Radiation Therapy for Treatment of Soft Tissue Sarcoma in Adults
Roles and indications for RT in the treatment of extremity and superficial truncal adult STS
1. For patients with localized STS, expert pathology and radiology review and multidisciplinary evaluation is recommended before treatment initiation.
(Strong, Low)2. For patients with primary, localized extremity and truncal STS for whom oncologic resection is planned, RT is recommended for those at increased risk for local recurrence.
(Strong, High)Implementation remarks:
• Assessment of risk for local recurrence is complex and incorporates multiple factors.• Potential morbidity of future surgical salvage options may also be considered when determining the role of RT.
3. For patients with primary, localized extremity and truncal STS for whom oncologic resection is planned and a close or microscopically positive margin is anticipated, RT is recommended.
(Strong, Moderate)4. For patients with primary, localized extremity and truncal STS for whom oncologic resection is planned, RT is not recommended for those at low risk for local recurrence.
(Strong, Moderate)5. For patients with primary, localized extremity and truncal STS who have had an unplanned excision, oncologic resection is recommended, when feasible.
(Strong, Low)Sequence of RT and surgery for extremity and superficial truncal adult STS
1. For patients with primary, localized extremity and truncal STS, the sequencing of surgery and RT should be determined based on multidisciplinary evaluation of patient and tumor characteristics.
(Strong, Moderate)Preoperative RT
2. For patients with primary, localized extremity and truncal STS, where surgery and RT are indicated, preoperative RT is recommended over postoperative RT.
(Strong, Moderate)Postoperative RT
3. For patients with primary, localized extremity and truncal STS treated with initial oncologic resection (without preoperative RT) found to have unanticipated adverse pathologic features, postoperative RT is recommended.
(Strong, Moderate)4. For patients with primary, localized extremity and truncal STS, where surgery and RT are indicated, initial oncologic resection followed by postoperative RT is conditionally recommended in specific clinical circumstances (eg, uncontrolled pain or bleeding, fungating tumors), or when the risk of wound healing complications outweighs that of late toxicity.
(Conditional, Expert Opinion)Following an unplanned excision
5. For patients with primary, localized extremity and truncal STS following an unplanned excision where oncologic resection is planned and RT is indicated, preoperative RT is recommended over postoperative RT.
(Strong, Moderate)6. For patients with primary, localized extremity and truncal STS following an unplanned excision when oncologic resection is not feasible, postoperative RT is recommended.
(Strong, Moderate)Dose-fractionation regimens and target volumes for EBRT in extremity and superficial truncal adult STS
Radiation Dose and Fractionation
1. For patients with primary, localized extremity and truncal STS receiving preoperative RT, 5000 cGy in 25 once daily fractions is recommended.
(Strong, Moderate)2. For patients with primary, localized extremity and truncal STS receiving postoperative RT, 5000 cGy in 25 once daily fractions or 5040 cGy in 28 once daily fractions to CTV1 and additional dose to a reduced volume CTV2 is recommended.
(Strong, Moderate)Implementation remark:
• Additional dose to CTV2 of 1000-1600 cGy is used for negative margins and 1600 cGy for microscopic positive margins.Targets and OARs
3. For patients with primary, localized extremity and truncal STS receiving preoperative RT, an anatomically constrained CTV is recommended.
(Strong, Moderate)4. For patients with primary, localized extremity and truncal STS receiving postoperative RT, an initial dose to an anatomically constrained CTV1 and additional dose to a reduced volume CTV2 is recommended.
(Strong, Moderate)5. For patients receiving either preoperative or postoperative RT for primary, localized extremity and truncal STS, volumetric contouring of the OARs and use of appropriate dose constraints are recommended.
(Strong, Moderate)6. For patients with primary, localized extremity and truncal STS, elective nodal RT is not recommended.
(Strong, Moderate)RT simulation, planning, and delivery techniques for EBRT of extremity and superficial truncal adult STS
1. For patients with primary, localized extremity and truncal STS, use of custom immobilization for RT delivery is recommended for reproducibility of accurate patient positioning.
(Strong, Moderate)2. For patients with primary, localized extremity and truncal STS receiving preoperative RT, routine use of bolus is not recommended.
(Strong, Low)3. For patients with primary, localized extremity and truncal STS receiving postoperative RT, routine use of bolus is not recommended unless the clinical target includes subcutaneous tissue or skin.
(Strong, Expert Opinion)4. For patients with primary, localized extremity and truncal STS, IMRT, including VMAT, is recommended to minimize dose to OARs and reduce toxicity.
(Strong, Moderate)Implementation remark:
• 3-D CRT may be preferred in certain clinical scenarios to better spare OARs or reduce integral dose.5. For patients with primary, localized extremity and truncal STS, daily IGRT with at least weekly volumetric image guidance is recommended.
(Strong, Moderate)Role for RT, dose-fractionation regimens, and treatment planning for RPS
1. Due to the rarity and heterogeneity of RPS, expert pathology and radiology review as well as multidisciplinary evaluation is recommended before treatment initiation.
(Strong, Low)2. Routine use of RT in addition to oncologic resection for patients with primary localized RPS is conditionally not recommended.
(Conditional, Moderate)Implementation remark:
• Selective use of RT may be considered for patients at high risk of local recurrence.
3. If RT is planned in addition to oncologic resection in patients with primary, localized RPS, preoperative RT is recommended.
(Strong, Moderate)4. If preoperative RT is planned for patients with primary, localized RPS, 5000 cGy in 25 once daily fractions or 5040 cGy in 28 once daily fractions is recommended.
(Strong, Moderate)5. If preoperative RT is planned for patients with primary, localized RPS, 4-D CT and delineation of an iGTV to account for internal motion are recommended for tumors above the iliac brim.
(Strong, Moderate)6. If preoperative RT is planned for patients with primary, localized RPS, an anatomically constrained CTV or ITV, volumetric contouring of OARs, and use of appropriate dose constraints are recommended for treatment planning
(Strong, Moderate)Implementation remark:
• Before RT planning, discuss with the surgeon whether ipsilateral kidney and/or partial liver resection is planned as this will affect OAR constraints.
7. If preoperative RT is planned for patients with primary, localized RPS, IMRT, including VMAT, is recommended to minimize dose to OARs with the aim of reducing toxicity.
(Strong, Moderate)Implementation remark:
• 3-D CRT may be used instead of IMRT in certain clinical scenarios if it achieves similar or better sparing of OARs or reduced integral dose.
8. If preoperative RT is planned for patients with primary, localized RPS, daily IGRT with at least weekly volumetric image guidance is recommended.
(Strong, Moderate)9. Routine use of postoperative RT for patients with primary, localized RPS is not recommended.
(Strong, Moderate)Implementation remark:
• Selective use of postoperative RT may be considered in highly select patients including those with high risk of local recurrence where salvage surgery would not be feasible, and the target volume is well defined and can be treated safely.
Recommendation Grading
Overview
Title
Radiation Therapy for Treatment of Soft Tissue Sarcoma in Adults
Authoring Organization
American Society for Radiation Oncology
Publication Month/Year
July 24, 2021
Last Updated Month/Year
September 3, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Male, Female, Adult
Health Care Settings
Ambulatory, Hospital, Outpatient
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Treatment, Management
Diseases/Conditions (MeSH)
D012509 - Sarcoma, D064746 - Therapy, Soft Tissue
Keywords
radiation therapy, Clinical Practice Guideline, soft tissue sarcoma
Source Citation
Salerno KE, Alektiar KM, Baldini EH, Bedi M, Bishop AJ, Bradfield L, Chung P, DeLaney TF, Folpe A, Kane JM, Li XA, Petersen I, Powell J, Stolten M, Thorpe S, Trent JC, Voermans M, Guadagnolo BA. Radiation Therapy for Treatment of Soft Tissue Sarcoma in Adults: Executive Summary of an ASTRO Clinical Practice Guideline. Pract Radiat Oncol. 2021 Sep-Oct;11(5):339-351. doi: 10.1016/j.prro.2021.04.005. Epub 2021 Jul 26. PMID: 34326023.