Müller D A, Beltrami G, Scoccianti G, Frenos F, Capanna R
Department of Orthopedic Surgery, University Hospital Balgrist, Forchstrasse 340, 8008 Zürich, Switzerland.
Department of Orthopedic Oncology, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134 Firenze, Italy.
Eur J Surg Oncol. 2016 Jul;42(7):1057-63. doi: 10.1016/j.ejso.2016.02.004. Epub 2016 Feb 12.
Limb-sparing surgery in combination with radiation therapy is a well-established treatment for high-grade soft tissue sarcomas of the extremities. But selection of cases and optimal sequence of irradiation and surgery still remain controversial.
769 patients with a high-grade soft tissue sarcoma of the extremities, who underwent a limb-sparing surgery, were retrospectively reviewed. Group 1 (N = 89) was treated with neo-adjuvant radiation therapy, group 2 (N = 315) with adjuvant irradiation and group 3 (N = 365) with surgery alone.
After a mean follow up of 45 months 95 local recurrences occurred resulting in a local recurrence-free survival of 83.2% after 5 years and 75.9% after 10 years. Contaminated surgical margins (Odds ratio: 2.42) and previous inadequate surgeries (Odds ratio: 1.89) were identified as risk factors for failed local control. Neo-adjuvant radiation therapy provides the best local recurrence-free rate for 5 years (90.0%), whereas after 10 years (78.3%) adjuvant irradiation showed better local control. The metastatic-free rate was independent from achieved surgical margins (p = 0.179). Group 1 showed the highest rate of revision surgery (9.0%), followed by group 3 (5.5%) and group 2 (4.4%) (p = 0.085). However, the rate of irradiation-correlated side effects was higher in group 2 (15.2%) than in group 1 (11.2%) (p = 0.221).
Surgery has to be effective for successful local control and remains the mainstay of the treatment in combination with neo-adjuvant as well as adjuvant irradiation. In really wide or even radical resections the benefit of radiation therapy can be discussed as the irradiation induced side effects are not negligible.
保肢手术联合放射治疗是治疗四肢高级别软组织肉瘤的一种成熟方法。但病例选择以及放疗与手术的最佳顺序仍存在争议。
对769例行保肢手术的四肢高级别软组织肉瘤患者进行回顾性研究。第1组（N = 89）接受新辅助放射治疗，第2组（N = 315）接受辅助放疗，第3组（N = 365）仅接受手术治疗。
平均随访45个月后，发生95例局部复发，5年局部无复发生存率为83.2%，10年为75.9%。手术切缘污染（比值比：2.42）和既往手术不充分（比值比：1.89）被确定为局部控制失败的危险因素。新辅助放射治疗5年局部无复发生存率最佳（90.0%），而10年后（78.3%）辅助放疗显示出更好的局部控制效果。无转移率与手术切缘情况无关（p = 0.179）。第1组翻修手术率最高（9.0%），其次是第3组（5.5%）和第2组（4.4%）（p = 0.085）。然而，第2组放疗相关副作用发生率（15.2%）高于第1组（11.2%）（p = 0.221）。
手术必须有效才能成功实现局部控制，并且仍然是与新辅助及辅助放疗联合治疗的主要手段。在真正广泛甚至根治性切除中，由于放疗引起的副作用不可忽视，放疗的益处值得探讨。
