Suit H, Spiro I J
Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School 02114-2617, USA.
Ann Acad Med Singap. 1996 Nov;25(6):855-61.
There is continuing assessment to find the most effective management strategy for primary soft tissue sarcomas. The goal of treatment for any patient with malignant neoplasm is to provide a tumour-free survival without clinically appreciable treatment-related morbidity. For most adult patients, this currently is attempted by a combination of relatively conservative surgery and moderate dose of radiation. The concept being that radiation at dose levels of 50 to 60 Gy is adequate to inactivate the tumour cells which lie beyond the margins of a conservative resection, i.e., it replaces the resection of large volumes of normal tissue. Laboratory measurements of radiation sensitivity of cell lines derived from sarcomas of soft tissue tumours have shown that they are not radiation-resistant relative to the cell lines derived form epithelial tumours. Hence, there is no surprise the this combined modality approach has been demonstrated to be effective. The frequency of local control (85% to 90%) is at least as high as that combined by ablative surgery, but with much lesser decrement in functional and cosmetic status. Additionally, radiation at dose levels of about 75 Gy is effective in achieving worthwhile local control rates when administered against small sarcomas of the soft tissues, e.g. volumes of < or = 60 ml. Thus, for selected tumours, radiation alone does offer a reasonable option when surgery is not feasible for technical reasons or the patient is not operable for medical reasons. Available data do not indicate a clear advantage for adjuvant chemotherapy for this group of tumours. Trials are in progress to assess the efficacy of neo-adjuvant chemotherapy. We are conducting a phase II trial of MAID chemotherapy and radiation preoperatively; the results to date are superior to matched concurrently treated patients. For local therapy, high and approximately comparable local control rates are being reported for several approaches: radical compartmental resection for selected patients, surgery and postoperative radiation therapy, surgery and preoperative radiation treatment, resection and intraoperative placement of catheters for brachytherapy and intra-arterial adriamycin, radiation and resection. Our preferred approach for T 2, grades II-III sarcomas of the soft tissues is radiation prior to surgery. There are, however, no data on the functional and cosmetic status after treatment of patients whose sarcomas are of a specified site and volume for treatment by these diverse methods. This is a critically important question in the assessment of proper clinical role of each of these approaches.
对于原发性软组织肉瘤，一直在进行评估以找到最有效的管理策略。任何恶性肿瘤患者的治疗目标都是实现无瘤生存，且无明显的与治疗相关的临床发病率。对于大多数成年患者，目前尝试通过相对保守的手术和中等剂量的放疗相结合来实现这一目标。其理念是，50至60 Gy剂量水平的放疗足以使位于保守切除边缘之外的肿瘤细胞失活，即它替代了大量正常组织的切除。对源自软组织肿瘤肉瘤的细胞系进行的辐射敏感性实验室测量表明，相对于源自上皮肿瘤的细胞系，它们并非抗辐射的。因此，这种综合治疗方法已被证明是有效的也就不足为奇了。局部控制率（85%至90%）至少与根治性手术联合治疗的效果一样高，但功能和美容状态的下降要小得多。此外，当针对软组织小肉瘤（例如体积≤60 ml）进行放疗时，约75 Gy剂量水平的放疗在实现可观的局部控制率方面是有效的。因此，对于某些特定肿瘤，当由于技术原因手术不可行或患者因医学原因无法手术时，单纯放疗确实提供了一个合理的选择。现有数据并未表明辅助化疗对这类肿瘤有明显优势。正在进行试验以评估新辅助化疗的疗效。我们正在进行一项术前MAID化疗和放疗的II期试验；迄今为止的结果优于同期匹配的接受治疗的患者。对于局部治疗，几种方法报告的局部控制率较高且大致相当：为选定患者进行根治性间室切除、手术及术后放疗、手术及术前放疗、切除及术中放置近距离放疗导管和动脉内注射阿霉素、放疗及切除。我们对于软组织T2、II - III级肉瘤的首选方法是术前放疗。然而，对于通过这些不同方法治疗的特定部位和体积的肉瘤患者，治疗后的功能和美容状态尚无数据。这是评估这些方法各自适当临床作用时的一个至关重要的问题。
