So what you want to avoid are the surgical errors. Avoiding the shelling out procedure. If it’s a surprise diagnosis on frozen section, closing up, seeing what the pathology really is, and then probably getting the patient to a center that does a lot of this surgery, to make sure that the margins are documented. So that will help the radiation therapists and help know whether that patient is at high risk for local recurrence. And if the margins are positive, to – instead of going right to radiation – if possible, and especially in an extremity, to consider first doing a re-resection and then consider giving radiation therapy.
Well, what about our next modality, radiation therapy? For the most part, for the majority of times, these patients are going to receive postoperative radiation therapy. This is an adjunct to surgery. It’s usually for those patients who have had limb-sparing surgery with no more than 1-2 cm margins, or less, or where the tumor is adjacent to bone or nerve where you can’t get good margins. We usually give about 6500 centigray; usually about 5000 to the whole tumor and then another 1500-2000 boost. The advantage of this is that the port is encompassed but it is fully defined because you know what the tumor margins are, having gone in. There is rapid surgical recovery and you have a pathology of an un-irradiated specimen, if you are still concerned that you don’t know what the specific histopathology is. But there are other modalities. There is preoperative radiation. The advantage of that is there is a smaller port size. It could inhibit potential metastatic deposits, this could facilitate limb-sparing surgery and increase operability, if this were a very large 15 cm lesion. But the problems with it is that you may have to delay surgery, there may be problems with wound healing, and in a prospectively randomized study by the NCI of Canada recently finished, comparing preoperative to postoperative for extremity lesions, there was about twice the amount of wound complications. In terms of survival, how the patients did in terms of the amount of limb-sparing surgery that was performed, there was no mention of that and the numbers that were included in the study were probably not large enough to give us a definite answer for that.
What’s been popularized by the Memorial Sloan-Kettering Cancer Center is brachytherapy and that’s because many of their patients come from a very far distance. So they were trying to get away from having to keep the patient after surgery for another five, six, seven weeks of radiation therapy. So they popularized the use of brachytherapy. The value of that is, there’s a smaller volume treated. It’s usually started on the sixth postoperative day. There is a shorter treatment time, about 4-5 days. It’s cheaper. It’s very good for difficult anatomy where you are concerned about radiation hitting vital structures, or those patients who have had previous radiation where you can’t deliver a high dose of external beam. You need surgical input, detailed planning, and despite its use you sometimes still need external beam radiation in addition.