Radiotherapy sarcomas

Role of radiotherapy in sarcomas and especially extremity sarcomas

1. ROLE OF RADIOTHERAPY IN
SOFT TISSUE SARCOMAS
Dr. AshutoshMukherji
Senior Consultant and Academic Coordinator,
Department of Radiation Oncology
YashodaHospital, Hyderabad, India

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4. What is the Role of Radiation Therapy
in Limb Salvage?
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6. Thetreatmentofsoft-tissuesarcomasoftheextremities:prospective
randomizedevaluationsof(1)limb-sparingsurgeryplusradiation
therapycomparedwithamputationand(2)theroleofadjuvant
chemotherapy.RosenbergSA,TepperJ,etalAnnSurg.1982Sep;196
(3):305-15.
Theonlyrandomizedtrialpublishedtilldatecomparinglimbsparing
surgeryfollowedbyadjuvantradiationtherapyversusamputation
showedthattherewasnodifferenceinlocaldiseasecontrol&overall
survivalbetweenthetwotreatmentgroups.
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Radiotherapy –role in optimisinglocal
control
•Localcontrolratesforcombinationof
surgery+radiotherapysimilarto
amputationwithoutaffectingpatient
survival(Potteretal;1986).
•Yangetal,JClinOncol,1998,looked
athighgradeextremitylesions:Surgery
vsSurgery+EBRT(63Gyin1.8Gy),
-increasedlocalcontrolfrom70%
to99%,NodifferenceinOS.
Summary: Post operative radiotherapy is highly
effective in preventing local recurrence.
•Brachytherapycanbeusedasthesoletherapyiftargetvolume
islocalizedandaccessible.
•Interstitialbrachytherapy(BT)foundtoimprovelocalcontrol
rates(LC)inpatientswithlimb-sparingresectionsofextremity.

8. •Randomizedprospectivestudyofthebenefitofadjuvant
radiationtherapyinthetreatmentofsofttissuesarcomasof
theextremity.YangJC,ChangAE,etalJClinOncol;16(1):197-
2031998.
•Thiscomparedtheresultsoflimbsparingsurgeryalone
comparedtolimbsparingsurgery&adjuvantexternalbeam
radiotherapy(EBRT)showedthattherewasasignificant
decreaseinthelocalrecurrenceratesinthepatientsreceiving
EBRT.Thisimprovementinlocalcontrolwasnotonlyseen
amongstpatientswithhigh/intermediategradetumorsbut
alsoinpatientswithlowgradetumors.
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9. Pre-operative versus Post-operative
Radiotherapy?
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10. PREOPERATIVE RADIATION
•RTOGIntergroupphaseIItrialwithchemo(modifiedMAIDregimen)
concurrentwithpreopRTf/dresectioninptswithhighrisksofttissue
sarcoma(Grade>2,or>8cminmaxdiameter)followedby3cyclesofpost
opCTwithG-CSF.
•88%ofptscompletedpre-opCTand98%completedRT.Delayedwound
healingobservedin26%.
•Estimated2yrsurvivalwas95%.
KarybillWG,SpiroI,HarrisJ,etal:RTOG95-14;aphasetwostudyofNACTandRTinhighrisk,highgrade,soft
tissuesarcomasoftheextremityandthebodywall:apreliminaryreport.PROCASCO.2001;20:34a

11. OVERVIEW OF PREOP RT
First AuthorRadiation
Dose (GY)
Study DesignNo. of PatientsLocalfailure %
Suit 50–56 Retrospective89 17
Barkley 50 Retrospective110 10
Brant 50.4 Retrospective58 9
O'Sullivan 50 RCT 94 7

12. •Preoperative versus postoperative radiotherapy in soft tissue sarcoma of the
limbs: a randomisedtrial. -O’Sullivan Bet al Lancet. 2002 Jun 29;359
(9325):2235-41.
•Theonlyrandomizedtrialpublishedtilldatecomparingpre-operative
versuspost-operativeradiotherapyshowedthatpost-operativewound
complications(120dayspost-op)weresignificantlyhigherinthepre-
operativeRTgroup.Theoverallsurvivalwasmarginallysuperiorinthe
patientsreceivingpre-operativeradiotherapyarm.
•Preoperative vs. postoperative radiotherapy in the treatment of soft tissue
sarcomas: a matter of presentation -Pollack A et al. Improvement in local
control with pre-op EBRT was only in patients with gross disease while the
benefit of postop EBRT was significant in the patients presenting with
unknown margins after gross total resection.
•Pre-operativeradiotherapyisbeneficialforpatientswithgrossdisease/
primarydiseasewhilePORTbeneficialforpatientswithunknownsurgical
marginsaftergrosstotalresection.
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16. Five year actuarial local control for primary soft
tissue sarcoma according to size and RT sequencing
MGH experience
POST OP RTPOST OP RTPREOP RT PRE OP RT
SIZE (mm) Pts,n % Local
Control
Patients,n % Local
control
25 20 100 11 80
25-49 45 95 16 100
50-100 64 83 63 93
101-150 12 91 34 100
150-200 6 50 25 79
200 3 67 11 100
TOTAL 150 87 160 92

17. POST OPERATIVE RADIATION
•MDAH–300ptswithSTSoftheextremities,H&Nand
retroperitoneumweretreatedwithconservativeexcisionf/bRT
toatotaldoseof60-75Gy.
•Localrecurrencerateswere20%forextremity,38%for
abdominaland23%forH&Nsarcomas.5yrDFSwas61%forall
sites.
•1/3
RD
oftheextremityfailuresoccurredbeyondmarginsofthe
irradiatedfield.Thelocalcontroldidnotchangewith10Gydose
reductioninthelaterperiod.
LindbergRD,MartinRG,RomsdhalMM,etal:ConservativesurgeryandpostoperativeRTin300
adultswithsofttissuesarcomas.Cancer.1981;47:2391.

18. UCSF:29ptswithextremitysarcomasweretreatedwith
conservativesurgeryandpostopRT.Themajorityofthe
caseshadgradeIIIorlargerthan5cmtumors.TheRTdose
Rangedfrom50-75Gy.82%ofptsreceivedmorethan55Gy.
Thelocalcontrolratewithsurgery+RTwas90%,withafive
yearrelapsefreesurvivalof68%.Localrecurrenceratewas
14%forptsreceivingpostopRTvs79%wasthosereceiving
Surgeryalone.
Theseresultsweresuperiortoexcisionalsurgeryaloneand
comparabletoradicalsurgeryonastagebystagebasis.
LeibelSA,TrenbergRF,WaraWM,etal:Softtissuesarcomasoftheextremities;survivaland
patternsoffailurewithconservativesurgeryandpostopRTcomparedtosurgeryalone.
Cancer.1982;50:1076

19. First Author
RT Dose
(GY) Study Design
No. of
Patients
Local
Failure (%)Subset
Karakousis45–60 Retrospective53 14
Suit 60–68 Retrospective131 12
Yang 45 + 18RCT 91 0 (high-grade)
50 5 (low-grade)
O'Sullivan RCT 96 7
Lindberg 60-75 Retrospective300 22

20. Indications for Adjuvant RT
•All High Grade STS.
•Low-IntGrade STS with close or positive margins.
•Tumourrecurrence
•Tumor size of >5 cm,
•Lesions deep to or invading the superficial fascia,
and younger than 50 years
BRACHYTHERAPY –
ABS recommendations for use of brachytherapy in
different situations
•When the tumour is completely resected (Gr2 –
Gr3): surgery followed by brachytherapy alone;
•When the CTV cannot be adequately implanted,
and the surgical margins are positive:
•Surgery followed by brachytherapy and EBRT.
•Other situations, different kinds of brachytherapy
may be indicated
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PreopRT indicated if:
•If tumouradjacent to or
involving critical
•structures.
•Likely difficult resection.
•Tumourinitially
inoperable at diagnosis

21. COMBINED CONSERVATIVE SURGERY AND
RADIATION THERAPY
Treatment Advantages Disadvantages
Preoperative
radiation
1.Smaller treatment volume
2.Decreases risk of surgical implant or
dissemination
3.Smaller surgery
4.Increases tumor resectibility
1.Delay in surgery
2.Delayin wound healing
3.Diagnosis based on small tissue
specimen
4.Need to relay on good radiographic
images and physical examination to
asses the tumor extent
Postoperative
radiation
1.Immediate surgery
2.Tumor extentassessed directly by surgery
3.Larger specimen for pathological diagnosis
4.No radiation induced delay in wound healing
1.Larger treatment volume
2.Delay in radiation
Brachytherapy/
IORT
1.Radiationapplied directly to tumor bed
2.Minimizes radiation damage to surrounding
tissue
3.No delay in radiation to allow for tumor
repopulation and hypoxia
4.Shortens treatment time with possible cost
reduction
1.Needs local expertise in IORT or
brachytherapy
2.Requires closecooperation between
surgeon and oncologist
3.Treatment volume is limited to direct
tumor bed
4.Radiation exposure to hospital staff

22. Can we avoid Radiation Therapy for
High Grade STS with Wide Surgical
Margins?
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23. •Long-termresultsofprospectivetrialofsurgeryalonewithselectiveuseof
radiationforpatientswithT1extremityandtrunksofttissuesarcomas.
PistersPWetal.AnnSurg.2007Oct;246(4):675-81;discussion681-2.This
studyfromMDAndersonCancerCentrereportedlocalrecurrenceratesof
8%&11%at5&10yearsforpatientswithT1alesionshavingundergoneR0
resectionandnofurtheradjuvanttherapy.
•Improved survival with radiation therapy in high-grade soft tissue Sarcomas
of the extremities: a SEER analysis. Matthew Koshy et al. Int. J. Radiation
Oncology Biol. Phys., Vol. 77, No. 1, pp. 203–209, 2010. SEER data suggested
that adjuvant RT could possibly be avoided in patients with T1 (<5cm) who
have undergone WLE with negative surgical margins. The results need to be
interpreted in the correct perspective as this being a nonrandomized study
and patients with poor prognostic features went on to receive adjuvant
radiotherapy.
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24. •Surgeryaloneisadequatetreatmentforearlystagesofttissuesarcomaof
theextremity.Al-RefaieWBetal.BrJSurg.2010May;97(5):707-13.
•Associationoflocalrecurrencewithsubsequentsurvivalinextremitysoft
tissuesarcoma.-LewisJJetal.JClinOncol.1997Feb;15(2):646-52.
Intheabsenceofrandomizedtrialaddressingtheissueofadjuvant
radiotherapyforT1highgradeSTS;itwouldbeadvisabletotreatsuchpatients
withradicalinterstitialbrachytherapythatwouldbeidealforpatientswith
suchsmalllesions.
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25. What is the benefit of Radiation
Therapy for Low Grade STS?
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26. •Randomizedprospectivestudyofthebenefitofadjuvantradiationtherapyin
thetreatmentofsofttissuesarcomasoftheextremity.YangJCetal;JClin
Oncol;16(1):197-2031998.Theauthorsreported50patientswithlow-grade
lesions(24randomizedtoresectionaloneand26toresectionand
postoperativeXRT),therewasalowerprobabilityoflocalrecurrence(p
=0.016)inpatientsreceivingadjuvantradiotherapy,althoughwithouta
differenceinoverallsurvival.
This is the only RCT. Thus Adjuvant radiotherapy can be avoided only in very
select group of patients in the absence of any of the adverse prognostic factors
like deep seated tumor, >5cm, & close or positive surgical margins
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27. Impact of Interval between Surgery &
Radiation Therapy?
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28. •Intervalbetweensurgeryandradiotherapy:effectonlocalcontrolofsoft
tissuesarcoma.BalloMT,etal.IntJRadiatOncolBiolPhys.2004Apr1;58
(5):1461-7.
•Therecordsof799patientspostPORTforsofttissuesarcomabetween
1960and2000wereretrospectivelyreviewed.Univariateandmultivariate
analyseswereusedtoevaluatethepotentialimpactofthetimingof
postoperativeRTontherateoflocalcontrol(LC).
•AdelaybetweensurgeryandthestartofRTof>30dayswasassociated
withadecreased10-yearLCrate,butthisassociationwasnotstatistically
significant(76%vs.83%,p=0.07).ThepotentialassociationbetweenRT
delayandinferiorLCattributedtoanimbalanceinthedistributionofother
prognosticfactors.
•TheauthorsconcludedthattheintervalbetweensurgeryandRTdidnot
significantlyimpactthe10-yearLCrateandthatanRTdelayshouldnotbe
viewedasanindependentadversefactorforLC.Treatmentintensification
maynotbenecessaryforpatientswithtreatmentdelay.
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29. Wither Safe Margins?
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Usualextentof
surgicalexcision

31. •2217patientswithnonmetastaticextremityandtruncalSTStreatedwith
surgicalresectionandmultidisciplinaryconsiderationofperioperative
radiotherapywereretrospectivelyreviewed.
•Marginswerecodedbyresidualtumor(R)classification(inwhich
microscopictumoratinkedmargindefinesR1),theR+1mmclassification
(inwhichmicroscopictumorwithin1mmofinkdefinesR1)
•TorontoMarginContextClassification(TMCC;inwhichpositivemargins
areseparatedintoplannedclosebutpositiveatcriticalstructures,positive
afterwhoopsre-excision,andinadvertentpositivemargins).
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32. •TheAJCCmanualdescribesanR0marginasfreeofmalignancy,an
R1marginisdefinedasmicroscopictumorcellspresentattheinked
borderofthespecimen,andR2referstoagrosslypositivemargin.
•SeveralstudiesofsurgicalmarginsinextremitySTShaveusedthis
definitionandfounditprognosticforLR.
•Otherauthorshavedefinedasurgicalmarginof<1mmfromtumor
asmicroscopicallypositive;thissystemhaslikewisebeenreported
asprognosticforLR.
•CurrentguidelinesrecommendcompleteresectionofSTSwitha
negativesurgicalmargin,withoutaspecificrecommendationfor
thewidthofthatmarginorastandarddefinitionofanegative
margin
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33. •ByRclassification,LRratesat10-yearfollow-upwere8%,21%,and44%in
R0,R1,andR2,respectively.
•R+1mmclassificationresultedinincreasedR1margins(726v278,P<.001),
butledtodecreasedLRforR1marginswithoutchangingR0LR;forR0,the
10-yearLRratewas8%(range,7%to10%);forR1,the10-yearLRratewas
12%(10%to15%).
•TheTMCCalsoshowedvariousLRratesamongitstiers(P<.001).LRrates
forpositivemarginsoncriticalstructureswerenotdifferentfromR0at10
years(11%v8%,P=.18),whereasinadvertentpositivemarginshadhigh
LR(5-year,28%[95%CI,19%to37%];10-year,35%[95%CI,25%to46%];
P<.001).
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38. DOSE VOLUME GUIDELINES FOR ADJUVANT RT
FOR EXTREMITY SOFT TISSUE SARCOMA
Mode ofRT Treatment
phase
Volumetric coverage Dose
Preoperative EBRTPhase 1
Phase 2
GTV + 4cm CTV margin
OriginalGTV + 2cm CTV margin
50Gy/25#/5wks
If required
Postoperative
EBRT
Phase1
Phase 2
Limits of surgical dissection
including scars and drain sites
plus 4cm CTV margin
High risk target volume(original
GTV and surgical scar) plus 1cm
CTV margin
50Gy/25#/5wks
16Gy/8#/1.3wks
Brachytherapy Course Surgicalbed plus 2cm 45Gy in 4-6days

39. •Circumferentialirradiationofextremityresultsinseverefibrosis
withpain,edemaandlossoffunction–trytospareasmuch
normaltissuecompartmentsaspossibleorat-least1cmstripof
normaltissue.
•Portionofcircumferenceofuninvolvedboneshouldbesparedto
preventfracture
•Bolusshouldbekeptoverthesurgicalscar
•Ifthescarcrossesajoint,partofjointshouldbeblockedoutunless
thejointwasviolatedsurgically
•Gonadalshielding
•Longfields–gapped,matchlinetobemovedweekly
•Wedgefiltersandcompensators

40. Dosages
NCI guidelines –post op dose 63Gy at 1.8Gy fractions, 70-75Gy for gross
residual disease
NCCN guidelines 2008
Post op RT
Positive margins-50Gy/25#/5wks EBRT
+ 20Gy BRT boost
Negative margins -45Gy BRT
OR
IORT f/b 50Gy/25# /5wks EBRT
OR
Microscopically positive margins-50Gy/25#/5wks EBRT
+16 –20Gy boost
Macroscopically positive margins -50Gy/25#5wks EBRT
+ 20-24Gy boost
Negative margins-50Gy/25# EBRT
+10-16Gy boost

41. Can Radical Interstitial Brachytherapy
obviate the need for External Beam
Radiation Therapy?
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43. •Withamedianfollow-uptimeof76months,the5-year
actuariallocalcontrolrateswere82%and69%intheBRTand
noBRTgroups(P=.04),respectively.
•Patientswithhigh-gradelesionshadlocalcontrolratesof89%
(BRT)and66%(noBRT)(P=.0025).
•BRThadnoimpactonlocalcontrolinpatientswithlow-grade
lesions(P=.49).
•The5-yearfreedom-from-distant-recurrencerateswere83%
and76%intheBRTandnoBRTgroups(P=.60),respectively.
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45. Perioperative Interstitial Brachytherapy for Soft Tissue Sarcomas:
Prognostic Factors and Long-Term Results of 155 Patients
Annals of Surgical Oncology; February 2007, Volume 14, Issue 2,
pp 560–567, Laskar et al
•60% had lesions involving the lower extremities. Treatment included
wide local excision of primary tumor with BRT with or without
external beam radiotherapy (EBRT).
•median follow-up 45 months, the local control (LC), disease-free
survival (DFS), and overall survival (OS) was 71%, 57%, and 73%,
respectively.
•DFS was superior for superficial tumors compared with that for deep
tumors (96% vs. 54%, P =0.02). Tumor size less than 5 cm had
superior OS (88% vs. 63%, P =0.05).
•Cumulative radiotherapy dose greater than 60 Gy had a significant
positive impact on LC (P = 0.003), DFS (P =0.003), and OS (P =0.048).
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46. RESULTS ADJUVANT HDR
BRACHYTHERAPY IN SOFT TISSUE
SARCOMAS OF EXTREMITIES
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Author BrachyusedSample size Local control%Complications %
Alekhteyar LDR-HDR 18 90 38
Chuba HDR 32 82 48
Crownover HDR 10 100 0
Donath HDR 19 70 16
Koizumi HDR 16 50 6
Pellizzon HDR 25 84 24
Yoshida HDR 13 72 8

47. RESULTS ADJUVANT LDR
BRACHYTHERAPY IN SOFT TISSUE
SARCOMAS OF EXTREMITIES
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Author BrachyusedSample size Local control %Complications %
Chaudhary LDR 118 96 10
Cionini LDR 33 91 6
Gemer LDR 25 80 36
O’ Connor LDR 68 91 22
Schray LDR 63 96 10
Thomas LDR 57 89 28
Rosenblatt LDR 11 100 15

48. American Brachytherapy Society (ABS)
consensus statement for sarcoma brachytherapy
•Adjuvant external beam radiation therapy (EBRT) or brachytherapy
(BT) can enhance local control (LC) in patients undergoing limb-
sparing sarcoma resections in the extremity and is supported by
Level 1 evidence.
•No controlled studies comparing EBRT with BT.
•Limitations for BT are large target volumes, restrictions in catheter
placement because of bone or visceral organs, anatomic sites
where good catheter geometry may be difficult to achieve (i.e.,
around the shoulder), and risk of radiation injury to nerves.
•There is no consensus on whether BT should be combined with
EBRTin the setting of positive margins or whether one modality is
sufficient.
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49. •ResultsfromMemorialSloanKettering(MSKCC):improvedwith
additionofinterstitialbrachytherapytoRTinadjuvantsetting
withpositivemarginsandrecurrentdisease.
•MSKCCgroupnoticedthatshoulderlocationwasanindependent
prognosticfactorforpoorlocalcontrolwithinterstitial
brachytherapy.
•BTincombinationwithexternalbeamisrecommendedforcases
withrecurrentdiseasewhohavenotbeenpreviouslyirradiated.
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50. What I would like from my surgeon
•Place metallic clips at boundaries of
resection
•Skin exit point of drain to be near the
incision
•Bury the neurovascular bundle if
exposed and mark the site with a clip
•Please give me clear radial margins; RT
boost does not improve results, better
to re-excise for clear margins
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52. TARGET VOLUME
•Targetvolume:definedfrompreoperativeimagingand/orintra
operativeevaluation.
•TheGTVisbasedonimaging(MRI)andthepre-operative
description,
•CTVisconsideredtobetheex-GTVplusa2-3cmmarginforBT.
Theradio-opaquemarkersorclipsplacedatthetimeofsurgery
helpthephysiciancontourtheCTV.
5-10cmmarginaroundthetumourbedisusedforexternalbeam
therapy.However,marginsarenowconsideredtobebasedmoreon
anatomicalmuscularcompartmentsthanoncmmargins.
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53. 53
ExposedNeuro-vascular
bundlecanbe“buried”
underamuscular
pedicle
Thebedorthe
targetvolume
isre-aligned
anatomicallyby
staysutures

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Intraoperativeplacementofbrachytherapycatheters
demonstratingboth(a)paralleland(b)perpendicular
orientationofthecathetersinrelationtothewound.

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Implantation of the
metallic needles
Replacement of the
needles by parallel
plastic tubes

56. •Thepositioningoftheplastictubesisadaptedtothedimensions
oftheCTV.Parallelandequidistantplastictubesarespaced10to
20mm,accordingtothedepthofthetissuetobetreated.
•Toachievegoodparallelismandequidistancebetweentheplastic
tubes,theycanbepartiallyfixedbysurgicalsutureseitherinside
thetumourbedoratskinlevel(attheentranceandexitpoints).
•CTsimulationisthecurrentstandardforBTdosimetryof
sarcomas.Itallowsfor3Ddosimetryoftheimplant.
•Presentationofaxialisodosecurves,dosevolumehistogram
(DVH)data,andvirtualimagesfacilitatesunderstandingofthe
targetdosesandpermitsplacementofdoseconstraints.
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57. 57
Closing of the surgical bed;
pre-perforated catheters
maintain the equidistance
of the plastic tubes
Surgical scar and
plastic tubes

58. •The quality of the implant can be measured in terms of
–D90 (dose to 90% of the CTV),
–V100 (percent of the CTV that receives the 100% isodose),
–V150 (percent of the CTV that receives the 150% isodose).
•attempt should be made to limit the dose to the surgical incision
to less than 100% isodose unless it is considered at high risk for
tumor involvement.
•The dose to the skin ideally should be no more than two-thirds of
the prescribed dose.
•In addition, source loading should be no closer than 0.5 cm from
the skin surface to minimize skin toxicity.
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3D CT-based dosimetryof an implant in (a) coronal and (b)
axial planes. The 150-50% isodosesare demonstrated. (b)
Surgical clips help to delineate the clinical target volume

60. 60
Dose covering 50%
isodoseline
Dose covering 90%
isodose/ prescribed dose

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63. 63
Treated sites
(over the anterior shoulder)

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Expected CTV marked out with wire before
CT scan

65. 65
Thermoplasticframefixedto
area;dentalwaxlayeredoverto
preparemouldofrequired
thickness;cathetersmarkedand
fixedintothemouldandagain
positionedonpatienttocheck
feasibilityofcatheterplacement
andlesioncoverage.

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67. 3D VIEW WITH MOULD IN PLACE
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68. Brachytherapy vs IMRT?
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69. 69
134adultpatientswithhigh-gradeprimary
non-metastaticSTSoftheextremitywere
treatedatthisinstitutionwithlimb-sparing
surgeryandadjuvantradiotherapy(RT).
Medianfollow-upwas46monthsforIMRT
and47monthsforBRT.5-yearlocalcontrol
was92%(95%confidenceinterval[CI],85-
100)forIMRTversus81%(95%CI,71-90)
forBRT,P¼0.04.Onmultivariateanalysis,
IMRTwastheonlypredictorofimproved
localcontrol,P¼0.04.

70. •Impactofintensity-modulatedradiationtherapyonlocalcontrolinprimary
soft-tissuesarcomaoftheextremity.AlektiarKMetal.JClinOncol.2008Jul
10;26(20):3440-4.
•Intensitymodulatedradiationtherapyforretroperitonealsarcoma:acasefor
doseescalationandorganatrisktoxicityreduction.KoshyM,LandryJC,etal.
Sarcoma.2003;7(3-4):137-48.
IMRTinSTSoftheextremityprovidesexcellentlocalcontrolinagroupof
patientswithhighriskfeatures.Thissuggeststhattheprecisionwithwhich
IMRTdoseisdistributedhasabeneficiaryeffectinsparingnormaltissueand
improvinglocalcontrol.
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71. Conclusions
Historicallydeemedradio-resistant.
IMRTshouldbeconsideredtoimproveoutcome
Ifresectionswithmicroscopicallyorgrosslypositive
marginsisexpected,surgicalclipsshouldbeleftinplace
toidentifyhighriskareasforrecurrence(retro
peritoneal,intra-abdominalsarcomas)
TotaldoseofRTisdeterminedbynormaltissue
tolerance
RTaloneisreservedforptswithunresectablelesions
duetoanatomiclocation,medicalinoperabilityor
refusaltoundergosurgery

72. Conclusions
•Adjuvantbrachytherapyimproveslocalcontrolaftercomplete
resectionofsofttissuesarcomasespeciallyinhigh-grade
tumours.IMRTinrecentyearscanreplicateresults.
•Butbrachydoesnotsignificantlyreducedistantmetastasisor
improvedisease-specificsurvival.
•Surfacemouldbrachytherapyusefulalternativetointerstitial
brachytherapy.Importantwheretargetvolumeisextensive/
underlyingcriticalstructurespresentorcatheterplacement
difficult.
Areas like nose, scalp, peri-orbital regions, shoulder or knees
areas where surface mouldbrachytherapy can be successfully
applied

73. THANK YOU