PowerPointPrsentation

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Intraoperative Radiation Therapy (IORT) for
primary and recurrent extremity soft tissue
sarcoma First results of a poole analysis
Krempien R1, Roeder F1, Buchler MW1, Di Paoli
A2, Bertola G2, Boz G, 2 Ferrer M3, Alvarez A3,
Calvo FA3 On behalf of the European Working
Party of the International Society of
Intraoperative Radiotherapy (ISIORT) 1University
of Heidelberg, Germany, 2National Cancer
Institute, CRO Aviano, Italy, 3University
Hospital Gregorio Maranon, Madrid, Spain
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Introduction Limb-sparing therapy of
soft-tissue sarcomas

• Amputation limb-sparing surgery
• radiotherapy
• (Rosenberg SA 1982)
• gt30 severe side-effects (fibrosis with
  contractures, neuropathy, bone necrosis, joint
  stiffness), but 70-85 acceptable functional
  outcome

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INTRODUCTIONadjuvant radiotherapyFacts and
Issues

• Radiotherapy increases local control. A benefit
  in survival has not yet been proved (Yang 1998,
  JCO / Pisters 1996,JCO)
• Indication for Radiotherapy Always after
  limb-conservation, or dependant on special risk
  constellations?
• Doses above 62 Gy are superior to lower
  doses,there is no benefit in hyperfractionation!
  (Fein 1995)
• Role of Hypofractionation e.g. by IOERT?
• - Size of treatment volume? Does a reduction of
  the high dose region improve the functional
  outcome without impairment in local control

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Aim pooled data analysis of patients treated
with multimodal concept consisting
of limb-sparing surgery with IOERT and
postoperative irradiation
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Method Standard Irradiation Conceptafter
limb-sparing surgery

• Indication
• - Always after limb-conservation, unless
  resection margin is gt 3cm and
• full compartment resection was conducted
• - generally after local relapse, resection
  margin lt1cm, G3-4,
• size gt 5 cm
• Standard Concept
• External Beam Radiotherapy 45-55 Gy (SD 1,8 -2
  Gy) with a safety margin cranio-caudal 5 cm,
  axial 2-4 cm according to size of muscle
  compartment involved. Boost to the tumorbed plus
  2 cm safety margin with 15-20Gy in conventional
  fractionation.
• IOERT Concept Intraoperative electron beam
  radiotherapy to the tumorbed with a single dose
  of 10-20 Gy with subsequent adjuvant external
  beam radiation with additional 40-50 Gy in
  conventional fractionation

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Method IOERT

• - Patient is beded on mobile operating table
• At the end of tumor resection the radiotherapist
  is called
• Tumor bed is delineated by surgeon, sometimes
  additional consultation of pathologist by phone
• - Applicator of adequate size is positioned above
  tumor bed, which is then marked with titan clips
• patient is covered with sterile sheets, then the
  table is positioned beneath linac
• Linear accelerator and applicator are brought
  into line via an air-docking laser system
• - Team leaves operating theater,
  video-monitoring of patient, IOERT starts
  (duration 2-3 minutes)

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Patients retrospective analysis of 320 patients
with IOERT and adjuvant EBRT from 1991 to 2007
median follow up 61 months
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5-year overall survival 75 10-year overall
survival 58
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Survival (non metastatic patients)
5-year overall survival 77 10-year overall
survival 70
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5-year local control 82 10-year local
control 78
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Prognostic Factors
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Results Analysis of local relapses

• relapse inside/border IORT-field 30
• relapse inside/border EBRT-field 40
• Relapse gt 2cm outside EBRT-field 30

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Side effects / functional outcome
acute side effects wound healing disturbance
17 skin reaction (CTC gt2)
4 thrombosis 2 late toxic
effects ulcus/-fistula/-necrosis
4 (LENT-SOMA gt2) chronic lymph edema
3 fibrosis/contracture
5 neuropathia 5 limb
preservation 90 acceptable functional
outcome 86
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Context - Discussion
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Conclusion

• Implementation of IOERT in limb-preserving
  therapy of STS is justified
• Combination of IOERT and EBRT results in
• good functional outcome
• low incidence of side effects and
• reduced overall treatment time
• without compromising local control
• R1/X-resection can be compensated by IOERT EBRT
• In R2-situations IOERT should be employed in
  palliative intention
• only