Elsevier

Brachytherapy

Volume 16, Issue 3, May–June 2017, Pages 466-489
Brachytherapy

Consensus Statement
American Brachytherapy Society consensus statement for soft tissue sarcoma brachytherapy

https://doi.org/10.1016/j.brachy.2017.02.004Get rights and content

Abstract

Purpose

Radiation therapy represents an essential treatment option in the management of soft tissue sarcomas (STS). Brachytherapy represents an important subset of radiation therapy techniques used for STS, with evolving indications and applications. Therefore, the purpose of this guideline was to update clinicians regarding the data surrounding brachytherapy (BT) and provide recommendations for the utilization of BT in patients with STS.

Methods and Materials

Members of the American Brachytherapy Society with expertise in STS, and STS BT in particular, created an updated guideline for the use of BT in STS based on a literature review and clinical experience.

Results

Guidelines are presented with respect to dose and fractionation and technical features to improve outcomes and potentially reduce the risk of toxicity. Brachytherapy as monotherapy can be considered in low-risk cases or in situations where re-irradiation is being considered. Brachytherapy boost can be considered in cases at higher risk of recurrence or where BT alone cannot adequately cover the target volume. To limit wound complications, the start of BT delivery should be delayed until final wound closure, or if after immediate reconstruction, started after postoperative Day 5.

Conclusions

The current guidelines have been created to provide clinicians with a review of the data supporting BT in the management of STS as well as providing indications and technique guidelines to ensure optimal patient selection and clinical outcomes.

Introduction

Soft-tissue sarcoma (STS) describes a heterogeneous group of malignant entities, consisting of various pathologies, histologic grades, and sites of origin. Treatment historically consisted of radical resections and amputation, which were associated with a significant detriment in structural function and quality of life. This led to a shift in STS treatment paradigms to a multidisciplinary approach using marginal resection and adjuvant radiation, in hopes of maintaining comparable disease control while improving the patient's quality of life [1], [2], [3], [4]. The first randomized trial to show equivalent disease-specific survival between amputation and limb-sparing surgery with adjuvant radiotherapy (RT) was over three decades ago (2). Now, limb-sparing treatment is the current standard of care.

There are selected cases that can be adequately controlled with wide local excision (WLE) alone [5], [6], [7]. In sarcoma patients with a higher risk of recurrence (i.e., size >5 cm, deep, high grade, recurrent, or closely resected margins), the addition of RT can improve local control (LC). In randomized trials, the addition of external beam radiation therapy (EBRT) (8) or brachytherapy (BT) [9], [10], [11] can offer an absolute LC benefit of ∼20–30% in the setting of limb preserving WLE. Radiation can be administered as EBRT alone, BT alone, or as a combination of EBRT with a brachytherapy boost (EBRT-BT). Treatment with EBRT can be administered in either the preoperative or postoperative setting. Initial trials used postoperative EBRT, but preoperative EBRT has become popular after randomized evidence showed similar LC with the potential for improved late complications [8], [12], [13], [14].

Brachytherapy is primarily delivered intraoperatively or postoperatively. During surgical resection, catheters are implanted in the tumor bed, allowing high radiation dose to the surgical bed with a rapid dose drop to the surrounding normal tissue. This rapid fall off in dose is because of the low energy radiation used in BT, with a limited dose penetration that is in proportion to the inverse square law (1/r2) (15). Historically, BT can better spare normal tissue than EBRT, which may translate to a lower rate of complications (i.e., lymphedema, subcutaneous fibrosis, or bone fractures) [8], [11], [16]. Brachytherapy offers a relatively short and convenient adjuvant treatment, delivered in the inpatient or outpatient setting, usually spanning <1–2 weeks in duration. BT alone is useful when avoiding normal tissue radiation is paramount but is limited in its volume coverage. EBRT can deliver dose to a large volume at risk with increased homogeneity than BT but can increase both low and high radiation dose volumes to normal tissue. The combination of EBRT and BT provides microscopic disease coverage over a sizable volume, which BT alone lacks, and provides faster boost delivery to the surgical bed and a steeper dose gradient, which EBRT alone lacks. In this review, we will discuss BT in STS, focusing on treatment considerations, BT procedures, and patient outcome.

Section snippets

Methods and materials

The American Brachytherapy Society (ABS) board of directors appointed a group of physicians with expertise in sarcoma BT to provide a consensus statement. The previous ABS guideline (17) was updated with recent studies on the topic. Literature review was conducted with inclusion of all human clinical studies available in English language evaluating BT and STS. The goal of these guidelines is to provide an adequate description of treatment considerations, procedural instructions, radiation

Patient workup

STS has a relatively low incidence in the United States, with an estimated 11,930 new cases in 2015 (18), which is best served by a multidisciplinary sarcoma team (19). In addition to staging, preoperative workup should be aimed at assessing extent of disease, resectability, neighboring critical structures, and whether a patient can tolerate treatment (i.e., comorbidities, performance status, previous radiation, etc.). During the history and physical examination, it is important to determine

Discussion

Treatment recommendations and guidelines for dose and fractionation as well technical guidelines are summarized on Table 5. Surgery is the primary component of STS treatment. Surgery alone may be adequate for small (<5 cm) low-grade STS with a clear surgical margin (>1 cm), with nomograms available to assess the risk of recurrence with surgery alone (7). For high-grade STS, adjuvant radiation therapy remains the standard of care with randomized data demonstrating an improvement in LC with EBRT

Conclusion

Brachytherapy remains an essential component in the treatment of STS with data supporting the use of adjuvant BT to improve disease control following local excision. The use of BT monotherapy offers a convenient and effective treatment that spares normal tissue, which is ideal for small high-grade disease, re-irradiation, frail and elderly patients, or children. In combination with EBRT, a BT boost offers an LC benefit for patients with higher risk of recurrence (>10 cm, recurrent, or close

References (226)

  • J. Itami et al.

    High-dose rate brachytherapy alone in postoperative soft tissue sarcomas with close or positive margins

    Brachytherapy

    (2010)
  • M. Delannes et al.

    Low-dose-rate intraoperative brachytherapy combined with external beam irradiation in the conservative treatment of soft tissue sarcoma

    Int J Radiat Oncol Biol Phys

    (2000)
  • R. Martinez-Monge et al.

    Perioperative high-dose-rate brachytherapy in soft tissue sarcomas of the extremity and superficial trunk in adults: Initial results of a pilot study

    Brachytherapy

    (2005)
  • C. Llacer et al.

    Low-dose intraoperative brachytherapy in soft tissue sarcomas involving neurovascular structure

    Radiother Oncol

    (2006)
  • S. Pohar et al.

    Adjuvant high-dose-rate and low-dose-rate brachytherapy with external beam radiation in soft tissue sarcoma: A comparison of outcomes

    Brachytherapy

    (2007)
  • G. Beltrami et al.

    Limb salvage surgery in combination with brachytherapy and external beam radiation for high-grade soft tissue sarcomas

    Eur J Surg Oncol

    (2008)
  • A. Muhic et al.

    Local control and survival in patients with soft tissue sarcomas treated with limb sparing surgery in combination with interstitial brachytherapy and external radiation

    Radiother Oncol

    (2008)
  • I. San Miguel et al.

    Determinants of toxicity, patterns of failure, and outcome among adult patients with soft tissue sarcomas of the extremity and superficial trunk treated with greater than conventional doses of perioperative high-dose-rate brachytherapy and external beam radiotherapy

    Int J Radiat Oncol Biol Phys

    (2011)
  • D.N. Sharma et al.

    Perioperative high-dose-rate interstitial brachytherapy combined with external beam radiation therapy for soft tissue sarcoma

    Brachytherapy

    (2015)
  • G. Voynov et al.

    Intraoperative (125)I Vicryl mesh brachytherapy after sublobar resection for high-risk stage I non-small cell lung cancer

    Brachytherapy

    (2005)
  • S. Mutyala et al.

    Permanent iodine-125 interstitial planar seed brachytherapy for close or positive margins for thoracic malignancies

    Int J Radiat Oncol Biol Phys

    (2010)
  • C. Ren et al.

    Experience of interstitial permanent i(125) brachytherapy for extremity soft tissue sarcomas

    Clin Oncol (R Coll Radiol)

    (2014)
  • D. Nori et al.

    Role of brachytherapy in recurrent extremity sarcoma in patients treated with prior surgery and irradiation

    Int J Radiat Oncol Biol Phys

    (1991)
  • C. Catton et al.

    Soft tissue sarcoma of the extremity. Limb salvage after failure of combined conservative therapy

    Radiother Oncol

    (1996)
  • L. Moureau-Zabotto et al.

    Management of soft tissue sarcomas (STS) in first isolated local recurrence: A retrospective study of 83 cases

    Radiother Oncol

    (2004)
  • M.A. Torres et al.

    Management of locally recurrent soft-tissue sarcoma after prior surgery and radiation therapy

    Int J Radiat Oncol Biol Phys

    (2007)
  • D.J. Indelicato et al.

    Effectiveness and morbidity associated with reirradiation in conservative salvage management of recurrent soft-tissue sarcoma

    Int J Radiat Oncol Biol Phys

    (2009)
  • J.L. Habrand et al.

    Twenty years experience of interstitial iridium brachytherapy in the management of soft tissue sarcomas

    Int J Radiat Oncol Biol Phys

    (1991)
  • R. Martinez-Monge et al.

    Interaction of 2-Gy equivalent dose and margin status in perioperative high-dose-rate brachytherapy

    Int J Radiat Oncol Biol Phys

    (2011)
  • R. Martinez-Monge et al.

    Volume of high-dose regions and likelihood of locoregional control after perioperative high-dose-rate brachytherapy: Do hotter implants work better?

    Brachytherapy

    (2014)
  • T.F. Delaney et al.

    Radiation therapy for control of soft-tissue sarcomas resected with positive margins

    Int J Radiat Oncol Biol Phys

    (2007)
  • D.L. Schwartz et al.

    The effect of delayed postoperative irradiation on local control of soft tissue sarcomas of the extremity and torso

    Int J Radiat Oncol Biol Phys

    (2002)
  • M.T. Ballo et al.

    Interval between surgery and radiotherapy: Effect on local control of soft tissue sarcoma

    Int J Radiat Oncol Biol Phys

    (2004)
  • Z. Lokmic et al.

    Hypoxia and hypoxia signaling in tissue repair and fibrosis

    Int Rev Cell Mol Biol

    (2012)
  • M. Nordsmark et al.

    The relationship between tumor oxygenation and cell proliferation in human soft tissue sarcomas

    Int J Radiat Oncol Biol Phys

    (1996)
  • M.A. Manning et al.

    Biologic treatment planning for high-dose-rate brachytherapy

    Int J Radiat Oncol Biol Phys

    (2001)
  • F. Roeder et al.

    Intraoperative electron radiation therapy combined with external beam radiation therapy and limb sparing surgery in extremity soft tissue sarcoma: A retrospective single center analysis of 183 cases

    Radiother Oncol

    (2016)
  • M. Cambeiro et al.

    Salvage wide resection with intraoperative electron beam therapy or HDR brachytherapy in the management of isolated local recurrences of soft tissue sarcomas of the extremities and the superficial trunk

    Brachytherapy

    (2015)
  • D.J. Demanes et al.

    Brachytherapy catheter spacing and stabilization technique

    Brachytherapy

    (2012)
  • M.M. Spierer et al.

    Tolerance of tissue transfers to adjuvant radiation therapy in primary soft tissue sarcoma of the extremity

    Int J Radiat Oncol Biol Phys

    (2003)
  • R.D. Lindberg et al.

    Conservative surgery and postoperative radiotherapy in 300 adults with soft-tissue sarcomas

    Cancer

    (1981)
  • S.A. Rosenberg et al.

    The treatment of soft-tissue sarcomas of the extremities: prospective randomized evaluations of (1) limb-sparing surgery plus radiation therapy compared with amputation and (2) the role of adjuvant chemotherapy

    Ann Surg

    (1982)
  • J.E. Tepper et al.

    The role of radiation therapy in the treatment of sarcoma of soft tissue

    Cancer Invest

    (1985)
  • E.H. Baldini et al.

    Long-term outcomes after function-sparing surgery without radiotherapy for soft tissue sarcoma of the extremities and trunk

    J Clin Oncol

    (1999)
  • P.W. Pisters et al.

    Long-term results of prospective trial of surgery alone with selective use of radiation for patients with T1 extremity and trunk soft tissue sarcomas

    Ann Surg

    (2007)
  • O. Cahlon et al.

    A postoperative nomogram for local recurrence risk in extremity soft tissue sarcomas after limb-sparing surgery without adjuvant radiation

    Ann Surg

    (2012)
  • J.C. Yang et al.

    Randomized prospective study of the benefit of adjuvant radiation therapy in the treatment of soft tissue sarcomas of the extremity

    J Clin Oncol

    (1998)
  • P.W. Pisters et al.

    A prospective randomized trial of adjuvant brachytherapy in the management of low-grade soft tissue sarcomas of the extremity and superficial trunk

    J Clin Oncol

    (1994)
  • P.W. Pisters et al.

    Long-term results of a prospective randomized trial of adjuvant brachytherapy in soft tissue sarcoma

    J Clin Oncol

    (1996)
  • C. Sadoski et al.

    Preoperative radiation, surgical margins, and local control of extremity sarcomas of soft tissues

    J Surg Oncol

    (1993)
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