Long-Term Follow-up Shows Surgery Plus Radiation Offers Mixed Results in Soft-Tissue Sarcoma


Key Points

  • Adjuvant external-beam radiation therapy following surgery for soft-tissue sarcoma of the extremities did not lead to a survival benefit.
  • Long-term complications seen in some patients who underwent surgery alone or surgery plus radiotherapy were pathologic fracture requiring surgical correction, hospitalization for limb edema, and amputation.
  • This follow-up study was based on trial data obtained before the advent of more complex and sophisticated radiation therapy modalities.

Adjuvant radiation following surgery for soft-tissue sarcoma of the extremities did not lead to a survival benefit and seemed to be associated with some degree of long-term limb complications, according to a presentation at the 2014 Society of Surgical Oncology (SSO) Cancer Symposium in Phoenix (Abstract 4).

Follow-up data from a 146-patient trial that compared limb-sparing surgery alone with surgery plus adjuvant external-beam radiation showed a 20-year survival rate of 64% (95% confidence interval [CI] = 52%–75%) for patients who received surgery alone and 71% (95 CI = 59%–81%) for patients who underwent the combination therapy (P = 0.22), reported Joal Beane, MD, of the National Cancer Institute in Bethesda, and colleagues.

Despite its widespread use in soft-tissue sarcoma of the extremities, the pairing of radiation and surgery has never turned in exceptional results for survival. For instance, in a 1982 prospective study comparing limb-sparing surgery plus external-beam radiation therapy to amputation, disease-free survival and overall survival were similar between the two study arms.

Study Details

Dr. Beane's group evaluated long-term data from a 1983–1991 trial that reported better local control with limb-sparing surgery and external-beam radiation therapy vs surgery alone, but still no differences in survival outcomes.

In the original trial, the external-beam radiation therapy protocol consisted of 4,500 cGy delivered to a wide field, 1,800 cGy boost to the tumor bed, and 180 cGy fractions given 5 days a week for 6 to 7 weeks. Patients with high-grade soft tissue sarcomas also received concurrent adjuvant chemotherapy with doxorubicin and cyclophosphamide.

In addition to survival, Dr. Beane's group analyzed patient-reported quality of life using a telephone-based questionnaire that included queries on severity of pain, need for pain medication more than three times a week, need for wound care, degree of limb edema, and impact of limb disability.

Long-Term Follow-up Results

Since the original publication of the trial results in 1998, 55 patients died, 76 were confirmed living, and 19 were lost to follow-up. The overall median follow-up time was 17.9 years. The authors noted that survival results did not differ between treatments for patients with high-grade (P = .59) or low-grade soft-tissue sarcoma (P = .14).

With regard to quality of life, among the 76 patients who were confirmed living, 54 completed the phone interviews. Results for variables related to pain favored limb-sparing surgery alone but did not reach statistical significance when compared with dual-modality treatment.

The majority of patients in either group did not require any wound care (79% for surgery alone and 73% for surgery plus radiotherapy). However, one patient in the surgery group had a pathologic fracture and required three orthopedic surgeries to correct the problem, while two patients in the combination treatment group required amputation.

One amputation was secondary to nonunion of a pathologic fracture, and the other was due to chronic wound complications and osteomyelitis, Dr. Beane stated.

In terms of limb edema, most patients in the two study arms did not require treatment (63% and 50%), although two patients in the external-beam radiation group did need to be hospitalized for treatment of limb edema (P = .21).

Dr. Beane noted that the study had many limitations including the small sample size and the fact that it was a retrospective analysis of limb function. In addition, the authors did not look at the effect of chemotherapy on long-term complications.

Finally, the study was done before the advent of three-dimensional radiation therapy and intensity-modulated radiation therapy. Both modalities require more complex planning, which could lead to improvements in outcomes.

Dr. Beane reported no conflicts of interest.

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