Wanebo H J, Temple W J, Popp M B, Constable W, Aron B, Cunningham S L
Department of Surgery, Brown University, Providence, RI 02908, USA.
Cancer. 1995 May 1;75(9):2299-306. doi: 10.1002/1097-0142(19950501)75:9<2299::aid-cncr2820750919>3.0.co;2-y.
Preoperative radiation with sensitizing doxorubicin has been popularized in the treatment of high grade sarcoma of the extremity. A multiinstitutional experience with this protocol that was initiated by the Southeastern Cancer Study Group in 1984 and maintained in three institutions was updated by the authors.
Patients with biopsied sarcoma had intraarterial infusion with doxorubicin hydrochloride (Adriamycin) 30 mg/24 hrs x 3 days and were allocated by the institution to receive radiation 30-35 Gy in 10 fractions or 46 Gy in 23-25 fractions followed by resection. Surgery was performed within 10 days or 30 days depending on the radiation dose. Postoperative chemotherapy was administered to 31 patients.
Of 66 patients, 32 were female and 34 were male. The median age was 46 years (range, 14-77 years); 73% had lower and 27% had upper extremity tumors. There were 55 soft-tissue and 9 malignant bone tumors. Common types were malignant fibrous histiocytoma 20%; liposarcoma, 17%; synovial sarcoma 18%; and 14% were osteosarcoma. American Joint Committee on Cancer stages were: I, IIB (17%), IIIA/B (59%), and IIIC/4A (24%). Limb salvage surgery was performed on 60 patients including radical resection in 21 with extensive tumors, wide local excision in 30, and limited excision in 2 patients. Primary amputation was performed on four patients and delayed amputation in two because of wound complications. Three patients had pulmonary metastasectomy in conjunction with primary surgery (2 are long term survivors > 5 years). There were no postoperative deaths, but wound complications occurred in 41% of the patients. Overall survival and disease free survival at 5 years was 59 and 49%. One patient (1.5%) had local recurrence 9 years after resection of an extensive synovial sarcoma of the shoulder. This was resected with limb salvage techniques. Among 23 patients who failed primarily in the lung, the median survival was 7 months with 4 surviving more than 5 years, after demonstration of the pulmonary metastases. Multivariant analysis of prognostic factors showed that extent of disease and stage correlated with disease free survival, whereas only extent of surgical resection correlated with overall surgical survival.
Combined therapy for extremity sarcoma in a multicenter setting using preoperative radiation with sensitizing chemotherapy and adequate resection was associated with an excellent local control rate (98.5%) and reasonable long term tumor control, although distant metastases continued to be a major challenge.
术前使用阿霉素进行放疗已广泛应用于肢体高级别肉瘤的治疗。作者更新了由东南癌症研究组于1984年发起并在三个机构维持的该方案的多机构经验。
经活检确诊为肉瘤的患者接受盐酸阿霉素（阿霉素）动脉内输注，剂量为30mg/24小时，共3天，然后各机构将患者分配接受10次分割照射30 - 35Gy或23 - 25次分割照射46Gy，随后进行手术切除。根据放疗剂量，手术在10天或30天内进行。31例患者接受了术后化疗。
66例患者中，女性32例，男性34例。中位年龄为46岁（范围14 - 77岁）；73%的患者肿瘤位于下肢，27%位于上肢。有55例软组织肿瘤和9例恶性骨肿瘤。常见类型为恶性纤维组织细胞瘤20%；脂肪肉瘤17%；滑膜肉瘤18%；骨肉瘤14%。美国癌症联合委员会分期为：I期、IIB期（17%）、IIIA/B期（59%）和IIIC/IVA期（24%）。60例患者接受了保肢手术，其中21例广泛肿瘤患者行根治性切除，30例行广泛局部切除，2例行有限切除。4例患者行一期截肢，2例因伤口并发症行二期截肢。3例患者在初次手术时同时行肺转移瘤切除术（2例为长期存活超过5年）。无术后死亡病例，但41%的患者出现伤口并发症。5年总生存率和无病生存率分别为59%和49%。1例患者（1.5%）在肩部广泛滑膜肉瘤切除9年后出现局部复发，采用保肢技术再次切除。在23例主要在肺部复发的患者中，中位生存期为7个月，4例在发现肺转移后存活超过5年。预后因素的多变量分析显示，疾病范围和分期与无病生存率相关，而只有手术切除范围与总手术生存率相关。
在多中心环境中，采用术前放疗联合敏感化疗和充分切除治疗肢体肉瘤，局部控制率极佳（98.5%），长期肿瘤控制效果合理，尽管远处转移仍然是一个主要挑战。
