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Surgery and radiation therapy in the treatment of soft tissue sarcomas of extremities
Annals of Oncology 3 (Suppl. 2): S93-S95, 1992. © 1992 Kluwer Academic Publishers. Printed in the Netherlands.
Original article Surgery and radiation therapy in the treatment of soft tissue sarcomas of extremities G. Frezza, E. Barbieri, I. Ammendolia, P. Corsa, S. Neri, C. Putti, A. Veraldi & L. Babini lstituto di Radioterapia 'L. Galvani' Universita di Bologna
2.3%; 10 cm: 5/42, 11.9%;), as were also distant metastases. The incidence of distant failures was higher in the group treated with preop. RT (44.0% vs. 22.4%), probably because a higher percentage of patients in this group had large volume diseases. Late sequelae were evaluable in 59 pts. with a follow up longer than 24 months. The incidence of complications was low (10.1%, 6/59); it was higher in the preoperative than in the postoperative group (15.4% vs. 6.1%); this observation is probably related to the different modalities of fractionation.
Introduction
Incisional biopsy was performed in each patient before treatment which allowed histology to be obtained. Results were as follows: fibrous malignant histiocytoma in 31 pts. (31.3%); liposarcoma in 23 pts. (23.2%); synovialsarcoma in 14 pts. (14.1%); fibrosarcoma in 9 pts. (9.1%); hemangiopericytoma in 7 pts. (7.1%); undifferentiated sarcoma in 6 pts. (6.1%); leiomyosarcoma in 4 pts. (4.1%); clear cell sarcoma in 2 pts. (2%); malignant schwannoma in 2 pts. (2%); epitheloid sarcoma in 1 pt. (1%). Stage according to the TNM classification is shown in Table 1. Fifty pts. underwent preop RT; they generally presented large tumours (the largest diameter was more than 13 cm in half of them), and RT was performed to make their resection easier. Doses ranged from 42 to 60 Gy, with 3 Gy daily fractions. RT was followed by a wide excision of the tumour after 15-29 days. Forty-nine pts. were submitted to surgery following RT. They had smaller tumours (mean diameter 8.1 cm) who had been marginally (16 pts.) or incompletely (4 pts.) resected. Other indications to postop. RT included an extracompartmental site of primary (11 pts.) or high grade histology (14 pts.). In this group doses ranged from 49 to 69 Gy with conventional (1.8-2 Gy daily) fractionation. The target volume comprised the mass or the surgical bed with adequate margins (generally the whole muscle compartment was
In the last years conservative surgery followed by radiation therapy has been widely employed in patients with soft tissue sarcomas (STS) of extremities, more recently preoperative radiation therapy has raised the interest of several authors [2, 4, 13-15]. The reasons of this interest are many: preop. RT often allows to perform a non mutilating surgical procedure also in pts. with large tumours; the target volume is generally smaller than in postop. RT; irradiation can inactivate a large number of cells and reduce, therefore, the risk of distant metastatization. In this paper we analyze the results of surgery and radiation therapy in a group of pts. who has been submitted to preop. (50 pts.) or postop. (49 pts.) RT for soft tissue sarcomas of extremities; the prognostic significance of stage, grading and tumour site will be evaluated in both groups, and late complications will be presented.
Key words: preoperative radiation therapy, postoperative radiation therapy, soft tissue sarcomas of extremities
Table I. TNM staging and histopathological grade.
Materials and methods
Preoperative RTa
Between January 1979 and December 1987, 99 pts. with localized STS of extremities were treated with surgery and radiation therapy. Age ranged from 13 to 80 years (mean age 46.5 yrs). Median follow up is 61.2 months (31-126). Primary sites were the following: thigh - 56 pts. (56.5%); leg - 12 pts. (12.1%); arm - 12 pts. (12.1%); pelvic girdle - 7 pts.(7.1%); forearm - 5 pts. (5.1%); shoulder - 3 pts. (3%); foot - 3 pts. (3%); hand - 1 pt. (1.1%).
Tl
T2
Tl
T2
1
41
11
30
Gl G2 G3 a b
Postoperative RT b
Diameter from 3 to 31 cm (average 13.2 cm). Diameter from 2 to 15 cm (average 8.1 cm).
Downloaded from http://annonc.oxfordjournals.org/ at University of Lethbridge on September 6, 2015
Summary. Between January 1979 and December 1987, 99 patients (pts.) with a diagnosis of localized soft tissue sarcoma of the extremities received preoperative radiation therapy (Preop. RT, 50 pts.) or postoperative irradiation (Postop. RT, 49 pts.). In the preop. RT group, doses ranged from 42 Gy/17 fractions to 51 Gy/17 fractions; pts. treated with RT after surgery, received a dose comprised between 46 Gy/23 fractions to 66 Gy/33 fractions. The surgical procedure consisted of making a wide resection of the mass with preservation of the affected limb, in each patient. The main cause of failure was dissemination of the disease (33.3%). The incidence of local failures was low (7.1%). Recurrences were related to the size of the disease (5 cm: 0/12; 5-10 cm: 2/45
94 treated), taking care to leave a strip of unirradiated skin to preserve lymphatic drainage. After 45-50 Gy, pts. treated with postop. RT received a booster dose of 15-20 Gy to a smaller volume comprising the tissues originally involved by the tumour. Since 1983 a CT scan was routinely performed before RT to optimize the treatment planning.
Results
Table 2. Causes of failure in the two treatment groups. No. pts.
Recurrences
Metastases
Total
Preop. RT Postop. RT
50 49
2 (4.0%) 5(10.2%)
22 (44.0%) 11 (22.4%)
24 (48.0%) 16 (32.6%)
Total
99
7 (7.1%)
33 (33.3%)
40 (40.4%)
Table 3. Causes of failure according to the size of the tumor. Size
Pts.
Preop.
Postop.
Local
Distant
Total
5 cm 5-10 cm 10 cm
12 45 42
1 22 27
11 23 15
2(4.4%) 5(11.9%)
1 (8.3%) 14(31.1%) 18(42.8%)
1 (8.3%) 16(37%) 23(54.7%)
Total
99
50
49
7(7.1%)
33(33.1%)
40(40.4%)
Limb sparing surgery followed by radiation therapy has been, in the last years, the main therapeutical approach in patients with localized STS of extremities. With this treatment modality, excellent rates of local control, and good functional results are reported by several authors [2-4,7-10]. While there is a general consensus on the role of RT in patients submitted to conservative surgery, the opinions on which are the best modalities of radiation therapy are discordant. Recently many authors [13, 14] have affirmed that preop. RT could not only present many theoretical advantages (necessity to treat smaller volumes, inactivation of tumour cells with a lower risk of distant metastases) but could also make resectable tumours which should otherwise be treated by amputation. Furthermore preop. RT could be followed by intraoperative boost with electrons or 192Ir in those pts. in which resection is not adequate. Local control in our patients is good (92.9%), and no difference was observed between the two groups. It is however notable that patients who have received preop. RT presented worse prognostic features as large tumours with adhesion to vessels or nerves or high grade histology. The high control rate observed in this group is, therefore, still more remarkable also if the high number of distant metastases reduces greatly the number of patients who could be observed for enough time. One of the aims of this study was an analysis of prognostic factors in STS of extremities. The size of the tumour at the diagnosis has shown to be the most significant feature in determining the chance of relapse. The incidence of distant metastases and local recurrence grows progressively with the volume of the disease; the failure rate is only 8.3% for pts. with a tumour smaller than 5 cm but it is higher than 50% for those who present a tumour of more 10 cm. An analysis of the recent literature does not show a clear relationship between dose and local control. For postop. RT, doses higher than 60 Gy do not improve the control rate and are followed by severe complications [13]. It must be, however, observed that in our experience, local control is higher at doses of more than 55 Gy, and the complications rate seems to be related to the fractions size more than to total dose. The optimal dose for preop. RT is unknown. In our opinion, however, it is not wise to give more than 50 Gy to the preoperative volume, and fraction size must not be higher than 2 Gy, or the incidence and severity of late complications could become unacceptable. As stated above, the main cause of failure in these patients is distant dissemination, since the combination of surgery and RT can give an excellent local control with good functional results. Up to now, there is no evidence that adjuvant chemotherapy can reduce the incidence of metastatization, also if there is a trend to better results in patients treated with this approach,
Downloaded from http://annonc.oxfordjournals.org/ at University of Lethbridge on September 6, 2015
Table 2 shows the sites of relapse according to the treatment received. The main cause of failure was distant metastatization, whose incidence was higher in the preop. RT group (44%). A local, recurrence was recorded in 7 pts., and, in all but 1 pt., it occurred within the booster volume. Distant metastases were observed mainly in the lungs (22 pts.), and were related to the stage of the disease (47.1% in stage lib pts.). The more significant prognostic factor was, however, represented by the tumour size (Table 3). The incidence of relapses increased with the diameter of the tumour; a large mass bared not only a higher risk of local recurrence, but also a higher chance of dissemination. It is not possible to analyze the relationship between the dose of RT and local control, since the number of recurrences is low. Treatment modalities were different between the two groups, and among each of them. It is, however, interesting to observe that, in the group treated with postop. RT, local recurrences were 16.0% at doses lower than 55 Gy, and only 4.1% at higher doses, even if this difference is not statically significant. Late complications were evaluated in 59 pts. alive and free of local disease at 24 months from irradiation. Six patients were scored as having an unacceptable functional result; 3 pts., severe subcutaneous fibrosis with impairment of joint motility; 2 pts., edema of the leg; 1 pt. pathologic fracture of the femur. Four pts. had been treated with preop. RT and 2 with postop. RT. None of them had received a dose of more than 60 Gy.
Discussion
95 especially for some histologies (e.g. synovialsarcoma) [1, 5, 6, 11, 12]. Further randomized studies are necessary to identify subgroups of patients in which chemotherapy can be helpful.
9.
10.
References 11.
12.
14. 15.
Correspondence to: Dr. Giovanni Frezza Istituto di Radioterapia 'L. Galvani' Policlinico S. Orsola Via Massarenti 9-40138 Bologna, Italy
Downloaded from http://annonc.oxfordjournals.org/ at University of Lethbridge on September 6, 2015
1. Bramwell V, Rouesses J, Steward W et al. European experience of adjuvant chemotherapy for soft tissue sarcoma: Interim report of a randomized trial of Cyvadic versus control. Dev Oncol 1988; 55:156-63. 2. Brennan MF, Hilaris B, Shiu MH et al. Local recurrence in adult soft tissue sarcoma. Arch Surg 1987; 122:1289-93. 3. Cade S. Soft tissue tumors, their natural history and treatment. Proch R Soc Med 1950; 44:19-36. 4. Collin CF, Friedrich C, Goldbold J et al. Prognostic factors for local recurrence and survival in patients with localized extremity soft tissue sarcoma. Semin Surg Oncol 1988; 4: 30-7. 5. Das Gupta TK, Patel MK, Chaudhuri PK et al. The role of chemotherapy as an adjuvant to surgery in the initial treatment of primary soft tissue sarcomas in adults. J Surg Oncol 1982; 19:139-44. 6. Eilber FR, Giuliano AE, Huth JF et al. A randomized prospective trial using postoperative adjuvant chemotherapy (Adriamycin) in high-grade extremity soft tissue sarcoma. Am J Clin Oncol 1988; 11: 39-45. 7. Leucutia T. Radiotherapy of sarcoma of the soft parts.Radiology 1985; 25:403. 8. Lindberg R. Treatment of localized soft tissue sarcoma in
adults at M.D. Anderson Hospital and Tumor Institute (19601981). Cancer Treat Symp 1985; 3: 59-65. National Institute of Health Consensus Development Panel on Limb Sparing Treatment of Adult Soft Tissue Sarcomas and Osteosarcomas: Introduction and Conclusions. Cancer Treat Symp 1985; 3: 1-5. Potter DA, Glenn J, Kinsella T et al. Patterns of recurrence in patients with high grade soft tissue sarcomas. J Clin Oncol 1985; 3: 353-66. Rosenberg SA, Tepper J, Glatstein E et al. Prospective randomized evaluation of adjuvant chemotherapy in adults with soft tissue sarcomas of the extremities. Cancer 1983; 52: 424-34. Sordillo PP, Magill GB, Shiu MH et al. Adjuvant chemotherapy of soft parts sarcomas with Alomad (S4). J Surg Oncol 1981; 18:345-53. 13.Suit HD, Mankin HJ, Wood WC et al. Preoperative, intraoperative and postoperative radiation in the treatment of primary soft tissue sarcoma. Cancer 1985; 55: 2659-67. Suit HD, Mankin HJ, Schiller AL et al. Results of treatments of sarcoma of soft tissue by radiation and surgery at Massachusetts General Hospital. Cancer Treat Symp 1985; 3:43-7. Tepper JE, Suit HD. Radiation therapy alone for sarcoma of soft tissue. Cancer 1985; 56:473-81.
Original article Surgery and radiation therapy in the treatment of soft tissue sarcomas of extremities G. Frezza, E. Barbieri, I. Ammendolia, P. Corsa, S. Neri, C. Putti, A. Veraldi & L. Babini lstituto di Radioterapia 'L. Galvani' Universita di Bologna
2.3%; 10 cm: 5/42, 11.9%;), as were also distant metastases. The incidence of distant failures was higher in the group treated with preop. RT (44.0% vs. 22.4%), probably because a higher percentage of patients in this group had large volume diseases. Late sequelae were evaluable in 59 pts. with a follow up longer than 24 months. The incidence of complications was low (10.1%, 6/59); it was higher in the preoperative than in the postoperative group (15.4% vs. 6.1%); this observation is probably related to the different modalities of fractionation.
Introduction
Incisional biopsy was performed in each patient before treatment which allowed histology to be obtained. Results were as follows: fibrous malignant histiocytoma in 31 pts. (31.3%); liposarcoma in 23 pts. (23.2%); synovialsarcoma in 14 pts. (14.1%); fibrosarcoma in 9 pts. (9.1%); hemangiopericytoma in 7 pts. (7.1%); undifferentiated sarcoma in 6 pts. (6.1%); leiomyosarcoma in 4 pts. (4.1%); clear cell sarcoma in 2 pts. (2%); malignant schwannoma in 2 pts. (2%); epitheloid sarcoma in 1 pt. (1%). Stage according to the TNM classification is shown in Table 1. Fifty pts. underwent preop RT; they generally presented large tumours (the largest diameter was more than 13 cm in half of them), and RT was performed to make their resection easier. Doses ranged from 42 to 60 Gy, with 3 Gy daily fractions. RT was followed by a wide excision of the tumour after 15-29 days. Forty-nine pts. were submitted to surgery following RT. They had smaller tumours (mean diameter 8.1 cm) who had been marginally (16 pts.) or incompletely (4 pts.) resected. Other indications to postop. RT included an extracompartmental site of primary (11 pts.) or high grade histology (14 pts.). In this group doses ranged from 49 to 69 Gy with conventional (1.8-2 Gy daily) fractionation. The target volume comprised the mass or the surgical bed with adequate margins (generally the whole muscle compartment was
In the last years conservative surgery followed by radiation therapy has been widely employed in patients with soft tissue sarcomas (STS) of extremities, more recently preoperative radiation therapy has raised the interest of several authors [2, 4, 13-15]. The reasons of this interest are many: preop. RT often allows to perform a non mutilating surgical procedure also in pts. with large tumours; the target volume is generally smaller than in postop. RT; irradiation can inactivate a large number of cells and reduce, therefore, the risk of distant metastatization. In this paper we analyze the results of surgery and radiation therapy in a group of pts. who has been submitted to preop. (50 pts.) or postop. (49 pts.) RT for soft tissue sarcomas of extremities; the prognostic significance of stage, grading and tumour site will be evaluated in both groups, and late complications will be presented.
Key words: preoperative radiation therapy, postoperative radiation therapy, soft tissue sarcomas of extremities
Table I. TNM staging and histopathological grade.
Materials and methods
Preoperative RTa
Between January 1979 and December 1987, 99 pts. with localized STS of extremities were treated with surgery and radiation therapy. Age ranged from 13 to 80 years (mean age 46.5 yrs). Median follow up is 61.2 months (31-126). Primary sites were the following: thigh - 56 pts. (56.5%); leg - 12 pts. (12.1%); arm - 12 pts. (12.1%); pelvic girdle - 7 pts.(7.1%); forearm - 5 pts. (5.1%); shoulder - 3 pts. (3%); foot - 3 pts. (3%); hand - 1 pt. (1.1%).
Tl
T2
Tl
T2
1
41
11
30
Gl G2 G3 a b
Postoperative RT b
Diameter from 3 to 31 cm (average 13.2 cm). Diameter from 2 to 15 cm (average 8.1 cm).
Downloaded from http://annonc.oxfordjournals.org/ at University of Lethbridge on September 6, 2015
Summary. Between January 1979 and December 1987, 99 patients (pts.) with a diagnosis of localized soft tissue sarcoma of the extremities received preoperative radiation therapy (Preop. RT, 50 pts.) or postoperative irradiation (Postop. RT, 49 pts.). In the preop. RT group, doses ranged from 42 Gy/17 fractions to 51 Gy/17 fractions; pts. treated with RT after surgery, received a dose comprised between 46 Gy/23 fractions to 66 Gy/33 fractions. The surgical procedure consisted of making a wide resection of the mass with preservation of the affected limb, in each patient. The main cause of failure was dissemination of the disease (33.3%). The incidence of local failures was low (7.1%). Recurrences were related to the size of the disease (5 cm: 0/12; 5-10 cm: 2/45
94 treated), taking care to leave a strip of unirradiated skin to preserve lymphatic drainage. After 45-50 Gy, pts. treated with postop. RT received a booster dose of 15-20 Gy to a smaller volume comprising the tissues originally involved by the tumour. Since 1983 a CT scan was routinely performed before RT to optimize the treatment planning.
Results
Table 2. Causes of failure in the two treatment groups. No. pts.
Recurrences
Metastases
Total
Preop. RT Postop. RT
50 49
2 (4.0%) 5(10.2%)
22 (44.0%) 11 (22.4%)
24 (48.0%) 16 (32.6%)
Total
99
7 (7.1%)
33 (33.3%)
40 (40.4%)
Table 3. Causes of failure according to the size of the tumor. Size
Pts.
Preop.
Postop.
Local
Distant
Total
5 cm 5-10 cm 10 cm
12 45 42
1 22 27
11 23 15
2(4.4%) 5(11.9%)
1 (8.3%) 14(31.1%) 18(42.8%)
1 (8.3%) 16(37%) 23(54.7%)
Total
99
50
49
7(7.1%)
33(33.1%)
40(40.4%)
Limb sparing surgery followed by radiation therapy has been, in the last years, the main therapeutical approach in patients with localized STS of extremities. With this treatment modality, excellent rates of local control, and good functional results are reported by several authors [2-4,7-10]. While there is a general consensus on the role of RT in patients submitted to conservative surgery, the opinions on which are the best modalities of radiation therapy are discordant. Recently many authors [13, 14] have affirmed that preop. RT could not only present many theoretical advantages (necessity to treat smaller volumes, inactivation of tumour cells with a lower risk of distant metastases) but could also make resectable tumours which should otherwise be treated by amputation. Furthermore preop. RT could be followed by intraoperative boost with electrons or 192Ir in those pts. in which resection is not adequate. Local control in our patients is good (92.9%), and no difference was observed between the two groups. It is however notable that patients who have received preop. RT presented worse prognostic features as large tumours with adhesion to vessels or nerves or high grade histology. The high control rate observed in this group is, therefore, still more remarkable also if the high number of distant metastases reduces greatly the number of patients who could be observed for enough time. One of the aims of this study was an analysis of prognostic factors in STS of extremities. The size of the tumour at the diagnosis has shown to be the most significant feature in determining the chance of relapse. The incidence of distant metastases and local recurrence grows progressively with the volume of the disease; the failure rate is only 8.3% for pts. with a tumour smaller than 5 cm but it is higher than 50% for those who present a tumour of more 10 cm. An analysis of the recent literature does not show a clear relationship between dose and local control. For postop. RT, doses higher than 60 Gy do not improve the control rate and are followed by severe complications [13]. It must be, however, observed that in our experience, local control is higher at doses of more than 55 Gy, and the complications rate seems to be related to the fractions size more than to total dose. The optimal dose for preop. RT is unknown. In our opinion, however, it is not wise to give more than 50 Gy to the preoperative volume, and fraction size must not be higher than 2 Gy, or the incidence and severity of late complications could become unacceptable. As stated above, the main cause of failure in these patients is distant dissemination, since the combination of surgery and RT can give an excellent local control with good functional results. Up to now, there is no evidence that adjuvant chemotherapy can reduce the incidence of metastatization, also if there is a trend to better results in patients treated with this approach,
Downloaded from http://annonc.oxfordjournals.org/ at University of Lethbridge on September 6, 2015
Table 2 shows the sites of relapse according to the treatment received. The main cause of failure was distant metastatization, whose incidence was higher in the preop. RT group (44%). A local, recurrence was recorded in 7 pts., and, in all but 1 pt., it occurred within the booster volume. Distant metastases were observed mainly in the lungs (22 pts.), and were related to the stage of the disease (47.1% in stage lib pts.). The more significant prognostic factor was, however, represented by the tumour size (Table 3). The incidence of relapses increased with the diameter of the tumour; a large mass bared not only a higher risk of local recurrence, but also a higher chance of dissemination. It is not possible to analyze the relationship between the dose of RT and local control, since the number of recurrences is low. Treatment modalities were different between the two groups, and among each of them. It is, however, interesting to observe that, in the group treated with postop. RT, local recurrences were 16.0% at doses lower than 55 Gy, and only 4.1% at higher doses, even if this difference is not statically significant. Late complications were evaluated in 59 pts. alive and free of local disease at 24 months from irradiation. Six patients were scored as having an unacceptable functional result; 3 pts., severe subcutaneous fibrosis with impairment of joint motility; 2 pts., edema of the leg; 1 pt. pathologic fracture of the femur. Four pts. had been treated with preop. RT and 2 with postop. RT. None of them had received a dose of more than 60 Gy.
Discussion
95 especially for some histologies (e.g. synovialsarcoma) [1, 5, 6, 11, 12]. Further randomized studies are necessary to identify subgroups of patients in which chemotherapy can be helpful.
9.
10.
References 11.
12.
14. 15.
Correspondence to: Dr. Giovanni Frezza Istituto di Radioterapia 'L. Galvani' Policlinico S. Orsola Via Massarenti 9-40138 Bologna, Italy
Downloaded from http://annonc.oxfordjournals.org/ at University of Lethbridge on September 6, 2015
1. Bramwell V, Rouesses J, Steward W et al. European experience of adjuvant chemotherapy for soft tissue sarcoma: Interim report of a randomized trial of Cyvadic versus control. Dev Oncol 1988; 55:156-63. 2. Brennan MF, Hilaris B, Shiu MH et al. Local recurrence in adult soft tissue sarcoma. Arch Surg 1987; 122:1289-93. 3. Cade S. Soft tissue tumors, their natural history and treatment. Proch R Soc Med 1950; 44:19-36. 4. Collin CF, Friedrich C, Goldbold J et al. Prognostic factors for local recurrence and survival in patients with localized extremity soft tissue sarcoma. Semin Surg Oncol 1988; 4: 30-7. 5. Das Gupta TK, Patel MK, Chaudhuri PK et al. The role of chemotherapy as an adjuvant to surgery in the initial treatment of primary soft tissue sarcomas in adults. J Surg Oncol 1982; 19:139-44. 6. Eilber FR, Giuliano AE, Huth JF et al. A randomized prospective trial using postoperative adjuvant chemotherapy (Adriamycin) in high-grade extremity soft tissue sarcoma. Am J Clin Oncol 1988; 11: 39-45. 7. Leucutia T. Radiotherapy of sarcoma of the soft parts.Radiology 1985; 25:403. 8. Lindberg R. Treatment of localized soft tissue sarcoma in
adults at M.D. Anderson Hospital and Tumor Institute (19601981). Cancer Treat Symp 1985; 3: 59-65. National Institute of Health Consensus Development Panel on Limb Sparing Treatment of Adult Soft Tissue Sarcomas and Osteosarcomas: Introduction and Conclusions. Cancer Treat Symp 1985; 3: 1-5. Potter DA, Glenn J, Kinsella T et al. Patterns of recurrence in patients with high grade soft tissue sarcomas. J Clin Oncol 1985; 3: 353-66. Rosenberg SA, Tepper J, Glatstein E et al. Prospective randomized evaluation of adjuvant chemotherapy in adults with soft tissue sarcomas of the extremities. Cancer 1983; 52: 424-34. Sordillo PP, Magill GB, Shiu MH et al. Adjuvant chemotherapy of soft parts sarcomas with Alomad (S4). J Surg Oncol 1981; 18:345-53. 13.Suit HD, Mankin HJ, Wood WC et al. Preoperative, intraoperative and postoperative radiation in the treatment of primary soft tissue sarcoma. Cancer 1985; 55: 2659-67. Suit HD, Mankin HJ, Schiller AL et al. Results of treatments of sarcoma of soft tissue by radiation and surgery at Massachusetts General Hospital. Cancer Treat Symp 1985; 3:43-7. Tepper JE, Suit HD. Radiation therapy alone for sarcoma of soft tissue. Cancer 1985; 56:473-81.