Combining limb-sparing surgery with radiation therapy in high-grade soft tissue sarcoma of extremities - Is it effective?

Background: Limb-sparing surgery in combination with radiation therapy is a well-established treatment for high-grade soft tissue sarcomas of the extremities. But selection of cases and optimal sequence of irradiation and surgery still remain controversial. Methods: 769 patients with a high-grade soft tissue sarcoma of the extremities, who underwent a limb-sparing surgery, were retrospectively reviewed. Group 1 (N = 89) was treated with neo-adjuvant radiation therapy, group 2 (N = 315) with adjuvant irradiation and group 3 (N = 365) with surgery alone. Results: After a mean follow up of 45 months 95 local recurrences occurred resulting in a local recurrence-free survival of 83.2% after 5 years and 75.9% after 10 years. Contaminated surgical margins (Odds ratio: 2.42) and previous inadequate surgeries (Odds ratio: 1.89) were identified as risk factors for failed local control. Neo-adjuvant radiation therapy provides the best local recurrence-free rate for 5 years (90.0%), whereas after 10 years (78.3%) adjuvant irradiation showed better local control. The metastatic-free rate was independent from achieved surgical margins (p = 0.179). Group 1 showed the highest rate of revision surgery (9.0%), followed by group 3 (5.5%) and group 2 (4.4%) (p = 0.085). However, the rate of irradiation-correlated side effects was higher in group 2 (15.2%) than in group 1 (11.2%) (p = 0.221). Conclusion: Surgery has to be effective for successful local control and remains the mainstay of the treatment in combination with neo-adjuvant as well as adjuvant irradiation. In really wide or even radical resections the benefit of radiation therapy can be discussed as the irradiation induced side effects are not negligible. (C) 2016 Elsevier Ltd. All rights reserved.