Skip to main content

Advertisement

SpringerLink
Log in

External-beam radiation therapy combined with limb-sparing surgery in elderly patients (>70 years) with primary soft tissue sarcomas of the extremities

A retrospective analysis

Perkutane Radiotherapie kombiniert mit extremitätenerhaltender Operation bei älteren Patienten (>70 Jahre) mit primären Weichteilsarkomen der Extremitäten

Eine retrospektive Analyse

  • Original Article
  • Published:
Strahlentherapie und Onkologie Aims and scope Submit manuscript

Abstract

Purpose

To report our experience with EBRT combined with limb-sparing surgery in elderly patients (>70 years) with primary extremity soft tissue sarcomas (STS).

Methods

Retrospectively analyzed were 35 patients (m:f 18:17, median 78 years) who all presented in primary situation without nodal/distant metastases (Charlson score 0/1 in 18 patients; ≥2 in 17 patients). Median tumor size was 10 cm, mainly located in lower limb (83%). Stage at presentation (UICC7th) was Ib:3%, 2a:20%, 2b:20%, and 3:57%. Most lesions were high grade (97%), predominantly leiomyosarcoma (26%) and undifferentiated pleomorphic/malignant fibrous histiocytoma (23%). Limb-sparing surgery was preceded (median 50 Gy) or followed (median 66 Gy) by EBRT.

Results

Median follow-up was 37 months (range 1–128 months). Margins were free in 26 patients (74%) and microscopically positive in 9 (26%). Actuarial 3‑ and 5‑year local control rates were 88 and 81% (4 local recurrences). Corresponding rates for distant control, disease-specific survival, and overall survival were 57/52%, 76/60%, and 72/41%. The 30-day mortality was 0%. Severe postoperative complications were scored in 8 patients (23%). Severe acute radiation-related toxicity was observed in 2 patients (6%). Patients with Charlson score ≥2 had a significantly increased risk for severe postoperative complications and acute radiation-related side effects. Severe late toxicities were found in 7 patients (20%), including fractures in 3 (8.6%). Final limb preservation rate was 97%.

Conclusion

Combination of EBRT and limb-sparing surgery is feasible in elderly patients with acceptable toxicities and encouraging but slightly inferior outcome compared to younger patients. Comorbidity correlated with postoperative complications and acute toxicities. Late fracture risk seems slightly increased.

Zusammenfassung

Zielsetzung

Erfahrungsbericht zur perkutanen Radiotherapie (EBRT) kombiniert mit extremitätenerhaltender Operation bei Patienten >70 Jahre mit Weichteilsarkom der Extremität.

Methoden

Retrospektiv analysiert wurden 35 Patienten (m:w 18:17; median 78 Jahre), die alle in Primärsituation ohne nodale/distante Metastasen waren (Charlson-Score 0/1 bei 18 und ≥2 bei 17 Patienten). Im Median war der Tumor 10 cm groß und betraf meist die untere Extremität (83 %). Klinische Stadien (UICC7) waren Ib:3 %, 2a:20 %, 2b:20 %, 3:57 %. Läsionen waren meist höhergradig (97 %), bevorzugt Leiomyosarkome (26 %) oder undifferenziert-pleomorphes/malignes fibröses Histiozytom (23 %). EBRT erfolgte vor (mediane Dosis 50 Gy) oder nach (mediane Dosis 66 Gy) extremitätenerhaltender Operation.

Ergebnisse

Die mediane Nachbeobachtungszeit betrug 37 Monate (Spanne 1–128 Monate). Freie Ränder hatten 26 (74 %) und mikroskopisch positive 9 Patienten (26 %). Es traten 4 Lokalrezidive auf. Aktuarische 3‑ und 5‑Jahres-Lokalkontrollraten lagen bei 88 % und 81 %. Entsprechende Raten für distante Kontrolle, krankheitsspezifisches und Gesamtüberleben waren 57/52 %, 76/60 % und 72/41 %. Die 30-Tage-Mortalität ergab 0 %. Höhergradige postoperative Komplikationen hatten 8 (23 %), höhergradige radiogene Akutnebenwirkungen 2 Patienten (6 %). Charlson-Score ≥2 war mit signifikant höherem Risiko für höhergradige postoperative Komplikationen und radiogene Akutnebenwirkungen assoziiert. Höhergradige Spätnebenwirkungen hatten 7 Patienten (20 %), inkl. 3 Frakturen (8,6 %). Finaler Extremitätenerhalt war bei 97 % möglich.

Schlussfolgerung

EBRT kombiniert mit extremitätenerhaltender Resektion ist bei älteren Patienten mit akzeptablen Nebenwirkungen durchführbar, mit vielversprechenden, aber im Vergleich zu jüngeren Patienten etwas unterlegenen Ergebnissen. Komorbiditäten korrelieren mit postoperativen Komplikationen und Akutnebenwirkungen. Das Frakturrisiko scheint leicht erhöht.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Zhao RP, Yu XL, Zhang Z et al (2016) The efficacy of postoperative radiotherapy in localized primary soft tissue sarcoma treated with conservative surgery. Radiat Oncol 11:25

    Article  PubMed  PubMed Central  Google Scholar 

  2. Andrä C, Rauch J, Li M et al (2015) Excellent local control and survival after postoperative or definitive radiation therapy for sarcomas of the head and neck. Radiat Oncol 10:140

    Article  PubMed  PubMed Central  Google Scholar 

  3. Jensen AD, Uhl M, Chaudhri N et al (2015) Carbon ion irradiation in the treatment of grossly incomplete or unresectable malignant peripheral nerve sheath tumors: acute toxicity and preliminary outcome. Radiat Oncol 10:109

    Article  PubMed  PubMed Central  Google Scholar 

  4. Calvo FA, Sole CV, Polo A et al (2014) Limb-sparing management with surgical resection, external-beam and intraoperative electron-beam radiation therapy boost for patients with primary soft tissue sarcoma of the extremity. Strahlenther Onkol 190:891–898

    Article  PubMed  Google Scholar 

  5. Hata M, Wada H, Ogino I et al (2014) Radiation therapy for angiosarcoma of the scalp. Strahlenther Onkol 190:899–904

    Article  PubMed  Google Scholar 

  6. Yang JC, Chang E, Baker R et al (1998) Randomized prospective study of the benefit of adjuvant radiation therapy in the treatment of soft tissue sarcomas of the extremity. J Clin Oncol 16:197–203

    Article  CAS  PubMed  Google Scholar 

  7. Pisters PW, Harrison LB, Leung DH et al (1996) Long-term results of a prospective randomized trial of adjuvant brachytherapy in soft tissue sarcoma. J Clin Oncol 14:859–868

    Article  CAS  PubMed  Google Scholar 

  8. Hoven-Gondrie ML, Bastiaannet E, Ho VK et al (2016) Worse survival in elderly patients with extremity soft-tissue sarcoma. Ann Surg Oncol 23:2577–2585

    Article  PubMed  PubMed Central  Google Scholar 

  9. Hutchins LF, Unger JM, Crowley JJ et al (1999) Underrepresentation of patients 65 years of age or older in cancer-treatment trials. N Engl J Med 341:2061–2067

    Article  CAS  PubMed  Google Scholar 

  10. Semrau S, Zettl H, Hildebrandt G et al (2014) Older patients with inoperable non-small cell lung cancer: long-term survival after concurrent chemoradiotherapy. Strahlenther Onkol 190:1125–1132

    Article  PubMed  Google Scholar 

  11. Brown ML, Glanzmann C, Huber G et al (2016) IMRT/VMAT for malignancies in the head-and-neck region: outcome in patients aged 80. Strahlenther Onkol 192:526–536

    Article  PubMed  PubMed Central  Google Scholar 

  12. Fentiman IS, Tirelli U, Monfardini S et al (1990) Cancer in the elderly:why so badly treated? Lancet 335:1020–1022

    Article  CAS  PubMed  Google Scholar 

  13. Balducci L (2000) Geriatric oncology: challenges fort he new century. Eur J Cancer 36:1741–1754

    Article  CAS  PubMed  Google Scholar 

  14. Biau DJ, Ferguson PC, Turcotte RE et al (2011) Adverse effect of older age on the recurrence of soft tissue sarcoma of the extremities and trunk. J Clin Oncol 29:4029–4035

    Article  PubMed  Google Scholar 

  15. Al-Refaie WB, Habermann EB, Dudeja V et al (2010) Extremity soft tissue sarcoma care in the elderly: insights into the generalizability of NCI Cancer Trials. Ann Surg Oncol 17:1732–1738

    Article  PubMed  Google Scholar 

  16. Kemeny M (2000) Cancer surgery in the older cancer patient. Hematol Oncol Clin North Am 14:169–192

    Article  CAS  PubMed  Google Scholar 

  17. Zachariah B, Balducci L (2000) Radiation therapy of the older cancer patient. Hematol Oncol Clin North Am 14:13–168

    Article  Google Scholar 

  18. Nijhuis PH, Schaapveld M, Otter R et al (1999) Epidemiological aspects of soft tissue sarcomas (STS) – consequences for the design of clinical STS trials. Eur J Cancer 35:1705–1710

    Article  CAS  PubMed  Google Scholar 

  19. Lahat G, Dhuka R, Lahat S et al (2009) Complete soft tissue sarcoma resection is a viable treatment option for select elderly patients. Ann Surg Oncol 16:2579–2586

    Article  CAS  PubMed  Google Scholar 

  20. Boden R, Clark M, Neuhaus SJ et al (2006) Surgical management of soft tissue sarcoma in patients over 80 years. Eur J Surg Oncol 32:1154–1158

    Article  CAS  PubMed  Google Scholar 

  21. Issels RD, Lindner LH, Verweij J et al (2010) Neoadjuvant chemotherapy alone or with regional hyperthermia for localized high-risk soft-tissue sarcoma: a randomized phase 3 multicentre study. Lancet Oncol 11:561–570

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Folkert MR, Singer S, Brennan MF et al (2014) Comparison of local recurrence with conventional and intensity-modulated radiation therapy for primary soft-tissue sarcomas of the extremity. J Clin Oncol 32:3236–3241

    Article  PubMed  PubMed Central  Google Scholar 

  23. Alektiar KM, Brennan MF, Healey JH et al (2008) Impact of intensity-modulated radiation therapy on local control in primary soft-tissue sarcoma of the extremity. J Clin Oncol 26:3440–3444

    Article  PubMed  Google Scholar 

  24. Gronchi A, Casali PG, Mariani L et al (2005) Status of surgical margins and prognosis in adult soft tissue sarcomas of the extremities: a series of patients treated at a single institution. J Clin Oncol 23:96–104

    Article  CAS  PubMed  Google Scholar 

  25. Eilber FC, Rosen G, Nelson SD et al (2003) High-grade extremity soft tissue sarcomas: factors predictive of local recurrence and its effect on morbidity and mortality. Ann Surg 237:218–226

    PubMed  PubMed Central  Google Scholar 

  26. Roeder F, Lehner B, Saleh-Ebrahimi L et al (2016) Intraoperative electron radiation therapy combined with external beam radiation therapy and limb sparing surgery in extremity soft tissue sarcoma: a retrospective single center analysis of 183 cases. Radiother Oncol 119:22–29

    Article  PubMed  Google Scholar 

  27. Roeder F, Lehner B, Schmitt T et al (2014) Excellent local control with IOERT and postoperative EBRT in high grade extremity sarcoma: results from a subgroup analysis of a prospective trial. BMC Cancer 14:350

    Article  PubMed  PubMed Central  Google Scholar 

  28. O’Sullivan B, Davis AM, Turcotte R et al (2002) Preoperative versus postoperative radiotherapy in soft-tissue sarcoma of the limbs: a randomised trial. Lancet 359:2235–2241

    Article  PubMed  Google Scholar 

  29. Weitz J, Antonescu CR, Brennan MF (2003) Localized extremity soft tissue sarcoma: improved knowledge with unchanged survival over time. J Clin Oncol 21:2719–2725

    Article  PubMed  Google Scholar 

  30. Zagars GK, Ballo MT, Pisters PW et al (2003) Prognostic factors for patients with localized soft-tissue sarcoma treated with conservation surgery and radiation therapy: an analysis of 1225 patients. Cancer 97:2530–2543

    Article  PubMed  Google Scholar 

  31. Buchner M, Bernd L, Zahlten-Hinguranage A et al (2004) Primary malignant tumours of bone and soft tissue in the elderly. Eur J Surg Oncol 30:877–883

    Article  CAS  PubMed  Google Scholar 

  32. Gortzak Y, Lockwood GA, Mahendra A et al (2010) Prediction of pathologic fracture risk of the femur after combined modality treatment of soft tissue sarcoma of the thigh. Cancer 116:1553–1559

    Article  PubMed  Google Scholar 

  33. Davis AM, Osullivan B, Turcotte R et al (2005) Late radiation morbidity following randomization to preoperative versus postoperative radiotherapy in extremity soft tissue sarcoma. Radiother Oncol 75:48–53

    Article  PubMed  Google Scholar 

  34. Cannon CP, Ballo MT, Zagars GK et al (2006) Complications of combined modality treatment of primary lower extremity soft-tissue sarcomas. Cancer 107:2455–2461

    Article  PubMed  Google Scholar 

  35. Holt GE, Griffin AM, Pintilie M (2007) Fractures following radiotherapy and limb-salvage surgery for lower extremity soft-tissue sarcomas. A comparison of high-dose and low-dose radiotherapy. J Bone Joint Surg Am 87:315–319

    Article  Google Scholar 

  36. Hong L, Alektiar KM, Hunt M et al (2004) Intensity-modulated radiotherapy for soft tissue sarcoma of the thigh. Int J Radiat Oncol Biol Phys 59:752–759

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Radiation Oncology, University Hospital of Munich (LMU), Marchioninistr. 15, 81377, Munich, Germany

    Claudia Andrä M.D.,  Josefine Rauch M.D.,  Claus Belka M.D. &  Falk Roeder M.D.

  2. Department of Orthopedics, University Hospital of Munich (LMU), Munich, Germany

    Alexander Klein M.D. &  Hans Roland Dürr M.D.

  3. Deparment of Internal Medicine, University Hospital of Munich (LMU), Munich, Germany

    Lars Hartwin Lindner M.D.

  4. Institute of Pathology, University Hospital of Munich (LMU), Munich, Germany

    Thomas Knoesel M.D.

  5. Department of Surgery, University Hospital of Munich (LMU), Munich, Germany

    Martin Angele M.D.

  6. Department of Radiology, University Hospital of Munich (LMU), Munich, Germany

    Andrea Baur-Melnyk M.D.

  7. CCU Molecular Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany

    Falk Roeder M.D.

Authors
  1. Claudia Andrä M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Alexander Klein M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Hans Roland Dürr M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Josefine Rauch M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Lars Hartwin Lindner M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Thomas Knoesel M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Martin Angele M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Andrea Baur-Melnyk M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Claus Belka M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Falk Roeder M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Claudia Andrä M.D..

Ethics declarations

Conflict of interest

C. Andrä, A. Klein, H.R. Dürr, J. Rauch, L.H. Lindner, T. Knoesel, M. Angele, A. Baur-Melnyk, C. Belka and F. Roeder declare that they have no competing interests.

Ethical standards

This article does not contain any studies with human participants or animals performed by any of the authors.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Andrä, C., Klein, A., Dürr, H.R. et al. External-beam radiation therapy combined with limb-sparing surgery in elderly patients (>70 years) with primary soft tissue sarcomas of the extremities. Strahlenther Onkol 193, 604–611 (2017). https://doi.org/10.1007/s00066-017-1109-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00066-017-1109-x

Keywords

Schlüsselwörter

Search

Navigation