RADIATION ONCOLOGIST MEDICAL ONCOLOGIST
STAGE WISE MANAGEMENT
IA LG SX--FOLLOW UP
IB LG SX ONLY if margin adequate
SX –PORT if close/positive margin
IIA Resectable without functional loss SX—PORT
IIB,III Resectable without fuctional loss SX ---PORT
Synchronous Stage IV
Single organ ,limited tumor bulk,
amenable to complete resection
Primary tr mx
+Metastatectomy/SBRT +/- CT
Palliation + BSC
Most effective treatment to ensure cure.
Adequate Oncologic clearance
-NOVIOLATIONOF FASCIAL PLANES
-NEEDLETRACK & SCARTO BE EXCISEDATTHETIMEOF
WITH NEGATIVE MARGINS
*LIMB SALVAGE SURGERY
Minimum margin 1 cm
Close <1 cm margin
AMPUTATION -GROSSTOTAL RESECTION IS EXPECTEDTO RENDER LIMB NON
-AT PATIENT PREFERENCE
Organ/site/Sx Status of Margin
Depth of tumor
Status of LN
Size of tumor Other studies
Necrosis +/-,Type,% TNM Stage.
Resectable disease but resection will lead to
significant functional loss
PREOP RT PORT
Treatment volume smaller-No need to
cover operated field
Treatment volume larger
Reduce seeding during surgery More seeding
Tumor regression and better resectability
Decreased risk of recurrence
Less toxic More toxic
No hypoxia-Blood supply uninterrupted Hypoxia in tumor bed may adversely affect
Disadv-Poor wound healing
-No complete HPR
Adv-Complete HPR available
Positioning & Immobilisation
Planning CT Scan 3-5 mm cuts with iv contrast
Co register Preoperative MRI /CT
GTV –contour tumor in preop MRI –T1C
---Initial GTV + Margin to encompass microscopic
---Surgical Scar/Drain sites/Surgical clips
---GTV to CTV Margin 3 cm longitudinally (RTOG)
1.5 cm laterally
CTV-PTV Margin 5-10 mm
OAR & Constraints—Depends on primary
55-year-old male with a large high-grade round
cell liposarcoma in right distal thigh. Clinical
stage (AJCC 7th edition) IIIT2bN0M0G3.
The MRI of right distal thigh showed a large well
circumscribed heterogeneous, multiloculated mass
located within the posterior thigh.
The tumor measured 14.8 cm in craniocaudal
dimension, 7.8 cm in AP dimension, and 11.3 cm in
maximal medial-lateral dimension.
Simulation CT images were fused with those
from the diagnostic thigh MRI
Pisters et al 160 extremity & trunk Randomized
42–45 Gy over 4–6d)
BT-LC for high-grade lesions
(65–90%), but not for LG.
No difference in DSS /DM.
(Yang et al. 1998):
140 ,extremity sarcoma, WLE.
LG to obs vs. PORT
HG post-opCT vs.
RT = large field to 45 Gy → boost to
RT increased LC for low-grade
(60% vs. 95%) and high-grade
(75% vs. 100%).
No difference in OS /DMFS
(Rosenberg et al.
43 , HG STS ,extremity
WLE + PORT vs. amputation alone.
RT = 45–50 Gy to compartment
with boost to 60–70 Gy.
No difference in LC, OS, or
Chemo decreased LR and
increased DFS (60% vs. 90%)
and OS (75% vs. 95%).
Pre-op or Post-op RT
NCIC (O’Sullivan et al.
2002; Davis et al. 2005):
with extremity STS
randomized pre-op RT (50
Gy) vs. post-op
RT (66 Gy). If +margins,
pre-op got 16 Gy boost..
No difference LC /DM /PFS
Pollack et al. (1998): post-op RT
(60–66 Gy) Vs pre-op RT
(50 Gy) before excision or
No difference in LC
presenting with gross
disease, best LC with pre-
op RT (88% vs.
presenting after excision -
immediate reexcision and
post-op RT (LC 91% vs.
Oertel et al. (2006): n=153
primary or recurrent
limb-sparing surgery + IORT
10–20 Gy → post-op EBRT
Five-year OS 77%, DMFS
48%, and LC 78%. IORT
dose >15 Gy improved
LC, but EBRT <45 or 45
Gy not significant for LC.
(Sindelar et al. 1993):
randomized to surgery +
IORT 20 Gy → post-op 35–40
Gy vs. surgery → post-op 50–
No difference in 5-year
OS (35%), nonsignificant
increase in LC ,IORT
increased neuropathy if
Alektiar et al. (2000): primary or recurrent
surgery + IORT 12–15 Gy →
post-op EBRT 45–50 Gy.
5-year OS 55%, DMFS
80%, LC 62%, 10%
BENEFIT OF PORT
WE with negative margin- 30%
WE with negative margin and PORT-5%
Adjuvant radiotherapy improves local control
without benefit in Overall survival
34% of all STS
MC- liposarcoma (40%), leiomyosarcoma
(25%), malignant peripheral nerve sheath
tumour and fibrosarcoma
MC visceral STS -GIST, leiomyosarcoma and
Neurological symptoms due to invasion of
Also allows evaluation of the liver, the most
common site of metastasis
No official staging system
The same grading system applies as for
Laparotomy with open biopsy
CT guided biopsy has a limited role only
- unresectable tumour
- doubtful diagnosis
- neoadjuvent chemotherapy considered
Surgery -The mainstay of treatment
Chemotherapy principles are the same as for
-High morbidity and mortality due to
radiosensitivity of surrounding organs
-Intensity-modulated radiation showing
Adverse factors for local recurrence:
>50 years age
fibrosarcoma type including desmoid, malignant
peripheral nerve sheath tumors.
Adverse factors for distant metastasis:
high-grade (at 5 years, <10% for low-grade, 50% for high grade)
leiomyosarcoma or malignant peripheral nerve sheath
CXR/CT Chest 3-6 mon x 2-3 yr
6monthly x 2yr
Baseline and periodic imaging of primary site
Local relaspse-Work up
Single organ &Limited tumor bulk-
Isolated Node-Nodal dissection+/- RT/CT
StageI extrimity 5-year LC 90–100%, OS 90%
II–III extremity ~5-year LC 90%, OS 80% for stage II,
60% for stage III.
For recurrence, amputation salvages
Stage IV EXTRIMITY Limited mets~5-year OS ~25%.
Disseminated ~5-year OS 10%
Retroperitoneal ~5-year LC 50%, DM
20–30%, OS 50%
Take home message
STS are hterogeneous neoplasms
Management of STS requires multidisciplinary
tumor boards and close collaboration between
Surgery is the most important form of treatment
Radiotherapy helps to improve local control.
Chemotherapy can be utilised in selected situations
in adjuvant/Neoadjuvant treatment.