Soft tissue sarcoma of the extremities: pending questions on surgery and radiotherapy

Abstract

Soft tissue sarcomas are uncommon tumours of mesenchymal origin, most commonly arising in the extremities. Treatment includes surgical resection in combination with radiotherapy. Resection margins are of paramount importance in surgical treatment of soft tissue sarcomas but unambiguous guidelines for ideal margins of resection are still missing as is an uniform guideline on the use of radiotherapy.The present paper reviews the literature on soft tissue sarcomas of the extremities regarding the required resection margins, the impact of new radiotherapy techniques and the timing of radiotherapy, more particularly if it should be administered before or after surgical resection.This review was started by searching guidelines in different databases (National Guideline Clearinghouse, EBMPracticeNet, TRIP database, NCCN guidelines,…). After refinement of the query, more specific articles were found using MEDLINE, PubMed, Web of Science and Google Scholar. Used keywords include "soft tissue sarcoma"; "extremities OR limbs"; "radiotherapy", "surgery", "margins", "local recurrence" and "overall survival". Finally, the articles were selected based on the accessibility of the full text, use of the English language and relevance based on title and abstract.Literature demonstrates positive resection margins to be an important adverse prognostic factor for local recurrence of soft tissue sarcomas of the extremities. Still, no consensus is reached on the definition of what a good margin might be. The evolution of new radiation techniques, especially Intensity Modulated Radiotherapy, resulted in a s healthy surrounding tissues. However, the timing of radiotherapy treatment remains controversial as both preoperative and postoperative radiotherapy are characterised by several advantages and disadvantages.

Keywords: Extremities; Radiotherapy; Soft tissue sarcoma; Surgery.

Fig. 1

Surgical versus radiotherapeutic margins in the treatment of soft tissue sarcoma of the extremities Schematic description of margins used in the therapy of ESTS. Margins used for radiotherapy differ from those used in surgical resection of the tumour. Nevertheless both include an extra rim of healthy tissue as an attempt to include all microscopic disease around the vast tumour. CC = Cranio-caudal, CTV = clinical target volume, GTV = gross tumour volume, LM = Latero-medial, RT = Radiotherapy