Radiotherapy for Soft Tissue Sarcomas after Isolated Limb Perfusion and Surgical Resection: Essential for Local Control in All Patients?

Abstract

BackgroundStandard treatment for localized soft tissue sarcoma (STS) is resection plus adjuvant radiotherapy (RTx). In approximately 10% of cases, resection would cause severe loss of function or even require amputation because of the extent of disease. Isolated limb perfusion (ILP) with tumor necrosis factor alpha (TNF-α) and melphalan can achieve regression of the tumor, facilitating limb-saving resection. RTx improves local control but may lead to increased morbidity.MethodsIn our database of over 500 ILPs, 122 patients with unifocal STS were treated by ILP followed by limb-sparing surgery. All included patients were candidates for amputation.ResultsSurgery resulted in 69 R0 resections (57%), and in 53 specimens (43%) resection margins contained microscopic evidence of tumor (R1). Histopathological examination revealed >50% ILP-induced tumor necrosis in 59 cases (48%). RTx was administered in 73 patients (60%). Local recurrence rate was 21% after median follow-up of 31 months (2–182 months). Recurrence was significantly less in patients with >50% ILP-induced necrosis versus ≤50% necrosis (7% vs. 33%, P = 0.001). A similar significant correlation was observed for R0 versus R1 resections (15% vs. 28%, P = 0.04). In 36 patients with R0 resection and >50% necrosis, of whom 21 were spared RTx, no recurrences were observed during follow-up.ConclusionsIn patients with locally advanced primary STS, treated with ILP followed by R0 resection, and with >50% ILP-induced necrosis in the resected specimen, RTx is of no further benefit.

Treatment modifications in tumour necrosis factor-α (TNF)-based isolated limb perfusion in patients with advanced extremity soft tissue sarcomas

“…This means that even the demonstrated reduced pathological response rate in the low-dose era, has no clinical impact. We previously demonstrated that local recurrences did not occur in patients who underwent TM-ILP followed by R0 resection and had more than 50% necrosis in resection specimen, regardless of administration of adjuvant radiotherapy [21,22]. Therefore, we suggested that this particular group can be spared adjuvant radiotherapy.…”

The pathologic response of resected synovial sarcomas to hyperthermic isolated limb perfusion with melphalan and TNF-α: a comparison with the whole group of resected soft tissue sarcomas

“…Even after TM-HILP, the margin size and quality is generally poor [40]. However, we have previously demonstrated that local tumor control after TM-HILP and resection is superior compared with nonpretreated STSs, most probably due to the strong toxic effects of TM-HILP on the tumor periphery [3,40]. …”

Preclinical Validation of the Utility of BLZ-100 in Providing Fluorescence Contrast for Imaging Spontaneous Solid Tumors

“…Improvement in intraoperative tumor visualization would benefit any solid tumor resection, as it would enable surgeons to better determine the extent of local invasion or regional tumor spread. Helping determine which patients are candidates for sphincter-sparing surgery in colorectal cancer [11], for neurovascular bundle preservation in radical prostatectomy [12], or who would respond well to limb-sparing approaches for soft tissue sarcoma [13], are just a few examples of how intraoperative visualization of cancer tissue would be helpful in making surgical decisions.…”