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Radiat Oncol. 2019 Jan 9;14(1):2. doi: 10.1186/s13014-019-1207-2.

Neoadjuvant image-guided helical intensity modulated radiotherapy of extremity sarcomas - a single center experience.

Author information

1
Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany. jan.peeken@tum.de.
2
Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany. jan.peeken@tum.de.
3
Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany.
4
Department of Radiation Sciences (DRS), Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Ingolstädter Landstraße 1, Neuherberg, Germany.
5
Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, Munich, Germany.
6
Department of Orthopaedic Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany.
7
Department of Pathology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany.
8
Department of Radiology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany.

Abstract

BACKGROUND:

Advanced radiotherapy (RT) techniques allow normal tissue to be spared in patients with extremity soft tissue sarcoma (STS). This work aims to evaluate toxicity and outcome after neoadjuvant image-guided radiotherapy (IGRT) as helical intensity modulated radiotherapy (IMRT) with reduced margins based on MRI-based target definition in patients with STS.

METHODS:

Between 2010 to 2014, 41 patients with extremity STS were treated with IGRT delivered as helical IMRT on a tomotherapy machine. The tumor site was in the upper extremity in 6 patients (15%) and lower extremity in 35 patients (85%). Reduced margins of 2.5 cm in longitudinal direction and 1.0 cm in axial direction were used to expand the MRI-defined gross tumor volume, including peritumoral edema, to the clinical target volume. An additional margin of 5 mm was added to receive the planning target volume. The full total dose of 50 Gy in 2 Gy fractions was sucessfully applied in 40 patients. Two patients received chemotherapy instead of surgery due to systemic progression. All patients were included into a strict follow-up program and were seen interdisciplinarily by the Departments of Orthopaedic Surgery and Radiation Oncology.

RESULTS:

Thirty eight patients that received total RT total dose and subsequent resection were analyzed for outcome. After a median follow-up of 38.5 months cumulative OS, local PFS and systemic PFS at 2 years were determined at 78.2, 85.2 and 54.5%, respectively. Two of 6 local recurrences were proximal marginal misses. Negative resection margins were achieved in 84% of patients. The rate of major wound complications was comparable to previous IMRT studies with 36.8%. RT was overall tolerable with low toxicity rates.

CONCLUSIONS:

IMRT-IGRT offers neoadjuvant treatment for extremity STS with reduced safety margins and thus low toxicity rates. Wound complication rates were comparable to previously reported frequencies. Two reported marginal misses suggest a word of caution for reduction of longitudinal safety margins.

KEYWORDS:

Extremity; IGRT; IMRT; Image-guidance; Soft tissue sarcoma; Tomotherapy

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