Background and recommendations

Question 1

What are the acute toxicities of RT?

Answer 1

Dermatitis

Epilation

Question 2

What are the long term complications of RT?

Answer 2

Weakening of bone, 18 months is greatest risk of fracture
Fibrosis leading to loss of range of motion
Lymphedema
Skin discoloration
Telangietasia
2nd cancers

Question 3

How long after surgery should PORT be given?

Answer 3

3-8 weeks

Question 4

What dose should be delivered post-operatively?

Answer 4

1. PTV 1: 50 Gy at 2 Gy/fx
2. PTV 2: Boost to 60-66 (10-16 Gy) at 2 Gy/fx for R1

or

3. PTV 2: Boost to 70 to 76 Gy at 2 Gy/fx for R2

Question 5

What dose is recommended preoperatively?

Answer 5

50 Gy at 2 Gy/fx to one volume

Question 6

What are outcomes after RT alone?

Answer 6

LR is 66% and 2 year DFS is 17%

Question 7

What patients can get surgery alone?

Answer 7

Low grade soft tissue sarcomas

Question 8

What are the advantages of preop RT vs. post-op RT?

Answer 8

1. Lower RT dose
2. Smaller RT fields
3. Better resectability
4. Better oxygenation of tumor cells
5. Fewer long-term toxicities

Question 9

What is the recommended follow up after surgery and RT for STS?

Answer 9

1. Follow up and Chest CT every 3 months for 2 years
2. Follow up every 6 months for 3 years with Chest CT
3. Follow up yearly

MRI of the primary every 6 months for 2 years

Occupational and physical therapy

Question 10

What is the likelihood of local control after RT+ surgery?

Answer 10

> 90%

Question 11

What are the most common sites?

Answer 11

Extremity: 60%
Trunk: 30%
Head and neck: 10-15%

Retroperitoneum: 10-15%

Question 12

What elements of the history and physical should be inquired about on exam?

Answer 12

History: history of palpable mass, pain, weakness, numbness, changes in range of motion edema of extremity,

Physical exam: palpation of the mass, lymph node exam, range of motion, strength, sensation

Question 13

What are the most common histologues of STS?

Answer 13

1. High-grade undifferentiated pleomorphic sarcoma (20-30%)
2. Liposarcoma (10-20%)
3. Leiomyosarcoma (5-10%)
4. Synovial sarcoma (5-10%)
5. Malignant peripheral nerve sheath tumors (5-10%)

Question 14

T1

Answer 14

5 cm or less
T1a: superficial to superficial fascia
T1b: Deep to superficial fascia

Question 15

T2

Answer 15

> 5 cm
T1a: superficial to superficial fascia
T1b: Deep to superficial fascia

Question 16

N1

Answer 16

Regional nodes

Question 17

M1

Answer 17

Distant metastatic disease

Question 18

What is the grading system?

Answer 18

French 3 grade system based on
Differentiation: 1-3
Mitotic index: 1-3
Necrosis: 0-2

Grade 1: 2-3
Grade 2: 4-5
Grade 3: 6-8

Question 19

Stage I

Answer 19

IA: T1ab N0 Grade 1
IB: T2ab N0 Grade 1

Question 20

Stage II

Answer 20

IIA: T1ab Grade 2-3
IIB: T2ab grade 2

Question 21

Stage III

Answer 21

T2ab N0 Grade 3

Any T N1 M0, Any grade

Question 22

Stage IV

Answer 22

M1

Question 23

What imaging and labs are needed at work up?

Answer 23

Imaging: CT scan with contrast and MR of the primary tumor. CT scan of the chest.

Labs: CBC, CMP

Question 24

How should these tumors be biopsied?

Answer 24

Incisional biopsy, vertical orientation

Question 25

What 5 factors are associated with an increased risk of DM?

Answer 25

1. Deep tumor 2. High grade 3. > 5 cm 4. Recurrent disease 5. Leiomyosarcoma

Question 26

How to defined RT volumes with preop RT?

Answer 26

GTV= tumor volume on contrast enhanced MRI (not T2 edema) CTV = GTV + 3 cm longitudinal margins and 1.5 cm radial margin Edit CTV for anatomical boundaries including adjacent bones, and fascia unless these structures are involved or have been violated PTV=CTV + 1 cm

Question 27

How to defined initial RT volumes with post-op RT?

Answer 27

GTV: presurgical tumor volume + post-op bed CTV= GTV + clips+drain sites+scar and use 1.5 cm radial margin and 4 cm longitudinal margin PTV=CTV + 1 cm

Question 28

How to defined boost RT volume with post-op RT?

Answer 28

GTV = predurgical tumor volume + post-op bed CTV=GTV+1.5 cm radially, 2 cm longitudinally PTV=CTV+1 cm

Question 29

What are subacute toxicites after RT and surgery?

Answer 29

Wound complications: 5-15% with PORT and 25-35% with preop

Question 30

What study supports preop RT?

Answer 30

Osullivan RCT

Question 31

What is the downside of preop RT?

Answer 31

34% risk of wound healing complications