Abstract
Soft tissue sarcomas are uncommon tumours of mesenchymal origin, most commonly arising in the extremities. Treatment includes surgical resection in combination with radiotherapy. Resection margins are of paramount importance in surgical treatment of soft tissue sarcomas but unambiguous guidelines for ideal margins of resection are still missing as is an uniform guideline on the use of radiotherapy.The present paper reviews the literature on soft tissue sarcomas of the extremities regarding the required resection margins, the impact of new radiotherapy techniques and the timing of radiotherapy, more particularly if it should be administered before or after surgical resection.This review was started by searching guidelines in different databases (National Guideline Clearinghouse, EBMPracticeNet, TRIP database, NCCN guidelines,…). After refinement of the query, more specific articles were found using MEDLINE, PubMed, Web of Science and Google Scholar. Used keywords include “soft tissue sarcoma”; “extremities OR limbs”; “radiotherapy”, “surgery”, “margins”, “local recurrence” and “overall survival”. Finally, the articles were selected based on the accessibility of the full text, use of the English language and relevance based on title and abstract.Literature demonstrates positive resection margins to be an important adverse prognostic factor for local recurrence of soft tissue sarcomas of the extremities. Still, no consensus is reached on the definition of what a good margin might be. The evolution of new radiation techniques, especially Intensity Modulated Radiotherapy, resulted in a s healthy surrounding tissues. However, the timing of radiotherapy treatment remains controversial as both preoperative and postoperative radiotherapy are characterised by several advantages and disadvantages.
Highlights
Surgery Different studies have highlighted the importance of adverse prognostic factors in the outcome of patients with Extremity soft tissue sarcomas (ESTS)
A radical excision is the resection of a full compartment, a wide excision is an excision of the tumour with a rim of normal tissue around it and a marginal excision is one where the resection margins go through the reactive zone
Using the American Joint Committee on Cancer (AJCC) staging system the National Comprehensive Cancer Network (NCCN) guidelines recommend to proceed as follows: Stage I Stage I Soft tissue sarcomas (STS) should be treated with surgery to obtain adequate surgical margins
Summary
Soft tissue sarcomas (STS) are relatively uncommon tumours, representing 1 % of adult and 7–15 % of paediatric malignancies [1]. Pisters et al found similar results while comparing surgery plus adjuvant brachytherapy with surgery alone [7] They found adjuvant brachytherapy to improve local control after complete resection of STS. A reduced occurrence of local recurrence in patients with high-grade lesions was not associated with a significant reduction in distant metastasis or improvement in disease-specific survival. The use of new radiation techniques e.g. intensity modulated radiotherapy (IMRT) has improved QOL and dose localizations, increasing local control and disease-free survival. High grade STS who are at considerable risk for recurrence and metastasis, may benefit from adjuvant chemotherapy [12]. A study of Mahmoud et al supports the use of neoadjuvant chemotherapy followed by limb-sparing surgery and adjuvant RT for local failure reduction with a trend toward improved disease free survival [13]. For radiotherapy the focus will mainly be on the IMRT technique and on the differences between preoperative versus postoperative radiotherapy
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