软组织肉瘤近距离治疗的研究进展

软组织肉瘤是一组异质性间叶来源的肿瘤,病理类型复杂多变.手术治疗是软组织肉瘤的一线治疗方式.对于不能或拒绝手术的患者,单纯放疗可以提高局部控制率.具有局部复发危险因素的患者,推荐进行术前或术后放疗.近距离治疗是外照射治疗的重要补充方式,对于特殊部位及病理类型或复发危险度高的患者,可考虑外照射治疗联合近距离治疗.对于外照射治疗后复发的软组织肿瘤患者,近距离治疗可作为重要的挽救性治疗手段.     

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。     

局部复发软组织肉瘤的再放疗

软组织肉瘤经局部扩大切除术加放疗局部复发率在5％～20％.局部复发软组织肉瘤的最佳治疗方案应该是个体化的,再次治疗的方案包括局部扩大切除加术后放疗.放疗技术主要包括外照射、近距离放疗、术中电子线放疗.最终,局部控制率为37％～ 100％.但每种放疗技术都有可能产生严重不良反应,对于一些选择性患者,再放疗也许是不必要的.     

术中置管近距离放疗在骨与软组织肉瘤治疗中的应用

目的分析术中置管近距离放疗在骨与软组织肉瘤综合治疗中应用的疗效和毒性。方法163例骨与软组织肉瘤的病例，其中59例采用手术＋化疗＋外照射，另外104例采用手术＋化疗＋近距离放疗＋夕h照射的综合治疗方法。结果采用近距离放疗的一组患者有较好的疗效和较低的毒性。结论术中置管近距离放疗在骨与软组织肉瘤的综合治疗中有较好临床应用价值．．     

软组织肉瘤术后复发原因探讨（附33例报告）

目的：探讨软组织肉瘤的术后复发原因及治疗方法。方法：33例软组织肉瘤术后复发病人，结合临床资料，分析其手术方法，术后辅助治疗和软组织肉瘤复发的关系。结果：复发病灶大小：1．5cm*1.5cm*1.0cm-20cm*20cm*18cm；复发时间：术后10天－4年，平均8．2月，术后3月内复发者10例（30．3％）。第1次术后行放疗和（或）化疗者13例（39．4％），未行放疗和（或）＿化疗者20例（60．6％），再次手术者广泛切除术27例，姑息性切除1例，不能手术者5例，结论：软组织肉瘤术后复发的主要原因为手术切除不彻底，术后不积极应用放疗和化疗，术后不进行病理检查或病理诊断错误，树术后复发病人应积极进行再次手术治疗。     

放射性粒子近距离治疗软组织肉瘤研究进展

近距离放疗以其独特的放射生物学及放射物理学特性成为软组织肉瘤治疗的重要手段,根据治疗时机分为术前放疗、术中放疗、术后放疗、单纯放疗,在提高患肢保存率及肉瘤局部控制率方面发挥了重要作用,但对治疗时机、治疗方式、植入剂量的选择仍存在争议.     

软组织肉瘤术后复发原因探讨(附33例报告)

目的　探讨软组织肉瘤的术后复发原因及治疗方法。方法　 33例软组织肉瘤术后复发病人 ,结合临床资料 ,分析其手术方式、术后辅助治疗和软组织肉瘤复发的关系。结果　复发病灶大小 :1 5cm× 1.5cm× 1.0cm～ 2 0cm× 2 0cm× 18cm ;复发时间 :术后 10天～ 4年 ,平均 8 2月。术后 3月内复发者 10例 (30 3% )。第 1次术后行放疗和 (或 )化疗者 13例 (39 4% ) ,未行放疗和 (或 )化疗者 2 0例 (6 0 6 % )。再次手术者广泛切除术 2 7例 ,姑息性切除 1例 ,不能手术者 5例。结论　软组织肉瘤术后复发的主要原因为手术切除不彻底 ,术后不积极应用放疗和化疗 ,术后不进行病理检查或病理诊断错误。对术后复发病人应积极进行再次手术治疗。     

高剂量率^192Ir后装近距离放疗中晚期直肠癌

目的：分析高剂量率＾１９２Ｉｒ后装近距离放疗在中晚期直肠癌中的价值。方法：３８例中晚期直肠癌,综合组高剂量＾１９２Ｉｒ后装近距离放疗结合外照射放疗２０例,对照组单纯外照射１８例。高剂量率＾１９２Ｉｒ后装近距离放疗根据肿瘤形态采用组织间插植术和腔内放疗,２周４次完成,总剂量２４Ｇｙ－２８Ｇｙ。１周后外加 照射。对照组外照射盆腔野总剂量４５Ｇｙ－５０Ｇｙ,２次／ｄ。结果：临床证状改善,局部肿瘤消退情况     

软组织肉瘤术后放疗疗效观察

软组织肉瘤术后放疗疗效观察孙光绮，阚玉成，王静芬，王瑞芝软组织肉瘤治疗以手术为主，局部切除后易复发。近年来以局部扩大切除加大剂量术后放射治疗的综合治疗为主。我院１９７６年６月至１９９２年１２月共治疗软组织肉瘤１６３例，其中３９例做截肢或关节离断手术，...     

隆突性皮肤纤维肉瘤诊治方法及临床预后分析

目的 探讨隆突性皮肤纤维肉瘤的诊断、治疗方法,分析影响预后的因素.方法 对35例经病理证实隆突性皮肤纤维肉瘤的诊治情况进行回顾性分析.结果 局部切除术10例,扩大切除术21例,扩大切除术+植皮或转移皮瓣4例.其中局部切除术+扩大切除术共24例,并且行术后辅助放疗,照射剂量50～70 Gy,11例未行放疗,全组复发率22.8%,5年无复发生存率71.2%,10年无复发生存率58.5%,术后放疗组与单纯手术组的5年无复发生存率分别为89.2%、59.2%,10年无复发生存率分别为81.1%、43.2%.结论 扩大切除术+辅助放疗是治疗隆突性皮肤纤维肉瘤的主要治疗方法,手术范围大小及术后辅助放疗与否是影响隆突性皮肤纤维肉瘤的独立预后因素.     

Re-resection with brachytherapy for locally recurrent soft tissue sarcoma arising in a previously radiated field

PURPOSE: The use of further radiotherapy among patients with soft tissue sarcoma that recurs in a previously irradiated area is controversial. Presented is a review of our 7-year experience with brachytherapy for recurrent soft tissue sarcoma. METHODS: A retrospective review was performed of 26 patients who underwent perioperative brachytherapy between 1990 and 1997 for recurrent soft tissue sarcoma. In all cases, the sarcoma recurred within a previously irradiated field. After-loading brachytherapy catheters were placed at the time of surgical extirpation of the sarcoma within a single-plane implant by use of 1-cm intercatheter spacing. Insertion of the radioactive 192Ir wire was delayed until the fifth to seventh postoperative day to allow initial wound healing. The prescribed dose rate for the 192Ir wire ranged between 50 and 80 cGy an hour, and the dose was specified at 0.5 cm from the plane of the implant. The anatomic locations treated included lower extremity (N = 10), upper extremity (N = 7), trunk (N = 7), and head and neck (N = 2). RESULTS: Total tumor extirpation, confirmed by negative frozen section margins, was accomplished in all cases. The mean dose of external-beam irradiation received before brachytherapy was 55.6 Gy +/- 1.8 Gy (range, 30.0 to 70.3 Gy). The mean dose of radiation prescribed at the implant procedure was 47.2 Gy +/- 1.6 Gy (range, 11.0 to 50.0 Gy). A tissue transfer flap was placed over the bed of resection in 13 cases. Complications occurred in five patients including, three with wound breakdown, one with osteonecrosis, and with neuralgia. Operative intervention was required in four of the five patients with complications; each of the patients requiring operative intervention for wound-related complications had undergone primary wound closure without tissue transfer. Recurrence of disease occurred in 13 patients: nine local and four distant metastases. The median follow-up was 16 months (range, 2 to 73 months). The 5-year local recurrence-free, distant recurrence-free, disease-free, and overall survival rates after brachytherapy were 52%, 75%, 33%, and 52%, respectively. CONCLUSION: Re-irradiation of recurrent soft tissue sarcoma by brachytherapy in conjunction with resection can be performed with acceptable complication rates. Local control can be achieved for the majority of patients who would otherwise require more radical surgical procedures.     

Early results of pulsed-dose-rate interstitial brachytherapy for head and neck malignancies after limited surgery

PURPOSE: The aim of this study was to evaluate the relative incidence of toxicity and local control in patients with head and neck malignancies who underwent interstitial pulsed-dose-rate (PDR) brachytherapy (iBT). PATIENTS AND METHODS: From October 1997 to December 1998, 61 patients underwent interstitial PDR brachytherapy procedures in our department; 47 were patients with head and neck cancer. Forty patients received brachytherapy as part of their curative treatment regimen, and 7 patients were implanted for palliative purposes and excluded from the analysis of therapy efficacy. Twenty-four patients had interstitial brachytherapy procedures alone with D(REF) = 50 Gy; in 23 patients, iBT procedures were performed with D(REF) = 24 Gy in combination with external radiation. A dose per pulse (dp) of 0.5 Gy was prescribed for 38/47 patients, and a dp = 0.7 Gy for 9/47 patients. The pulses were delivered 24 h a day, with a time interval of 1 h between two pulses, resulting in an effective dose rate of 0.5 Gy/h or 0.7 Gy/h. A follow-up of the patients was done to analyze acute and delayed toxicity, local control, and survival. The analysis was performed after median follow-up of 12 months (5-18 months). RESULTS: After a median follow-up of 12 months, soft tissue necrosis was seen in one patient and bone necrosis in another. No other serious side effects were observed. Permanent locoregional tumor control was achieved in 37 of 40 patients. No distant metastases were observed. CONCLUSIONS: PDR interstitial brachytherapy with 0.5-0.7 Gy/h is a safe therapy. These preliminary results suggest that PDR interstitial brachytherapy of head and neck cancer is comparable with low-dose-rate (LDR) brachytherapy.     

Pilot study of an alternative CYVADIC + CBDCA protocol for adult soft tissue sarcoma as adjuvant chemotherapy

An alternative CYVADIC + CBDCA protocol was tried as a postoperative adjuvant chemotherapy for patients with adult soft tissue sarcoma. The regimen for CYVADIC was day 1: VCR: 1.5 mg/m2 (day 1), doxorubicin: 50 mg/m2 (day 1), DTIC: 250 mg/m2 (day 1-2), and cyclophosphamide: 500 mg/m2 (day 2), and that for CBDCA was 400 mg/m2. CYVADIC and CBDCA were administered alternatively for 3 cycles each. From July 1995 to December 1997, 80 patients with soft tissue sarcoma underwent surgery in our hospital. This protocol was used in 8 of these cases of high grade adult soft tissue sarcoma. Round cell sarcoma was excluded from this study. The 5-year disease free survival rate was 60% and the overall survival rate was 70%. Three cases showed lung metastases. Two patients died of disease and one patient survives free from disease after removal of the lung metastases. No patients showed severe toxicity. We conclude that this protocol merits further evaluation.     

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.     

The American Brachytherapy Society recommendations for brachytherapy of soft tissue sarcomas

PURPOSE: This report presents the American Brachytherapy Society (ABS) guidelines for the use of brachytherapy for patients with soft tissue sarcoma. METHODS AND MATERIALS: Members of the ABS with expertise in soft tissue sarcoma formulated brachytherapy guidelines based upon their clinical experience and a review of the literature. The Board of Directors of the ABS approved the final report. RESULTS: Brachytherapy used alone or in combination with external beam irradiation is an established means of safely providing adjuvant local treatment after resection for soft tissue sarcomas in adults and in children. Brachytherapy options include low dose rate techniques with iridium 192 or iodine 125, fractionated high dose rate brachytherapy, or intraoperative high dose rate therapy. Recommendations are made for patient selection, techniques, dose rates, and dosages. Complications and possible interventions to minimize their occurrence and severity are reviewed. CONCLUSION: Brachytherapy represents an effective means of enhancing the therapeutic ratio, offering both biologic and dosimetric advantage in the treatment of patients with soft tissue sarcoma. The treatment approach used depends upon the institution, physician expertise, and the clinical situation. Guidelines are established for the use of brachytherapy in the treatment of soft tissue sarcomas in adults and in children. Practitioners and cooperative groups are encouraged to use these guidelines to formulate their treatment and dose-reporting policies. These guidelines will be modified, as further clinical results become available.     

The histologic response of soft tissue sarcoma to radiation therapy

Twenty-seven patients with soft tissue sarcoma had preoperative radiotherapy, limb-sparing marginal surgical resection and whole-mount tumor histologic analysis. Incisional biopsy specimens before radiotherapy were reviewed for tumor type, grade, and extent of necrosis. Preoperative radiotherapy was given in either of two regimens: 13 patients received a mean total dose of 5250 cGy in one daily 180 to 200 cGy fractions and 14 patients a mean total dose of 4770 cGy in two daily fractions of 180 to 200 cGy separated by 4 hours. Twenty-one specimens had at least 80% necrosis or severely altered cells, a 3+ to 4+ response. Grade and size of the tumor appeared to be indicators of response to treatment rather than histologic type. Three of five patients (60%) with Grade 1, eight of 11 patients (73%) with Grade 2 lesions, and ten of 11 patients (91%) with Grade 3 tumors had 80% or greater necrosis or severely altered cells. For tumors 10 cm or less in greatest diameter, the 3+ to 4+ histologic response was seen in 12 of 14 patients (86%) whereas for lesions greater than 10 cm, this response was observed in nine of 13 patients (69%). For patients with Grade 2 or 3 soft tissue sarcoma, 13 of 14 patients (93%) treated with two fractions per day and two of four patients (50%) receiving one fraction per day exhibited significant response. All six patients treated twice daily for lesions greater than 10 cm had 3+ to 4+ histologic response compared to three of seven (43%) patients treated once per day. Therefore, grade and size of soft tissue sarcoma are important predictors of response to radiotherapy and preoperative twice daily radiotherapy may more likely permit the conservative surgical excision of sarcomas of borderline resectability.     

Treatment of keloids by high-dose-rate brachytherapy: A seven-year study

PURPOSE: To analyze the results obtained in a prospective group of patients with keloid scars treated by high-dose-rate (HDR) brachytherapy with or without surgery. METHODS AND MATERIALS: One hundred and sixty-nine patients with keloid scars were treated with HDR brachytherapy between December 1991 and December 1998. One hundred and thirty-four patients were females, and 35 were males. The distribution of keloid scars was as follows: face, 77; trunk, 73; and extremities, 19. The mean length was 4.2 cm (range 2-22 cm), and the mean width 1.8 cm (range 1.0-2.8 cm). In 147 patients keloid tissues were removed before HDR brachytherapy treatment, and in 22 HDR brachytherapy was used as definitive treatment. In patients who underwent prior surgery, a flexible plastic tube was put in place during the surgical procedure. Bottoms were used to fix the plastic tubes, and the surgical wound was repaired by absorbable suture. HDR brachytherapy was administered within 30-60 min of surgery. A total dose of 12 Gy (at 1 cm from the center of the catheter) was given in four fractions of 300 cGy in 24 h (at 09.00 am, 15.00 pm, 21.00 pm, and 09.00 am next day). Treatment was optimized using standard geometric optimization. In patients who did not undergo surgery, standard brachytherapy was performed, and plastic tubes were placed through the skin to cover the whole scar. Local anesthesia was used in all procedures. In these patients a total dose of 18 Gy was given in 6 fractions of 300 cGy in one and a half days (at 9.00 am, 3.00 pm, and 9.00 pm; and at 9.00 am, 3.00 pm, and 9.00 pm next day). No further treatment was given to any patient. Patients were seen in follow-up visits every 3 months during the first year, every 6 months in the second year, and yearly thereafter. No patient was lost to follow-up. Particular attention was paid to keloid recurrence, late skin effects, and cosmetic results. RESULTS: All patients completed the treatment. After a follow-up of seven years, 8 patients (4.7%) had keloid recurrences. Five of these had undergone prior surgery (local failure rate 3.4%), and 3 had received only HDR brachytherapy (local persistence rate 13.6%). Cosmetic results were considered to be good or excellent in 130/147 patients treated with prior surgery and in 17/22 patients without surgery. Skin pigmentation changes were observed in 10 patients, and telangiectasias in 12 patients. No late effects such as skin atrophy or skin fibrosis were observed during the 7 years of follow-up. CONCLUSIONS: HDR brachytherapy is an effective treatment for keloid scars. It is well tolerated and does not present significant side effects. The brachytherapy results were more successful in patients who underwent previous surgical excision of keloid scar than in patients without surgery. We favor HDR brachytherapy rather than superficial X-rays or low energy electron beams in keloid scars, because HDR provides a better selective deposit of radiation in tissues and a lower degree of normal tissue irradiation. Other advantages of high-dose-rate brachytherapy over low-dose-rate brachytherapy are its low cost, the fact that it can be performed on an outpatient basis, its excellent radiation protection, and the better dose distribution obtained. From the clinical perspective, the technique provides a high local control rate without significant sequelae or complications.     

Role of brachytherapy in recurrent extremity sarcoma in patients treated with prior surgery and irradiation

The treatment options for recurrent extremity sarcoma following conservative surgery and irradiation are limited. Amputation is the treatment of choice offered for the majority of these patients. In a selected group of patients with recurrent sarcoma, we have investigated the role of brachytherapy along with function-preserving resection. From 1979 to 1988, 40 patients underwent resection and brachytherapy for recurrent extremity sarcoma. There were 23 males and 17 females. All of the patients received function-preserving resection and an afterloading temporary tumor bed implant. A median dose of 4500 cGy was delivered with a range from 3000 to 4800 cGy. The median follow-up was 36 months with a range of 12 to 120 months. The actuarial local control at 5 years is 68%. Five patients (12.5%) developed complications such as wound ulceration (4) and femoral fracture (1) requiring surgery. Five patients developed local failure and an additional two patients had both local and distant failure. All of the failures occurred in patients with more than two prior recurrences. This review suggests that brachytherapy can be used as an effective treatment option in selected patients with recurrent extremity sarcoma following prior surgery and irradiation with satisfactory limb preservation. The data also suggest that higher local control rates can be achieved with early brachytherapeutic intervention.     

A unique radiation scheme for the treatment of high-grade non-metastatic soft tissue sarcoma: the detroit medical center experience

Purpose:This is the initial report on the utilization of combined photon irradiation followed by a neutron boost irradiation for the initial management of patients with high-grade non-metastatic soft tissue sarcoma (STS). We present data on local control, complications, disease-free survival and overall survival in patients at high risk for local relapse.Methods and materials: Between 1/1/1995 and 10/31/02, twenty-three patients with high-grade non-metastatic soft tissue sarcoma were referred to the Department of Radiation Oncology at the Detroit Medical Center. These patients were referred for consultation due to surgical margin status (tumor within 3mm of surgical margin (n=11)), or gross residual disease (n=12). There were 14 males and nine females whose ages ranged from 12 to 75 at the time of diagnosis (med=44 years). The most common histology was malignant fibrous histiocytoma (n=6), followed by liposarcoma (n=5), synovial sarcoma (n=4), and angiosarcoma (n=2). Twenty-one of 23 patients also received multi-agent multi-cyclic cyto-reductive therapy. Treatment consisted of initial daily photon irradiation delivered either using twice daily fractions of 120 cGy (n=10) or once daily 200 cGy/fx (n=13).Total photon dose was 36-39.6 Gy. Neutron irradiation was initiated immediately following the photon irradiation and consisted of fraction sizes of 1.0-1.25NGy to a total dose of 6-10 NGy. The neutrons were given once daily. Follow-up is calculated from the day of last radiation treatment.Results: No patient has been lost to follow-up, which has ranged from 18 to 82 months (med=36 months). To date there have been two local relapses and three patients with distant disease development without local relapse. Each of the patients with distant disease has died. The local failures occurred at 9 and 12 months. The 36-month local control is 91%. Thirtysix month disease-free survival was 78%. Overall survival at 36 months was 87%. Three patients had unusual complications consisting of delayed wound healing, and in one of these patients a fracture of the tibia has been noted.Conclusion: The use of this unique radiation sequence post-surgically in patients at high risk for local relapse has resulted in an exciting 36-month local control rate of 91%. The 3-year disease-free survival of 78% and overall survival rate of 87% are exciting but need to mature. The low complication rate is similar to that reported in other large institutional series that have not utilized neutrons. We continue to evaluate the role of combined photon and once-off neutron irradiation in the treatment of patients with high-grade STS that are risk for local recurrence.