Extermity preservation by combined modality treatment of sarcomas of the hand and wrist

142

Radiation Oncology

??Biology ??Physics

October 1984, Volume 10, Sup. 2

127 EXTREMITY

PRESERVATION

Paul G. Okunieff, Department

M.D.

of Radiation

BY COMBINED

MODALITY

and Herman Medicine,

TREATMENT

OF SARCOMAS

OF THE HAND AND WRIST

0. Suit, M.D. D. Phil. Massachusetts

General

Hospital,

Harvard

Medical

School,

Boston,

MA

Soft tissue sarcomas are uncommon malignancies, less than 10% of which arise on the distal upper Consequently, experience with treatments which preserve both the limb and its function extremities. is lacking for tumors in this region. The treatment of these tumors has traditionally been amputation. The success of limb preserving therapy of extremity sarcomas with conservative surgery and radiation, suggests a role for similar treatment regimes for the therapy of distal upper extremity tumors. For the 12 year period ending January 1983, 16 patients with sarcomas arising in the hand and wrist and one with an aggressive desmoid tumor were treated by combined modality therapy at the Massachusetts General Hospital. Two patients had wide resections for multiple recurrent lesions, 5 had,excisional biopsies, and 9 had incomplete excisions to preserve anatomic structures of the hand. One patient refused an amputation and had no surgery. Sarcoma patients were given post-operative radiation with a dose range of 50.2 to 69 Gy (median 68 Gy). The desmoid tumor received 44 Gy. A shrinking field technique with customized castings and cerrobend blocks was used to assure precision and minimize treatment volumes. Chemotherapy was reserved for metastatic disease. Local control was achieved in I4 patients who received combined modality treatment (87%), with follow-up of 1-12 years (median 33 months). One patient with local failure after combined treatment had salvage surgery for local control, and the second patient developed axillary node involvement and was treated by amputation and axillary radiation with local control at autopsy 111 months after treatment. A third local failure occurred in the patient who declined surgery for a large fungating lesion and who later died of distant metastases 37 months after salvage amputation. Four patients developed metastases, one with epitrochlear lymph node metastases was salvaged by amputation, the others expired with lung disease 17, 37, and 111 months after treatment. Functional integrity of the limb was primarily dependent on the magnitude of the presenting mass, and the extent of surgical resection required. Among I2 patients with local and distant control, one patient (who had multiple wide resections of an extensive desmoid tumor preceding irradiation) lost over 50% of her limb utility, and no patients required amputation for edema or pain control. Most patients (IO/I2) had no pain or edema associated with normal use of their hand, and less then a 25% decrement in function. We conclude that for selected patients with sarcomas of the distal upper extremity, combined modality therapy consisting of conservative resection and careful radiation therapy is a viable alternative to amputation.

128 LOCALLY

RECURRENT

*D.A. Potter,

DISEASE

FOLLOWING

tT.J. Kinsella,

COMBINED

*J. Glenn,

MODALITY TREATMENT OF HIGH-GRADE SOFT TISSUE SARCOMAS

*D. White,

§R. Wesley,

tE. Glatstein,

*Surgery, tRadiation Oncology, and SBiometric Research Branches, Division Cancer Institute, National Institutes of Health, Bethesda, Maryland 20205

and *S.A. Rosenberg,

of Cancer

Treatment,

National

Three hundred seven patients with localized, high-grade soft tissue sarcomas were treated between Two hundred seven of these patients, with primary sarcomas of the extremiJuly, 1975 and December, 1982. ties (121), trunk (40), breast (6), head and neck (12) and retroperitoneum (28), were rendered grossly disease-free surgically and received adjuvant external beam radiotherapy postoperatively. One hundred twenty one patients (121/207) also received adjuvant chemotherapy with cyclophosphamide and doxorubicin. Radiotherapy, designed to treat potential residual microscopic disease, was delivered to the tumor bed and These 207 cases have been reviewed to determine the adjacent tissue to a tumor dose of tissue tolerance. frequency of local failure and the role of surgery in the salvage of patients with locally recurrent disease. Median follow-up for all 207 patients was 34 months. Thirty patients failed locally at some point in their course, (30/207, 15%), with a median period of Frequency of local failure by site of 18 months from resection of the primary sarcoma to local failure. breast, 0% (O/6), extremity, 8% (10/121), head and neck, 17% (2/12), trunk, 20% primary sarcoma was: (9/40), and retroperitoneum 32% (9/28). Twenty five local failures were within the radiation field, five were outside. Nineteen patients (19/30, 65%) presented with isolated, locally recurrent disease in the absence of Eighteen of these patients (18/19, 94%) were rendered fully disease-free surgically, distant metastases. including 6 patients with extremity recurrences treated by amputation, 7 with truncal recurrences, one One patient with a locally recurrent neck with a neck recurrence and 4 with retroperitoneal recurrences. Eleven patients with fully resected, Isolated local recurrences have sarcoma could not be fully resected. remained disease-free (11/18, 61%) with a median follow-up of 24 months after resection of locally recurThe remaining 7 patients developed subsequent recurrences, with a median disease-free interrent disease. The reOne patient with a second isolated local recurrence was again fully resected. val of 7 months. distant metastases and all 6 are dead at follow-up. maining six patients had unresectable,