Brachytherapy In Soft Tissue Sarcoma Research Articles

Adjuvant Low Dose-Rate vs. High Dose-Rate Brachytherapy for Soft Tissue Sarcomas: Analysis of Treatment Outcomes and Factors Predictive of Wound Healing Complications

Adjuvant Low Dose-Rate vs. High Dose-Rate Brachytherapy for Soft Tissue Sarcomas: Analysis of Treatment Outcomes and Factors Predictive of Wound Healing Complications

Perioperative high-dose-rate brachytherapy in soft tissue sarcomas of the extremity and superficial trunk in adults: Initial results of a pilot study

Purpose This study was undertaken to determine the feasibility of perioperative high-dose-rate brachytherapy (PHDRB) as an alternative to standard low-dose-rate brachytherapy in adult patients with soft tissue sarcomas. Methods and materials Twenty-five adult patients with soft tissue sarcomas of the extremities or the superficial trunk were treated with surgical resection and PHDRB (16, 24, or 32 Gy) for negative, close/microscopically positive, or grossly involved surgical resection margins, respectively. External beam radiation therapy (45 Gy) was added postoperatively. Adjuvant chemotherapy with ifosfamide and doxorubicin was given to patients with high-grade tumors. Results Resection margins were negative in 6 patients (24.0%), close/microscopically positive in 18 (72.0%), and grossly involved in 1 (4.0%). One patient (4.0%) with wound dehiscence needed reoperation. Three patients failed in the anatomical region treated, but relapse sites were not adjacent to the area treated with PHDRB. After a median followup of 23.2 months (range 2.8–48.0), the 4-year local and regional control rates were 100% and 80.5%, respectively. Four-year overall survival was 78.2%. Conclusions Locoregional control and survival results are encouraging for this high-risk patient population. PHDRB results seem to be similar to those obtained with low-dose-rate brachytherapy.

A single institution experience with interstitial brachytherapy for soft tissue sarcoma of the extremities

9058 Background: Soft tissue sarcomas (STS) are a rare, histologically diverse group of malignancies which are primarily treated with surgery. Depending on location and grade radiation therapy may be used as adjuvant treatment. In this single institution, retrospective series we examine treatment outcome for STS of the extremity treated with surgery and adjuvant interstitial brachytherapy (BTX). Methods: 21 patients were treated from 9/97 to 5/03 with adjuvant BTX for primary or recurrent STS. 14 patients were treated for primary and 7 for recurrent disease. Histologic subtypes included MFH, liposarcoma, synovial sarcoma, leiomyosarcoma, myxofibrosarcoma, and malignant peripheral nerve sheath sarcoma. 8 patients had low grade and 13 had high grade tumors. The majority of patients had lesions larger than 5 cm. 11 had T2b disease, 6 had T1b disease, 3 had T1a disease and 1 had T2a disease. The median age at presentation for BTX treatment was 45. Patients with low grade tumors received 2500 cGy with BTX, followed by 4500 cGy with external beam radiation therapy (EBRT). High grade tumors were treated with BTX alone to 4500 cGy if they were considered resectable at the time of diagnosis. If there was concern about resectability they received 4500 cGy of EBRT pre-operatively, followed by a 2500 cGy BTX boost. Results: Median follow-up was 21 months. 20 patients were known to be alive at last follow-up. One patient died of a metachronous primary STS. None of the patients with low grade tumors were known to have experienced local recurrence (LR). Of the 13 patients with high grade tumors 11 had no LR and 2 experienced LR. One of these patients had experienced 3 recurrences prior to treatment with BTX and the other recurred after 57 months of follow-up. The freedom from local recurrence rate (FFLR) for low grade disease was 100% and for high grade disease 85%. Overall FFLR was 93%. One patient developed a foot drop post treatment which could possibly have been related to BTX. No other functional deficits have occurred. Conclusions: Interstitial BTX appeared to improve local control in both patients with low grade and high grade STS of the extremity. No significant financial relationships to disclose.

A single institution experience with interstitial brachytherapy for soft tissue sarcoma of the extremities

9058 Background: Soft tissue sarcomas (STS) are a rare, histologically diverse group of malignancies which are primarily treated with surgery. Depending on location and grade radiation therapy may ...

83 poster dis Pulsed dose rate (PDR) intraoperative brachytherapy in soft tissue sarcomas : a retrospective study of 30 patients

83 poster dis Pulsed dose rate (PDR) intraoperative brachytherapy in soft tissue sarcomas : a retrospective study of 30 patients

123 oral Low dose rate intraoperative brachytherapy in soft tissue sarcomas involving neurovascular structures

123 oral Low dose rate intraoperative brachytherapy in soft tissue sarcomas involving neurovascular structures

Current results of brachytherapy for soft tissue sarcoma.

Perioperative brachytherapy results in a better local control rate than surgery alone for extremity soft tissue sarcoma. Brachytherapy enables the delivery of a high radiation dose to a limited volume of tissue, allows the reduction of radiation treatment time, enables direct visualization of the tumor bed and surrounding critical structures, and costs less than external beam radiotherapy. The literature seems to regard the effectiveness of brachytherapy as comparable to that of external beam radiotherapy, and the side effect profile is acceptable. Traditional low-dose-rate brachytherapy methods require extended periods of patient isolation, but recent technologic advances may obviate this necessity. Newer high-dose-rate (HDR) brachytherapy delivery methods allow for the fractionation of radiation delivery and outpatient treatment in some cases. Furthermore, with HDR brachytherapy, the radiation dose distribution can be tailored around critical anatomic structures. Although the application of HDR brachytherapy to soft tissue sarcoma is relatively new, it seems to result in a satisfactory local control rate and may replace traditional low-dose-rate techniques.

Long-term morbidity in children treated with fractionated high-dose-rate brachytherapy for soft tissue sarcomas.

The purpose of this study was to determine the long-term local control, disease-free survival, and morbidity of fractionated high-dose-rate brachytherapy (F-HDR) in infants and children with soft tissue sarcomas. Fifteen children (13 girls and 2 boys, ages 5-101 months) with soft tissue sarcomas were treated with chemotherapy, organ-preserving surgery, and F-HDR (36 Gy in 12 fractions) to post-chemotherapy volumes. External beam radiotherapy was not part of the primary treatment, although four patients (27%) subsequently received salvage external beam radiotherapy after treatment failure. Chemotherapy was administered to all patients based on their tumor histology and stage. After a median follow-up of 10 years (range 32-154 months), 12 patients (80%) were alive without evidence of disease. Ten-year overall survival and local control rates were both 80% (12/15 children). The overall survival was better (91%) for children with microscopic residual versus gross residual disease (75%). With longer follow-up, grade 3 to 4 brachytherapy-related late morbidities increased from 8% (1/12) to 20% (3/15) and included trismus/osteonecrosis, vaginal stenosis, and periurethral fibrosis. There were two late complications associated with puberty that occurred 8 to 10 years after the initial treatments. Acute toxicity occurred in five patients (38%) and consisted primarily of grade 1 to 3 skin and mucosal reactions. As the sole radiation modality, F-HDR achieved excellent local control and disease-free survival in properly selected children with soft tissue sarcomas while preserving normal bone and organ development. A significant percentage of patients experience adverse late sequelae as a result of this treatment.

Brachytherapy in soft tissue sarcomas

Soft tissue sarcomas are rare tumors with a high risk or local recurrence and a risk of distant metastases. Standard treatment advocated is the combination of conservative resection and external radiotherapy. Brachytherapy is an integrated part of the multidisciplinary treatment. Brachytherapy can increase local control with good functional results. Primary exclusive brachytherapy has been used and is effective and safe in high grade sarcomas (randomized trial of MSKCC). Brachytherapy seems to be important as part of the treatment of central localization (shoulder, groin) and sarcomas with positive resection margins, but its relation with external radiotherapy has to be defined. Brachytherapy used with special guidelines allows to obtain an improved local control with an acceptable level of complication.

93 poster Interstitial brachytherapy in soft-tissue sarcomas; experience with 31 patients

93 poster Interstitial brachytherapy in soft-tissue sarcomas; experience with 31 patients

High dose rate interstitial brachytherapy in soft tissue sarcoma: technical aspects and results.

Radiation is essential for function preservation in the management of soft tissue sarcoma (STS). One of the advantages of brachytherapy is that it allows for specific localization of radiation dose to the tumor bed. We examined the results of our clinical experiences with immediate postoperative high dose rate (HDR) brachytherapy and external beam radiation treatment (EBRT) for STS. A total of 17 patients (11 primary and six recurrent) between 1995 and 1999 were included in this review. The inclusion criteria for HDR and EBRT were as follows: (1) high-grade tumor, (2) low-grade tumor of > or = 10 cm, (3) recurrent tumor, (4) tumor abutting or invading critical structures and (5) positive margin. The catheters (six French) were placed parallel to the long axis of the tumor with a 1-1.5 cm spacing in between. If necessary, muscle or gel-foam was placed over the critical structures to maintain a minimum space of 0.5 cm from the catheters. On postoperative day 6, patients received HDR (2-3 Gy/fraction x6, twice daily). Three weeks later, patients received EBRT (total 36-60 Gy). The follow-up duration was between 13 and 60 months (median 31 months). There was no local failure within the radiation field in any of the patients. One patient required wound revision for delayed healing after brachytherapy. During EBRT, most patients experienced only mild erythema (grade 1 or 2 skin reaction). In long-term follow-up, there were no patients with neuropathy or significant fibrosis. Our results suggest that immediate postoperative HDR with a total dose of 12-18 Gy over 3 days is an effective treatment combined with EBRT in the management of STS.

Morbidity of adjuvant brachytherapy in soft tissue sarcoma of the extremity and superficial trunk

Purpose: We have previously shown that adjuvant brachytherapy (BRT) improves local control in soft tissue sarcoma (STS) of the extremity and superficial trunk. A detailed assessment of the morbidity of this approach has not been examined. The purpose of this study was to evaluate the toxicity associated with adjuvant BRT in terms of wound complications, bone fracture, and peripheral nerve damage. Methods and Materials: Between July 1982 and June 1992, 164 adult patients with STS of the extremity or superficial trunk were randomized intraoperatively to receive or not to receive BRT after complete resection. BRT was delivered with 192Ir to a total dose of 42–45 Gy. The BRT and no-BRT arms were balanced with regard to age, sex, presentation (primary vs. recurrent), site, grade, size, and depth. Morbidity was assessed in terms of significant wound complication, bone fracture, and peripheral nerve damage (grade ≥ 3). The significant wound complications were defined as those wound problems requiring operative revision for coverage or threatened limb loss, persistent seroma requiring repeated aspirations and/or drainage, wound separation > 2 cm, hematoma > 25 ml, and/or purulent wound discharge. The median follow-up was 100 months. Results: The significant wound complication rate was 24% in the BRT group and 14% in the no-BRT group, ( p = 0.13). The rate of wound reoperation, however, was significantly higher in the BRT arm (10% vs. 0%; p = 0.006). Examination of other covariables that may have contributed to wound reoperation revealed the width of the excised skin (WES) to be a significant factor [1% (WES ≤ 4 cm) vs. 10% (WES > 4 cm), p = 0.02]. Bone fracture only occurred in patients receiving BRT (n = 3, 4%), although this was not statistically significant ( p = 0.2). The rate of peripheral nerve damage, however, was similar in both arms (7% vs. 7%). Conclusion: The overall morbidity associated with adjuvant BRT was not significantly higher than that with surgery alone. However, BRT and WES > 4 cm were associated with significantly higher wound reoperation rate. This has significant implications for strategies designed to maximize wound coverage in patients who receive BRT.

174 Morbidity and long term results of adjuvant brachytherapy in soft tissue sarcoma: A prospective randomized trial

174 Morbidity and long term results of adjuvant brachytherapy in soft tissue sarcoma: A prospective randomized trial

13 Low dose rate intraoperative brachytherapy in soft tissue sarcomas

13 Low dose rate intraoperative brachytherapy in soft tissue sarcomas

Brachytherapy for soft tissue sarcomas.

In this chapter we focus on the use of brachytherapy for soft tissue sarcoma. It is recognized that external-beam radiation therapy has been the traditional radiation approach to these tumors. However, emerging retrospective and prospective data have shown the value of the brachytherapy approach. We review soft tissue sarcoma of the extremity and superficial trunk, and also of the retroperitoneum. We also review the implant technique, retrospective data, our prospective trial, and our current practice at the Memorial Sloan-Kettering Cancer Center (MSKCC).

12 Low dose-rate intra-operative brachytherapy for soft tissue sarcomas: 85 cases report

12 Low dose-rate intra-operative brachytherapy for soft tissue sarcomas: 85 cases report

11 Institut Gustave-Roussy experience with intraoperative interstitial low dose rate (LDR) brachytherapy in soft tissue sarcomas

11 Institut Gustave-Roussy experience with intraoperative interstitial low dose rate (LDR) brachytherapy in soft tissue sarcomas

70 Daily versus twice-daily fractionation for high dose-rate afterloading brachytherapy in soft-tissue sarcoma

70 Daily versus twice-daily fractionation for high dose-rate afterloading brachytherapy in soft-tissue sarcoma

Comparison of charges related to radiotherapy for soft-tissue sarcomas treated by preoperative external-beam irradiation versus interstitial implantation

We compared treatment-related charges associated with external beam irradiation and interstitial implantation for soft-tissue sarcoma of the extremity. Charges related to radiotherapy in 35 patients with soft-tissue sarcoma of the extremity were reviewed. Preoperative external beam irradiation (EB) delivering 50 Gy in 25 fractions with 6 MV photons was administered to 12 of the patients evaluated. The remaining 23 patients were treated with interstitial implantation (IR) as the only radiotherapeutic intervention. The anatomic distribution of the sarcomas treated by IR included 14 lower-extremity (LE) and nine upper-extremity (UE) lesions. The average length of iridium wire used for IR was 78 cm. Because LE lesions tend to be larger, the average length equaled 109.5 cm as compared with the 47 cm for UE implants. The radiotherapeutic approach represented the only difference in treatment-related charges because the operative procedure of wide local excision was performed in each group. No difference in perioperative complications was observed between the two treatment approaches. Charges were stratified according to hospital-based and professional services. Radiotherapy-based hospital charges for the administration of EB averaged $6,515 compared with $4,050 for IR (p < 0.0001). Professional services also were significantly different, totaling $4,390 for EB and $3,240 for IR (p < 0.0001). The total of these charges for radiotherapy procedures and professional fees equaled $10,905 for EB compared with $7,290 for IR (p < 0.0001). Incorporating the necessary operating-room time for implant placement ($750) and five additional hospital days ($1,800), the costs associated with IR totaled $9,840; using chi-square analysis, the cost for IR remained significantly (p < 0.0001) less expensive than the $10,905 associated with EB. Because a large component of the radiotherapy cost for IR is related to the length of iridium 192 wire required, charges were stratified according to the location of the tumor. The total charge for IR of the UE equaled $9,345 compared with $10,335 for LE implants. Chi-square comparison for both UE and LE implants continued to show significant differences (p < 0.0001) when related to EB therapy. Cost-analysis comparison of brachytherapy versus external beam irradiation found lower charges for patients undergoing adjuvant irradiation with brachytherapy for soft-tissue sarcoma. To optimize the cost-benefit ratio, prospective studies are necessary to define the application of these radiotherapeutic approaches based on clinical criteria.

Long-term results of a prospective randomized trial of adjuvant brachytherapy in the management of completely resected soft tissue sarcomas of the extremity and superficial trunk

Purpose : A prospective randomized trial evaluating adjuvant brachytherapy for soft tissue sarcomas was conducted between July 1982 and July 1987. Methods and Materials : One hundred twenty-six patients with soft tissue sarcoma of the extremity or superfacial trunk (STS) underwent grossly complete resection with limb-sparing surgery. Intra-operatively, patients were randomized to receive either adjuvant brachytherapy (BRT) or no further therapy (no BRT). BRT consisted of an Iridium-192 implant which delivered 4200–4500 cGy over 4–6 days. Total hospital stay for combined surgery and BRT was 10–14 days. Patients in each group were well matched with respect to age, sex, site, tumor size, depth, histologic type, and grade. Median follow-up is 665 months for all living patients. Results : At 5 years, local control was 82% in the BRT group vs. 67% in the no BRT group ( p = .049). When analyzed by histologic grade, high grade tumors had local control of 90% with BRT vs. 65% with no BRT ( p = .013). There was no difference in local control in the low grade patients in either arm. At 5 years, the proportion free of distant metastases was approximately 76% in both arms, with no difference between BRT and no BRT. When analyzed by grade, high grade patients had a similar proportion free of distant metastasis in the BRT vs. no BRT arms despite improved local control in those receiving BRT. Similarly, the disease-specific survival for all patients at 5 years was 81% for BRT vs. 80% for no BRT ( p = NS). When analyzed by grade, and treatment (BRT vs. no BRT), 5-year disease-specific survival for high grade was the same in both groups. Conclusions : Adjuvant BRT significantly improves local control in completely resected STS. This improvement is confined to patients with high grade histology. BRT provides excellent local control in this group, and significantly shortens the treatment time when compared to adjuvant external beam radiation. However, the improved local control does not translate into either decreased distant metastasis or increased disease-specific survival.