrent deep seated and/or
intermediate/high grade
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Patients and methods

• 225 patients
• 122 (54) women, 103 (46) men
• Median age 54 years (range 18-82)
• Median follow up 34 months (range 1-80)
• Bioethical committee approval

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Patients and methods

• 140 patients (62.2)- primary tumors
• 75 patients (33) clinical local recurrence
  after previous surgery in another center
• 10 patients (4.4)- after non-radical surgery in
  another center, but without clinical recurrence
  (scar)
• 56 (24.9) patients received preoperative
  chemotherapy
• 75 of these patients had high grade tumors (G3)

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Patients and methods
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Patients and methods
Synovial sarcoma
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Patients and methods
16 patients had also postoperative radiotherapy
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Results

• 51 (22.6) patients were dead at the time of
  analysis
• 93 (41.3) recurrences of the disease
• 46 - local recurrence (20 local recurrence
  80 local control rate) - in 10 patients after
  local recurrence amputation was performed
• 78 (34.7)- distant metastases
• 31 (13.8) patients had local and distant
  recurrence of the disease

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70
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80
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Factors influencing survival (univariate analysis)

• OS
• Tumor size (p 0.05)
• Tumor grade (p 0.0002)
• LRFS
• - Tumor grade (p 0.007)

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p0.05
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80
60
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75
57
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Complications of the treatment
97 patients (43) had postoperative wound
complications including 9 patients (4) who
required an additional surgical procedure 33.6
of patients with complications received
preoperative chemotherapy 87 patients with
wound complications (89.6) had tumor localized
on the lower limb
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Early local complications

• 38 (16.9) patients had prolonged healing of the
  wound (gt1 month)
• 28 (12.4) patients had wound dehiscence
• 9 (4) patients required prolonged punctures of
  the collecting lymph fluid
• 6 (2.7) patients had an increased acute skin
  toxicity

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Late complications

• 2 (0.8) patients severe fibrosis leading to
  contracture of the limb
• 24 (10.7) patients prolonged edema of the
  operated limb
• 6 (2.7) patients - fracture of the treated limb
  (median time from treatment to fracture 18 months)

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Discussion
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Discussion
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Conclusions

• Local control rates an overall survival similar
  to those seen in patients treated with
  preoperative radiotherapy conventionally
  fractionated
• Our series comprises majority of high risk
  patients with large high grade tumors
• Wound complication - quite high rate of early
  complications but low percentage of severe
  complications
• Late complications - similar to those seen in
  patients treated with preoperative radiotherapy
  conventionally fractionated

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Clinical trial? Short-course preoperative
radiotherapy vs conventional radiotherapy
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ACKNOWLEDGEMENTS

• Cancer Center Institute Warsaw
• K. Wiater, S. Falkowski, A. Klimczak, T. Switaj,
  K. Ptaszynski,
• U. Grzesiakowska, E. Bylina,
• A, Gluszcz,
• Our patients and their families

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Cancer Center, Warsaw, Poland
Thank you for your attention!