21例软组织肉瘤局部复发的治疗

目的探讨复发软组织肉瘤的治疗方案。方法分析宁德市医院放疗科1999至2007年收治的局部复发软组织肉瘤患者21例的治疗情况并复习有关文献。结果 21例复发患者再次行扩大切除术,术后辅以放疗,放疗剂量DT66～70Gy,预后良好,随访无复发。结论复发软组织肉瘤患者行再次扩大切除后辅以术后放疗是较好的治疗方法。     

软组织肉瘤的放射治疗

放疗是软组织肉瘤重要治疗手段之一,术前或术后放疗可降低肿瘤局部复发风险,局部扩大切除结合术前或术后放疗能达到与截肢术同等的长期生存率并且保存肢体功能,近些年来随着放疗技术的进步,软组织肉瘤放疗的正常组织损伤风险正在减少。     

骨和软组织肉瘤的术前局部化疗和快速分割放疗

骨和软组织肉瘤的治疗,常采用根治性的外科切除术,包括截肢。但对一些病例,特别是低分化肉瘤.术后复发率也可达10～25％。 Morton和Eilber首先提出了一种术前治疗的方法,即动脉内局部化疗加快速分割的放疗。对Ⅲ期肉瘤或已有局部复发的患者,治疗也获得了成功。 本文对30名骨和软组织肉瘤的患者,进行此法治疗.患者都是Ⅲ期的低分化肉瘤或靠近大血管、骨骼和神经的大肉瘤,按常规需要截肢的;还包括有局部复发和有局限性肺转移适合切除者。     

软组织肉瘤术后放射治疗

目的探讨软组织肉瘤术后放射治疗疗效。方法对软组织肉瘤８０例，按治疗方式分为两组：一组为保守手术，术后给于放射治疗，靶区剂量为６０００～７５００ｃＧｙ；另一组为扩大切除术，术后不行放疗。对两组疗效进行对比研究。结果保守手术加术后放疗组５年和１０年生存率分别为６７％和４５％；扩大手术组分别为５２％和３５％。经统计学处理无明显差异。结论软组织肉瘤保守手术加放射治疗，既不降低生存率，又保持了肢体器官的功能。     

42例复发性软组织肉瘤治疗分析

目的探讨软组织肉瘤术后复发原因及治疗问题。方法回顾性分析了４２例软组织肉瘤术后复发的病例，分析了首次手术方式与复发时间的关系及综合治疗与单纯手术疗效间的差异。结果首次手术方式为肿瘤切除术者３１例，扩大切除术者１１例，半年内局部复发率前者显著高于后者（８０６％和２７３％，Ｐ＜００５）。４２例全部再次行扩大切除术，其中手术加放疗、化疗２９例，单纯手术１３例，３年的局部未复发率，前者较后者显著提高（８２８％和５３８％，Ｐ＜００５）。结论软组织肉瘤治疗的效果取决于首次治疗的正确性和彻底性。扩大手术辅以放疗、化疗可延缓局部复发时间。     

快中子放射治疗软组织肉瘤55例

[目的]观察快中子加光子混合射线放射治疗软组织肉瘤的临床疗效。[方法]19例软组织肉瘤患者接受快中子及光子根治性放射治疗（根治放疗组），36例为术后放疗（术后放疔组）。光子照射剂量为40～50Gy，快中子照射剂量为8～12Gv。[结果]放疗结束后根治性放疗组3年、5年、8年生存率分别为47．4％，36．8％及26．3％；术后放疗组分别为86．1％、69．6％及27．3％。放疗后所有患者均未出现严重并发症。[结论]快中子术后放疗是治疗软组织肉瘤的有效手段。     

纤维肉瘤的术后放射治疗

1982年8月至1985年8月,我院采用手术加放射治疗软组织纤维肉瘤16例。广泛切除11例,局部切除5例。均用~(60)Co外照射,设野包括原发肿瘤床及周围肌群,总剂量达到64～70 Gy/6～7周。3、5、7年生存率分别为81.3％、62.5％及50.0％。5年局部复发率18.0％,远处转移率25.0％。根据软组织肉瘤的生物学特性,实行广泛切除加放疗、化疗的综合治疗是提高生存率的重要手段。     

术中置管联合高剂量率近距离放疗治疗11例软组织肉瘤

目的：观察术中置管联合高剂量率近距离放疗软组织肉瘤的毒副作用及近期疗效.方法：对11例软组织肉瘤应用高剂量率近距离放疗进行治疗.术中广泛切除肿瘤后,在瘤床放置后装管.术后第3至5天开始高剂量近距离放疗,每次剂量为200cGy,每天2次,连续5天,待伤口愈合后,再追加外照射40～50 Gy.结果：10例患者无局部复发,1例局部复发,其中1例因远处转移而死亡.各例均无明显毒副反应.结论：高剂量率近距离放疗治疗软组织肉瘤是安全易行的,并取得较好的局部控制率.在治疗软组织肉瘤方面将有可能显示出良好的应用前景.     

软组织肉瘤治疗进展

约占全部恶性肿瘤1%的软组织肉瘤,由于术后易于局部复发及远处转移而致治疗失败,预后较差。近年来,随着对其生物学行为认识的深入及放疗技术的改进、新的化疗药物的问世等,综合治疗软组织肉瘤已趋定向,其预后大为改善。本文就软组织肉瘤手术治疗、放疗、化疗及综合治疗的现状予以综述。一、手术治疗由于软组织肉瘤可发生在机体任何部位,没有固定的解剖位置,故不可能有象乳腺癌、直肠癌等经典的根治术式。常用的术式有:(1)单纯肿瘤摘除术;(2)局部扩大切除术,(3)根治性局部切除术;(4)截肢     

90例软组织肉瘤术后放疗临床分析

目的回顾分析软组织肉瘤术后放射治疗的疗效。方法１９８８年５月～１９９５年５月间收治９０例软组织肉瘤（多次术后复发４０例,首次术后复发５０例）,全部用６０Ｃｏ或加深层Ｘ线外照射,常规照射４５～５０Ｇｙ／５ｗ,然后缩野再用６０Ｃｏ或改用深层Ｘ线照射,总剂量低度恶性肉瘤６０Ｇｙ／６ｗ,中度恶性６５Ｇｙ／６．５ｗ,高度恶性７０Ｇｙ／７ｗ。结果３、５年生存率分别为８３．３％（７０／９０）和６１．３％（３８／６２）。局部复发率为５．６％（５／９０）,远处转移率为１１．１％（１０／９０）。影响软组织肉瘤的预后因素包括肿瘤大小、恶性程度、临床分期、术后放疗间隔时间。结论放射治疗能大幅度降低软组织肉瘤术后局部复发率。     

屏障切除术治疗复发性软组织肉瘤的疗效分析

目的：评价屏障切除术治疗复发性软组织肉瘤（STS）的疗效。方法：对81例复发性STS行屏障切除术。27例术中切缘再确认。修复重建73例。手术＋放疗＋化疗3例;手术＋放疗3例;手术＋化疗10例。1例术前隔离热药灌注。结果：术中切缘阳性2例,占7.4%。随访时间平均30个月（12～138个月）,复发13例,占16.0%。屏障切除后的平均复发时间较前次延长18个月。结论：屏障切除术复发率明显低于广泛切除术。     

The significance of a marginal excision after preoperative radiation therapy for soft tissue sarcoma of the extremity

BACKGROUND:

Marginal excision of soft tissue sarcoma (STS), defined as resection through the tumor pseudocapsule or surrounding reactive tissue, increases the likelihood of local recurrence and necessitates re‐excision or postoperative radiation. However, its impact after preoperative radiation therapy (RT) remains unclear. This study therefore investigated the significance of marginal margins in patients treated with preoperative RT for extremity STS, reporting long‐term local control and limb preservation endpoints.

METHODS:

The records of 317 adults at the University of Florida with nonmetastatic extremity STS treated from 1980 to 2008 with preoperative RT as part of a limb conservation strategy were reviewed. The median follow‐up was 4.7 years (8.3 years for living patients). The median tumor size was 10 cm (range, 2‐36 cm), and 86% were high grade. The median RT dose was 50.4 Gy (range, 12.5‐57.6 Gy). Margins were classified as wide/radical (n = 105), marginal (n = 179), contaminated (n = 15), positive (n = 17), or unknown (n = 1). Endpoints were local control (LC), amputation‐free survival (AFS), cause‐specific survival (CSS), and overall survival (OS).

RESULTS:

Five‐year CSS and OS rates were 62% and 59%, respectively. Five‐year LC and AFS was 93% and 89%, respectively. AFS by margin status was 64%, 83%, 97%, and 92% for positive, contaminated, marginal, and wide/radical margins, respectively (P<.005). Marginal excision following preoperative RT resulted in equivalent LC and AFS compared with wide/radical margins.

CONCLUSIONS:

Marginal resection after preoperative RT does not compromise LC or AFS in extremity STS. This finding may be related to radiosterilization of tumor cells within the reactive zone following preoperative RT. Cancer 2012;118: 3199–207. © 2011 American Cancer Society.     

Extremity soft tissue sarcoma: controversial management issues

Unlike common malignancies, such as breast and colorectal carcinoma, where treatment modalities can be investigated with large prospective randomized trials, such an endeavor has been hampered with soft tissue sarcomas (STS) due to its rarity. In absence of such randomized clinical trials, controversy exists with regards to numerous clinically relevant questions and clinicians are left with single institutional experiences gathered either in a retrospective or prospective fashion. Some of these frequently encountered issues in the management of STS include (1) whether poorly executed biopsies affect outcome? (2) Do all unplanned excisions require re-excisions? (3) Is MRI a superior imaging modality? (4) Whether radiation should be provided pre- or post-operatively? (5) Does extent of surgical margin influence local control? (6) Is adjuvant radiation therapy necessary for stage IIB STS? (7) Does adjuvant chemotherapy influence local control? (8) Does local recurrence influence survival? We will address these topics in this review.     

Contemporary management of metastatic soft tissue sarcoma

Soft tissue sarcoma (STS) is a rare, heterogeneous cancer that can have high rates of distant metastases. Optimal treatment planning requires detailed knowledge of distinct sarcoma histologies as well as the wide array of therapeutic options through surgical, medical, radiation, and interventional oncology. In this review article, we discuss the contemporary management of metastatic STS and the underlying data behind these recommendations. All patients with metastatic STS should be discussed in a multidisciplinary tumor board at an experienced sarcoma center. For patients with oligometastatic disease, there should be strong consideration for definitive local therapy such as surgical resection, stereotactic body radiation therapy, or ablative procedures. In cases with widespread metastases, cytotoxic chemotherapy represents the standard treatment for STS patients with traditional chemotherapies, such as anthracyclines, gemcitabine/docetaxel, ifosfamide, and dacarbazine, still being the most commonly used drugs today. The recent approvals of trabectedin, eribulin, and pazopanib have expanded the therapeutic armamentarium for metastatic STS. Histology-directed treatment is crucial for certain subtypes of STS which are highly sensitive to targeted therapy and relatively insensitive to chemotherapy. Despite the significant progress that has been made in metastatic STS in the past decade, overall prognosis is poor and there is a critical need for novel therapeutics.     

软组织肉瘤的放射治疗

软组织肉瘤(soft tissue sarcomas,STS) 是起源于结缔组织的软组织恶性肿瘤,具有多种不同类型。手术是 STS 主要治疗方法,放疗也是其重要的治疗方式并且是综合治疗早期选择之一。对 STS 进行放疗已经超过 50 年历史,术前和术后放疗对于局部控制都有疗效,只是不良反应不同。软组织肉瘤放疗技术包括远距离放疗(适形放疗、调强放疗、立体定向放疗等) 、近距离放疗(组织间插植放疗、腔内后装放疗、术中放疗等) 等。放疗技术的进步,提高了放疗的精准性和确定性,降低了对病灶周围正常组织的损伤。本文主要针对 STS 放疗技术以及适用原则进行综述。      

Adjuvant brachytherapy in the treatment of soft-tissue sarcomas.

For many patients with STS, administering adjuvant radiation treatments in the form of interstitial brachytherapy provides an excellent alternative to a protracted course of EBRT. Ideal patients are those with intermediate- or high-grade tumors amenable to en bloc resection. Attractive features of this approach include an untainted pathologic specimen, expeditious completion of treatment, reduction in wound complications, and improved functional outcome. Brachytherapy can permit definitive reirradiation by tightly localizing the high dose radiation exposure. It is also useful in patients who are known to have or be at high risk of metastatic disease, for whom the rapid completion of local treatment allows systemic therapy to begin quickly. Introduction of HDR techniques has shifted the delivery of brachytherapy from inpatient solitary confinement to an outpatient setting. Early reports using HDR brachytherapy for treatment of adult and pediatric STS are quite encouraging. The clinical equivalence between hyperfractionated HDR schedules and traditional LDR techniques is gaining acceptance.     

Significance of intraoperative radiation therapy and high cumulative radiation doses in retroperitoneal soft tissue sarcoma

IntroductionIn retroperitoneal soft tissue sarcoma (STS) local recurrence (LR) rates remain high despite more aggressive surgical approaches. Since wide resection margins cannot be achieved in all patients, application of intraoperative radiation therapy (IORT) has been frequently discussed. Still, the significance of IORT in multimodal treatment of retroperitoneal STS remains unclear.Material and methodsPatients undergoing resection of primary or recurrent retroperitoneal STS at the University of Heidelberg Department of General, Visceral and Transplantation Surgery were retrospectively analyzed. Univariate Kaplan-Meyer and multivariate Cox regression analyses were performed to identify predictors of LR-free survival and to investigate the impact of IORT and high cumulative radiation doses. Analyses with propensity-score matched subgroups for IORT and cumulative radiation dose were performed to control for selection bias. Subgroup analyses for patients with retroperitoneal liposarcoma were likewise performed.Results272 patients were identified. Recurrent tumors, histology of dedifferentiated liposarcoma or unclassified sarcoma and microscopically incomplete resection were associated with decreased LR-free survival. In liposarcoma, only recurrent and dedifferentiated tumors were confirmed as poor prognostic factors concerning LR. IORT and cumulative radiation doses exceeding 60 Gy did not influence LR rates (estimated 5-year LR-free survival: IORT: 39%, non-IORT: 46%; p = 0.79).ConclusionIn this retrospective evaluation, additional application of IORT does not significantly influence oncological outcome in retroperitoneal soft tissue sarcoma. Randomized trials are needed to clarify the benefit of IORT.     

Radiosensitivity translates into excellent local control in extremity myxoid liposarcoma

BACKGROUND:

Myxoid liposarcoma has been reported to be more radiosensitive compared with other soft tissue sarcomas (STS). The authors report the results of multidisciplinary treatment of extremity myxoid liposarcoma compared with a contemporary cohort of other STS subtypes with an emphasis on the role of radiotherapy (RT) in improving local control.

METHODS:

Between 1989 and 2004, 691 patients were identified from a prospective STS database who underwent combined management for localized extremity STS and were followed for a minimum of 12 months or until death. All patients underwent surgery together with pre or postoperative RT, depending on their presenting characteristics and resection margins. Demographics and outcomes were compared between patients with myxoid liposarcoma and other STS subtypes (other‐STS).

RESULTS:

Of 691 patients, 88 patients had myxoid liposarcoma and 603 had other STS subtypes (other‐STS). Median age was 48 and 60 years for the myxoid liposarcoma and other‐STS groups, respectively. Median follow‐up was 86 and 61 months, respectively. For myxoid liposarcoma and other‐STS groups, preoperative RT was used in 57% versus 61% of patients and postoperative RT in 43% versus 39%, respectively. The 5‐year local recurrence‐free survival was 97.7% for patients with myxoid liposarcoma compared with 89.6% for patients with other‐STS tumors (P = .008). High‐grade tumors were present in 7% and 59% of myxoid liposarcoma and other‐STS patients, respectively (P = .0003). Two myxoid liposarcoma patients with local recurrence had positive resection margins, whereas only 33% of patients in the other‐STS group who developed a local recurrence had positive resection margins. No patients with myxoid liposarcoma required amputation as primary management, whereas 8 (1.3%) required amputation as primary management in the other‐STS group. Systemic disease control was superior in myxoid liposarcoma compared with other‐STS patients, with 5‐year overall and metastasis‐free survival rates of 93.9% versus 76.4% (P = .0008) and 89.1% versus 66.0% (P = .0001) respectively. Of 12 myxoid liposarcoma patients with distant metastases, 7 appeared in nonpulmonary sites. In comparison, 205 (34%) patients with other‐STS tumors developed systemic disease but 78% had pulmonary metastases.

CONCLUSIONS:

Multidisciplinary management of extremity STS achieves high rates of local control. Myxoid liposarcoma is associated with higher rates of local control compared with other STS subtypes, after combined surgery and radiation, suggesting a particular radiosensitivity that can be exploited to improve oncologic outcome in appropriate cases. Cancer 2009. © 2009 American Cancer Society.     

Optimizing radiation therapy and post-treatment function in the management of extremity soft tissue sarcoma

Opinion statement When treating soft tissue sarcomas (STS) of the extremities, the major therapeutic goals are survival, local tumor control, optimal function, and minimal morbidity. Surgical resection of the primary tumor is the essential component of treatment for virtually all patients. However, local control by surgery alone is poor for the majority of patients with extremity lesions unless the procedure removes large volumes of grossly normal tissue (ie, widely negative margins are attained, because sarcomas tend to infiltrate normal tissue adjacent to the evident lesion). Thus, removal of the gross lesion by a simple excision alone is followed by local recurrence in 60% to 90% of patients. Radical resections reduce the local recurrence rate to 10% to 30%, but may compromise limb function. The combination of function-sparing surgery and radiation achieves better outcomes than either treatment alone for nearly all patients with STS. Because both surgical and radiation technique are critically important for optimizing local control of tumor and functional outcome, it is important to manage these patients in dedicated multispecialty clinics comprised of physicians with expertise in sarcomas, including orthopedic and general oncologic surgeons, radiation oncologists, medical oncologists, sarcoma pathologists, and bone and soft tissue diagnostic radiologists. Radiation therapy can be given by external beam radiation therapy (EBRT) or brachytherapy (BRT) or combination thereof. External beam radiation can be given either preoperatively or postoperatively. The clinical considerations and the outcome data that must be considered in choosing the most appropriate treatment technique for the individual patient are discussed.     

Results of radiation therapy performed after unplanned surgery (without re-excision) for soft tissue sarcomas

BACKGROUND AND PURPOSE: For soft tissue sarcomas (STS), some patients undergo an "unplanned surgery," non-oncologic resection for presumed benign tumor. The treatment of choice, in such cases, is re-excision combined (if indicated) with radiation. However, there are clinical situations when treatment by radiation alone is recommended. Here results of such an approach are assessed. MATERIALS AND METHODS: Seventy-eight patients irradiated after unplanned surgery between 1970 and 1997 were identified from the MGH institutional database. Surgical margins were inevaluable in 50 (64%) and 28 (36%) had positive margins. Tumor characteristics: location, lower extremity (63%), upper extremity (27%), other (10%); median tumor size, 5 cm; grade-G1 (19%), G2 (49%), G3 (32%); AJCC stage (2002)-I (19%), II (54%), III (27%). Median radiation dose given was 66 Gy (range: 51-88). RESULTS: With a median follow-up of 10 years, estimated local control rate was 88% and 86% at 5 and 10 years, respectively. Distant control rate was 80% at 5 and 10 years. Depth in the relation to the fascia, tumor size, and AJCC stage significantly influenced local recurrence- and distant metastasis-free survival. Ten major radiotherapy complications occurred from 1 to 21 years after treatment. CONCLUSIONS: Despite convincing data about the necessity for re-excision after unplanned surgery for STS, these results demonstrate that radiation therapy alone can be an effective alternate for those patients in whom functional or medical considerations preclude further surgery. The risk for potential radiation therapy complications, however, must also be considered in the treatment decision.