术后放射治疗在原发肢体软组织肉瘤治疗中的作用

分析本院收治的原发于肢体的软组织肉瘤的治疗情况 ,评价术后放射治疗的作用。方法　本院共收治 15 1例 ,可供分析的 139例 ,分析影响生存和局控的因素及术后放射治疗的意义。生存率和局控率用Kaplan Meier方法计算 ,单因素分析用Logrank检验 ,多因素分析用Cox回归方法。结果　全组 5年生存率为 70 .2 % ,10年为 5 0 .4% ;5年无瘤生存率为 5 2 .9% ,10年为41.2 %。单因素分析对全组病例生存率有影响的因素 :肿瘤大小、年龄和治疗方式 (P值分别为0 .0 0 8,0 .0 0 7和 0 .0 40 )。多因素分析只有治疗方式对生存有影响 (P =0 .0 40 )。首次治疗方式对局控影响差异有极显著性 (P <0 .0 1)。手术方式对单纯手术组局控影响差异有极显著性 (P <0 .0 1) ;肿瘤 <5cm时 ,射野大小对术后放射治疗组局控影响差异有极显著性 (P <0 .0 1)。结论　术后放射治疗能提高局部控制率 ,初始射野应相对大 ,并采用缩野技术。对恶性度低、肿瘤 <5cm、手术切缘阴性患者第 1次术后可不做放射治疗。     

软组织肉瘤术后放射治疗疗效分析

目的 探讨软组织肉瘤术后放射治疗的疗效。方法 37例软组织肉瘤患者,术后及时放射治疗,27例术后局部复发再行扩大切除术及术后放射治疗,对两者的疗效进行对比分析。结果 术后及时行放射治疗者的3年和5年生存率分别为64.9%和43.2%;术后局部复发再行扩大切除术者的3年和5年的生存率分别为55.2%和37.9%。结论 软组织肉瘤术后及时行放射治疗可提高患者3、5年生存率,可减少肿瘤局部复发。     

术后辅助放疗对局限期软组织肉瘤疗效影响

目的 评价局限期软组织肉瘤(STS)的疗效并分析其预后因子,重点探讨术后放疗在STS治疗中的作用。方法 回顾分析2000—2010年7月在复旦大学附属肿瘤医院接受保留器官手术的203例STS患者,76例(37.4%)接受辅助放疗,采用前后对穿野放疗技术,剂量45~70 Gy。采用 Kaplan-Meier法计算生存率并Logrank法检验,Cox模型多因素分析。结果 随访率94.7%,5年OS、LFFS、DMFS率分别为69.1%、69.3%、68.0%。多因素分析显示病理亚型、大小、切缘状况和是否接受放疗是影响OS因素,其中放疗显著降低STS患者LR风险(HR=0.327,95%CI为0.177~0.605,P=0.000),放疗显著提高OS (HR=0.489,95%CI为0.266~0.897,P=0.021)。结论 术后放疗不仅可提高STS的LC还可改善患者OS,其作用值得进一步研究。     

70例肢体软组织肉瘤临床分析

目的 探讨肢体软组织肉瘤(LSTS)的临床特点,并分析影响LSTS患者预后的影响因素.方法 回顾性分析70例LSTS患者的临床资料,包括年龄、性别、肿瘤直径、肿瘤位置、病理分期以及手术外科切缘等临床资料,并对患者进行随访,分析LSTS患者局部复发和发生全身转移的影响因素.结果 术后随访期间,70例LSTS患者中,局部复发患者为15例,局部复发率为21.43%;发生全身转移的患者为22例,全身转移率为31.43%;初治、广泛切除肿瘤以及外科切缘阴性LSTS患者的术后局部复发率和全身转移率低;LSTS患者的术后局部复发率和全身转移率随着FNCLCC分级和MSTS分期的升高而升高,而与LSTS患者的年龄、性别、肿瘤直径、肿瘤位置以及肿瘤深度无关(P﹥0.05).结论 LSTS患者应优先考虑广泛切除治疗,高分期、外科切缘阳性和二次治疗的LSTS患者术后应注意局部复发和全身转移情况的发生.     

肢体软组织肉瘤709例外科治疗分析

目的探讨肢体软组织肉瘤(STS)的诊断与规范化的手术方式,以提高治疗效果。方法回顾性分析行手术治疗并经病理证实的709例肢体STS患者的临床资料。结果全组709例肢体STS患者中,术前行B超709例,CT 135例,MRI 587例。本组除216例行补充广泛切除术患者术前未再行术前活检,其余493例均进行术前活检,其中细针穿刺活检350例,粗针穿刺活检89例,切检54例。手术方式:434例行广泛切除术,125例行根治性间室切除术,113例行屏障切除术,37例行截肢术。术后病理检查结果显示,恶性纤维组织细胞瘤103例,滑膜肉瘤89例,脂肪肉瘤78例,横纹肌肉瘤74例,隆突性皮肤纤维肉瘤67例,纤维肉瘤62例,平滑肌肉瘤46例,腺泡状软组织肉瘤41例,透明细胞肉瘤36例,韧带样瘤型纤维瘤病31例,上皮样肉瘤29例,恶性神经鞘瘤27例,骨外尤文肉瘤11例,骨外骨肉瘤10例,血管肉瘤5例。531例术后随访0.3~4.5 a,73例复发(13.7%),复发时间11~32个月,中位复发时间为21个月。127例(23.9%)出现远处转移,其中86例为肺转移,31例为肝转移,10例为骨转移。结论 MRI或CT应为术前常规的辅助检查,活检有助于明确诊断,手术是肢体STS最重要的治疗手段,规范化的手术方式可以降低复发率。     

软组织肉瘤41例术后放射治疗的效果分析

软组织肉瘤４１例术后放射治疗的效果分析吴青莲林权冰李德和戴慧吴剑朱彤（温州市肿瘤医院放疗科，温州３２５００７）１９８８年６月～１９９４年１２月，我们收治软组织肉瘤４１例，现将术后放射治疗的效果作一分析。材料和方法一、临床资料４１例中，男性２５例，女性...     

肢体软组织肉瘤术后放疗缩小放疗野的临床观察

目的 探讨肢体软组织肉瘤术后缩小放疗野放疗的效果,重点观察局部控制率和不良反应发生情况。方法 回顾性分析2017年10月至2021年3月清华大学第一附属医院收治的49例肢体软组织肉瘤患者,所有患者术后均接受调强放疗。采用定位CT和术后MRI图像融合的方法进行靶区勾画,定义瘤床（GTV_tb）在纵轴方向外扩3 cm,横轴方向外扩1.5 cm形成临床靶区（CTV,解剖屏障可适当修回,且需包全肿瘤周围水肿区）。GTV_tb和CTV分别外扩0.5 cm形成计划靶区1（PTV1）和PTV2,放疗处方剂量：PTV1_95%为63~66 Gy,PTV2_95%为50~56 Gy,单次1.8~2.0 Gy。若术后镜下切缘阳性,瘤床区域推量至70 Gy。结果 随访7.9~45.6个月,中位随访时间32.1个月。3年无局部失败生存率、总生存率和无远处转移生存率分别为91.7%、77.6%、71.5%。单因素分析结果显示,术后镜下切缘阳性的患者更容易出现局部复发,P<0.05。2级及以上伤口并发症、关节僵硬、骨折、水肿、皮肤纤维化的发生率分别为2%、4.1%、2%、8.2%、26.5%。结论 术后放疗缩小放射野治疗肢体软组织肉瘤得到了较好的局部控制率,且晚期不良反应发生率较低。     

肢体软组织肉瘤术后放疗缩小放疗野的临床观察

目的 探讨肢体软组织肉瘤术后缩小放疗野放疗的效果,重点观察局部控制率和不良反应发生情况。方法 回顾性分析2017年10月至2021年3月清华大学第一附属医院收治的49例肢体软组织肉瘤患者,所有患者术后均接受调强放疗。采用定位CT和术后MRI图像融合的方法进行靶区勾画,定义瘤床（GTV_tb）在纵轴方向外扩3 cm,横轴方向外扩1.5 cm形成临床靶区（CTV,解剖屏障可适当修回,且需包全肿瘤周围水肿区）。GTV_tb和CTV分别外扩0.5 cm形成计划靶区1（PTV1）和PTV2,放疗处方剂量：PTV1_95%为63~66 Gy,PTV2_95%为50~56 Gy,单次1.8~2.0 Gy。若术后镜下切缘阳性,瘤床区域推量至70 Gy。结果 随访7.9~45.6个月,中位随访时间32.1个月。3年无局部失败生存率、总生存率和无远处转移生存率分别为91.7%、77.6%、71.5%。单因素分析结果显示,术后镜下切缘阳性的患者更容易出现局部复发,P<0.05。2级及以上伤口并发症、关节僵硬、骨折、水肿、皮肤纤维化的发生率分别为2%、4.1%、2%、8.2%、26.5%。结论 术后放疗缩小放射野治疗肢体软组织肉瘤得到了较好的局部控制率,且晚期不良反应发生率较低。     

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。     

肢体软组织肉瘤临床诊疗专家共识

软组织是指机体非上皮性的骨外组织，不包括单核巨噬细胞系统、神经胶质细胞和各个实质器官的支持组织。软组织主要来源于中胚层，部分来源于神经外胚层。软组织肿瘤是根据组织发生学中与其类似的成人组织类型进行分类的一组高度异质性的肿瘤。软组织肉瘤的特点为具有局部侵袭性、呈浸润性或破坏性生长，可复发和远处转移。     

The added value of chest imaging after neoadjuvant radiotherapy for soft tissue sarcoma of the extremities and trunk wall: A retrospective cohort study

IntroductionThere is no clear evidence regarding the benefit of restaging for distant metastases after neoadjuvant radiotherapy (RTX) in patients with soft tissue sarcoma (STS) of the extremities and trunk wall. This study aimed to determine how often restaging of the chest identified metastatic disease that altered management in these patients.MethodsWe performed a single-centre retrospective study from 2010 to 2020. All patients with non-metastatic STS of the extremities and trunk wall who were treated with neoadjuvant RTX and received a staging and restaging chest CT scan or X-ray for distant metastasis were included. The outcome of interest was change in treatment strategy due to restaging after neoadjuvant RTX.ResultsWithin the 144 patients who were staged and treated with neoadjuvant RTX, a restaging chest CT or X-ray was performed in 134 patients (93%). A change in treatment strategy due to new findings at restaging after RTX was observed in 26 out of 134 patients (19%). In 24 patients the scheduled resection of the primary STS was cancelled at restaging (24/134, 18%), given the findings at restaging. The other two patients did receive the intended local resection, but either with palliative intent, or as a part of a previously unplanned multimodality treatment.ConclusionIn approximately one in five patients restaging results in a change in treatment strategy. This underlines the added value of routine restaging for distant metastases with chest CT or X-ray after neoadjuvant RTX in patients with STS.     

Chemotherapy of soft tissue sarcomas in the extremities.

A retrospective study on chemotherapy against soft-tissue sarcomas in the extremities was carried out on 98 patients. The local recurrence rate was 10.3% with intensive chemotherapy in post-1980 patients with high-grade sarcomas but 46.7% without chemotherapy--a fairly significant difference (P less than 0.01). The survival rate was significantly higher with intensive chemotherapy in post-1980 patients with high-grade sarcomas. Thus, intensive chemotherapy based on a new protocol should be given in cases of high-grade sarcoma. Considering surgical margin, the local recurrence rate was 33.3% in post-1980 cases inadequately operated upon but 8.6% in those adequately operated upon, which shows a significant difference (P less than 0.05).     

Tumour volume changes following pre-operative radiotherapy in borderline resectable limb and trunk soft tissue sarcoma

Aims

To evaluate tumour volume changes after preoperative radiotherapy (PRT) for borderline operable soft tissue sarcomas (STS).

Materials and methods

A retrospective review was performed of 68 patients who received PRT between December 2004 and July 2011. Endpoints were radiological response, surgical margins, local control and survival.

Results

Median tumour size was 12.5 cm. Tumour location was extremity (87%), trunk (12%), and neck (1%). Commonest histological subtypes were myxoid liposarcoma (32%) and myxofibrosarcoma (16%). The majority of patients (88%) received 50 Gy in 25 fractions. Post-radiotherapy imaging was available in 55 cases. By RECIST there was stable disease in 89%, partial response in 7% and progressive disease in 4%. Tumour volumes reduced in 80%. Median change in maximal tumour dimension was −13.6%; median change in volume was greater, at −33.3%. Tumour volumes increased in 11 cases (20%). However, surgical margins were clear in all 11 cases, with no local recurrences in this group. For the entire group, surgical margins were clear in 93%, and microscopically positive in 7%. Eight patients (12%) had local relapse at 2–24.8 months after surgery. Two year local relapse free survival was 87.5%; 2 year overall survival was 74.7%.

Conclusion

The majority of tumours showed reduction in volume. A small number of tumours increased in volume, but there was no definite relationship between volume increase and poor surgical outcomes or lower local control rates. Local control was equivalent to published series' of PRT. PRT is a reasonable approach in patients with borderline resectable tumours.     

Bone invasion in soft tissue sarcomas of the extremities: An underappreciated prognostic factor. Bone invasion in soft tissue sarcomas

BackgroundBone invasion is unfrequently reported in soft tissue sarcomas of the extremities (eSTS), it is difficult to assess preoperatively and its prognostic impact has not been extensively studied. The objective of this paper was to analyze the incidence and the clinical impact of histologically proven bone invasion in individuals with eSTS.MethodsA retrospective analysis was performed using the medical files patients who had eSTS and were treated between 2012 and 2016. A 5 years survival was estimated using the Kaplan-Meier method and a Cox proportional risk assessment. The outcomes of patients with and without bone invasion were compared.Results370 patients were included in the analysis. The median follow up was 25 months, the median age was 45 years (IQR 31–58). Bone invasion was found in 41 (11.08%). Median tumor size was 11.8 cm. The majority of individuals were diagnosed at stage IV (n = 116, 31.4%), followed by stage IIIB (n = 87, 23.5%). High histological grade was associated with worse OS (HR 2.23, CI 95% 1.36–3.65, p = 0.001). Absence of bone invasion was associated with better prognosis (HR 0.541, CI 95% 0.34–0.86, p = 0.009). OS was 27.3 vs 49.28 months. The disease-free survival (DFS) was 25.1 in bone invasion vs 45.23 without bone invasion.ConclusionBone invasion in individuals with eSTS is an independent adverse prognostic factor associated with lower OS and DFS; although infrequently reported, bone invasion might be considered as part of the staging in the future     

Radiation therapy technique in soft tissue sarcomas of the extremity—policies of treatment at the national cancer institute

We have formulated certain treatment techniques for soft tissue sarcomas of the extremities in adults, based on the experience of treating 75 patients at the National Cancer Institute. Attaining a high likelihood of tumor control is heavily dependent on a variety of factors. These factors include a knowledge of the biological characteristics of the tumor, of the normal tissue anatomy and its relationship to the tumor and of the surgical techniques available and the details of the surgery already performed. Obtaining good long term function in the irradiated extremity is dependent on sparing a strip of soft tissue and using sophisticated radiation therapy techniques. These techniques include casting of the extremity for immobilization, using a variety of gantry and collimator angulations, using treatment planning for determining the necessity for wedges or compensating filters in the radiation field and utilizing secondary collimation. With this highly individualized approach to treatment of patients with soft tissue sarcomas, optimal results can be obtained.     

Comparison of conventional radiotherapy and intensity-modulated radiotherapy for post-operative radiotherapy for primary extremity soft tissue sarcoma

Introduction

Doses in conventional radiotherapy for extremity soft tissue sarcoma (STS) potentially exceed normal tissue tolerances. This study compares 3D-conformal radiotherapy (3D-CRT) with intensity-modulated radiotherapy (IMRT) in optimising target volume coverage and minimising integral dose to organs-at-risk (OAR).

Methods and materials

Ten patients undergoing post-operative radiotherapy for extremity STS were assessed. PTV₁ was defined as tumour bed plus 5 cm superiorly/inferiorly and 3 cm circumferentially, PTV₂ was defined as 2 cm isotropically. OAR were defined as whole femur, neurovascular bundle, tissue corridor and normal tissue outside PTV₁. For each patient 2-phase 3D-CRT was compared to 2/3 field (2/3f) and 4/5 field (4/5f) IMRT with simultaneous integrated boost (SIB). The primary planning objective was to minimise femur and skin corridor dose. Volumetric analysis and conformity and heterogeneity indices were used for plan comparison.

Results

A planning protocol containing dose/volume constraints for target and OAR was defined. 4/5f IMRT showed greatest conformity and homogeneity. IMRT resulted in significantly lower femur V45 using 2/3f (p = 0.01) and 4/5f (p = 0.0009) than 3D-CRT. 4/5f IMRT resulted in significantly lower normal tissue V55 (p = 0.004) and maximum dose (p = 0.04) than 3D-CRT.

Conclusions

A reproducible set of planning guidelines and dose-volume constraints for 3D-CRT and IMRT planning for extremity sarcomas was devised. 4/5f IMRT with SIB resulted in better target coverage and significantly decreased OAR dose. Further evaluation of this technique within a clinical trial is recommended to demonstrate that the technical benefit of the more complex technique translates into patient-derived benefit by reducing late toxicity.     

Comparison of the 7th and 8th version of the AJCC classification system for soft tissue sarcomas of extremities and trunk in patients with localised,intermediate or high-grade disease treated at European tertiary sarcoma centres

BackgroundThe updated 8th version of the AJCC-staging system for soft tissue sarcomas (STS) has been criticised for omitting tumour depth as category-defining variable and eventually not improving prognostic accuracy in comparison to the 7th version. This study aimed at investigating the prognostic accuracy of both AJCC-versions in STS-patients treated at European tertiary sarcoma centres.Methods1032 patients (mean age: 60.7 ± 16.3 years; 46.0% [n = 475] females; median follow-up: 38.6 months), treated at five tertiary sarcoma centres for localised, intermediate or high-grade STS of extremities and trunk were retrospectively included. Uni- and multivariate Cox-regression models and Harrell's C-indices were calculated to analyse prognostic factors for overall survival (OS) and assess prognostic accuracy.ResultsIn univariate analysis, prognostic accuracy for OS was comparable for both AJCC-versions (C-index: 0.620 [8th] vs. 0.614 [7th]). By adding margins, age, gender, and histology to the multivariate models, prognostic accuracy of both versions could be likewise improved (C-index: 0.714 [8th] vs. 0.705 [7th]). Moreover, tumour depth did not significantly contribute to prognostic accuracy of the 8th version's multivariate model (C-index for both models: 0.714). Stratification into four main T-stages based on tumour size only, as implemented in the 8th version, significantly improved prognostic accuracy between each category. However, T-stages as defined in the 7th version had poorer discriminatory power (C-index: 0.625 [8th] vs. 0.582 [7th]).ConclusionBoth AJCC-versions perform equally well regarding prognostic accuracy. Yet, simplification of the 8 ^th version by omitting tumour depth as T-stage-defining parameter, whilst emphasizing the importance of tumour size, should be considered advantageous.     

Multidisiciplinary “limb salvage” treatment of soft tissue and skeletal sarcomas

Sixty-five patients with soft tissue sarcomas and 40 patients with skeletal sarcomas were treated pre-operatively with infra-arterial Doxorubicin and radiation therapy (3500 rad in 10 fractions). The tumors were widely excised and in the case of skeletal sarcomas, the bone was replaced with a cadaver allograft or metal endoprosthesis in an attempt to achieve limb salvage. Chemotherapy consisting of Adriamycin and Methotrexate was administered post-operatively. These patients have been followed from 6 to 70 months with a median follow-up for soft tissue and skeletal tumors of 24 and 30 months respectively. In the soft tissue sarcoma group there have been 2 local recurrences; actuarial overall and disease-free survival at 3 years was 64 and 61%, respectively. In the skeletal sarcoma group there have been only 2 recurrences and the actuarial survival and disease-free survival of 75 and 55% at 2 years, respectively. In the soft tissue sarcoma group there have been 33 thigh lesions, 13 of which have required periosteal stripping. Five of the patients with thigh lesions have developed femoral fractures. All of these patients had post-operative chemotherapy and four of the five patients had periosteal stripping. In the skeletal sarcoma group, eleven of the twenty-one cadaver allografts have either fractured or become unstable requiring replacement with metallic endoprostheses that have been used exclusively for the past two years. Ninty-seven of the total group of 105 patients achieved limb salvage to the last follow-up or time of death with an acceptable complication rate. Longer follow-up is mandatory to determine the late effects of this combined modality regimen.