Intra-operative implant brachytherapy in the management of soft-tissue sarcomas

Background: The management of localized soft-tissue sarcomas remains complex. This is a retrospective review of a single institution experience with manual afterloaded brachytherapy following intra-operative implantation of the tumour bed during surgery. Methods: Twelve patients over a 3-year period had resection for localized soft-tissue sarcomas and desmoids with insertion of intra-operative brachytherapy implants combined with resection for localized soft-tissue sarcomas. Manual afterloading of the implant with iridium wires was performed postoperatively in all patients. The low dose rate brachytherapy dose varied from 13 to 20 Gy. Supplementary external beam radiation was administered pre-operatively or postoperatively to bring the total dose of adjuvant irradiation to 60-65 Gy. Results: After a median follow-up period of 29 months, the 3-year local disease-free survival rare was 63%. The 3-year actuarial survival rate was 83%. There were no failures within the high-dose region of the implant, although two patients had locoregional failures adjacent to the tumour bed at the edge of the radiation field. Three patients developed distant metastases. Side effects were noted in five patients. Wound breakdown and delayed wound healing occurred in two patients. One patient required an amputation as a result of chronic non-healing and wound pain. Pathological fractures occurred in two patients. Those patients who did not develop wound breakdown had good cosmetic and functional outcomes. Conclusion: Intra-operative implantation of the tumour bed in combination with tumour resection for soft-tissue sarcomas results in a high degree of local control with acceptable complications. This modality offers the patient a high chance of avoiding a more radical surgical procedure such as limb amputation.