CONSERVATIVE SURGERY AND ADJUVANT RADIATION-THERAPY IN THE MANAGEMENT OF ADULT SOFT-TISSUE SARCOMA OF THE EXTREMITIES - CLINICAL AND RADIOBIOLOGICAL RESULTS
CONSERVATIVE SURGERY AND ADJUVANT RADIATION-THERAPY IN THE MANAGEMENT OF ADULT SOFT-TISSUE SARCOMA OF THE EXTREMITIES - CLINICAL AND RADIOBIOLOGICAL RESULTS
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DOI：
10.1016/0360-3016(95)00111-b
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发表时间：
1995-07-15
影响因子：
7
通讯作者：
WEICHSELBAUM, RR
中科院分区：
文献类型：
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作者：
MUNDT, AJ;AWAN, A;WEICHSELBAUM, RR
目的：评估成年肢体软组织肉瘤患者接受保守手术和辅助照射治疗的结果，以(a)确定术后适当的治疗量和放射剂量，(b)将治疗前获得的体外放射生物学参数与临床结果相关联。方法与材料：回顾分析1978 - 1991年间，64例连续行保守手术和辅助放疗的成人四肢软组织肉瘤患者（下肢40例，上肢24例）（术前7例，术后50例，围手术期7例）。回顾性分析所有术后患者肿瘤床/疤痕周围的初始放射场边缘。12例患者的初始野缘< 5 cm， 32例患者为5-9.9 cm， 6例患者大于或等于10 cm。病理切缘阴性的患者最初采用传统的术后剂量（64-66 Gy）；然而，在后来的几年，术后剂量减少到60 Gy。在确定治疗前建立13个细胞系，获得放射生物学参数（多靶点和线性二次）并与结果相关。结果：初始野缘< 5 cm的患者术后5年局部控制率为30.4%，而初始野缘大于或等于5 cm的患者5年局部控制率为93.2% （p = 0.0003）。初始野缘为5-9.9 cm的患者（91.6%）与大于或等于10 cm的患者（100%）的5年局部控制率相似（p = 0.49）。虽然术后接受< 60 Gy的患者的局部控制比接受大于或等于60 Gy的患者差（p = 0.08），但接受低于传统术后剂量（60-63.9 Gy）的患者（74.4%）与接受6466 Gy的患者（87.0%）之间的局部控制没有差异（p = 0.5）。在研究的后期，严格注意手术和放疗技术的患者的局部控制率为87.6%。剂量大于或等于63 Gy的患者出现严重晚期后遗症的频率高于剂量小于63 Gy的患者（23.1%比0%）（p < 0.05）。13株细胞系Do、α、β、D、n和SF2的平均值分别为115.7、0.66、0.029、2.15、0.262。在治疗前建立的13个细胞系中，有4个最终在局部失败。这些细胞系的放射生物学参数在放射敏感性方面与其他9个细胞系相似。结论：我们的数据证实了在术后环境中保持肿瘤床/疤痕周围至少5cm的初始野缘的重要性。使用大于或等于10厘米的边缘没有任何好处。此外，接受阴性切缘大面积局部切除的患者可以使用低于传统术后剂量（60 Gy）的治疗，而不会影响局部控制，而且慢性后遗症较少。最后，似乎固有的肿瘤细胞敏感性并不是软组织肉瘤放射治疗和保守手术后局部失败的主要决定因素。
Purpose: The outcome of adult patients with soft tissue sarcoma of the extremities treated with conservative surgery and adjuvant irradiation was evaluated to (a) determine the appropriate treatment volume and radiation dosage in the postoperative setting, and (b) correlate in vitro radiobiological parameters obtained prior to therapy with clinical outcome.Methods and Materials: Sixty-four consecutive adult patients with soft tissue sarcoma of the extremities (40 lower, 24 upper) who underwent conservative surgery and adjuvant irradiation (7 preoperative, 50 postoperative, 7 perioperative) between 1978 and 1991 were reviewed. The initial radiation field margin surrounding the tumor bed/scar was retrospectively analyzed in all postoperative patients. Initial field margins were < 5 cm in 12 patients, 5-9.9 cm in 32 and greater than or equal to 10 cm in 6. Patients with negative pathological margins were initially treated with traditional postoperative doses (64-66 Gy); however, in later years the postoperative dose was reduced to 60 Gy. Thirteen cell lines were established prior to definite therapy, and radiobiological parameters (multitarget and linear-quadratic) were obtained and correlated with outcome.Results: Postoperative patients treated with an initial field margin of < 5 cm had a 5-year local control of 30.4% vs. 93.2% in patients treated with an initial margin of greater than or equal to 5 cm (p = 0.0003). Five-year local control rates were similar in patients treated with initial field margins of 5-9.9 cm (91.6%) compared with those treated with greater than or equal to 10 cm margins (100%) (p = 0.49). While postoperative patients receiving < 60 Gy had a worse local control than those receiving greater than or equal to 60 Gy (p = 0.08), no difference was seen in local control between patients receiving less than traditional postoperative doses (60-63.9 Gy) (74.4%) vs. those receiving 6466 Gy (87.0%) (p = 0.5). The local control of patients treated in the later years of the study, with strict attention to surgical and radiotherapeutic technique, was 87.6%. Severe late sequelae were more frequent in patients treated with doses greater than or equal to 63 Gy compared to patients treated with fewer doses (23.1% vs. 0%) (p < 0.05). Mean values for Do, alpha, beta, D, n and SF2 obtained from the 13 cell lines were 115.7, 0.66, 0.029, 2.15, 0.262, respectively. Four of the 13 cell lines established prior to therapy ultimately failed locally. The radiobiological parameters of these cell lines were similar to the other nine cell lines in terms of radiosensitivity.Conclusions: Our data confirm the importance of maintaining an initial field margin of at least 5 cm around the tumor bed/scar in the postoperative setting. No benefit was seen with the use of margins greater than or equal to 10 cm. In addition, patients undergoing wide local excision with negative margins can be treated with lower than traditional postoperative doses (60 Gy) without compromising local control and with fewer chronic sequelae. Finally, it does not appear that inherent tumor cell sensitivity is a major determinant of local failure following radiation therapy and conservative surgery in soft tissue sarcoma.