Adjuvant R adiotherapy

Abstract

We thank the authors for their excellent review article. However, it is only of limited value in terms of an oncologically correct approach for specialist physicians in private practice. The authors describe in their article that after magnetic resonance tomography-aided planning, a primary R0 situation can mostly be achieved and reconstruction can be performed simultaneously. According to what we know, in case of high-grade sarcomas that are located deep within the tissue, even maximum planning and using microsurgical methods, positive resection margins cannot be avoided with any degree of certainty unless one is willing to accept primarily functional damage. Especially where the tumor has infiltrated large nerves or blood vessels, adjuvant measures should be taken to enable local control. We are surprised that extensive reconstruction is performed before the histopathological results have become available. This does not seem helpful, especially with regard to morbidity associated with the harvesting of flap grafts. Liberal use of radiotherapy in high-grade sarcomas and R2 resected low-grade sarcomas can be recommended. In a Scandinavian cohort of patients with 1093 soft-tissue sarcomas, additional adjuvant/additive radiotherapy in high-grade sarcomas resulted in an improved local control rate, for any combination of location and resection status. Even patients with marginal or R2 resected subfascial low-grade sarcomas benefited from radiotherapy (1). In the meantime, two large epidemiological studies have been published that show a survival advantage due to adjuvant radiotherapy. In the analysis of 8249 sarcoma patients, surgery and radiotherapy were the therapeutic modalities that improved the survival rate significantly, independently of one another (2). This was not found for chemotherapy (2). The publication on chemotherapy with hyperthermia, which is now available as a full-text publication, did not show any advantage for soft-tissue sarcomas of the extremities (disease-free survival and overall survival) (3). In conclusion: Each patient with an unspecified soft-tissue tumor that cannot be declared a lipoma with complete certainty should be referred for diagnostic evaluation and further treatment to a center or a surgeon with experience in oncological orthopedic surgery.