RADIATION IN UPPER LIMB TUMORS

1. ROLE OF RADIATION IN UPPER LIMB SARCOMA
DR KANHU CHARAN PATRO
MD,DNB(RADIATION ONCOLOGY),MBA,FAROI(USA),PDCR,CEPC
HOD,RADIATION ONCOLOGY
Mahatma Gandhi Cancer Hospital And Research Institute, Visakhapatnam
drkcpatro@gmail.com /M+91-9160470564

2. ROLE OF RADIATION IN UPPER LIMB
INTRODUCTION
1. The upper extremity or arm is a functional unit of
the upper body.
2. It consists of three sections, the upper arm, forearm,
and hand.
3. It extends from the shoulder joint to the fingers and
contains 30 bones.
4. It also consists of many nerves, blood vessels
(arteries and veins), and muscles

3. The difference
Dr.Vandana Sinam/IOSR-JDM/2015

4. Main Sarcomas
•Sarcoma
•STS
•Ewing’s

8. Why?
Resectability
Response
Survival

9. Functional outcomes

10. Guidelines
ESMO
NCCN

11. SETTINGS
•Neoadjuvant
•Perioperative
•IORT
•ECRT
•Adjuvant

12. Adjuvant treatment
•Observation
•EBRT
•BRACHY
•XRT

13. Gunderson & Tepper’s

24. IMRT IN SOFT TISSUE SARCOMA

25. PREFER 3D OVER IMRT/ARC
IN SPECIAL SITUATIONS
PREVNT LOW DOSE TO
LUNG/GONADS

29. Extra corporeal radiotherapy

32. 50Gy/1#

38. Neoadjuvant radiotherapy

39. OPTIONS
Radiotherapy
Chemotherapy
Radiotherapy +
Chemotherapy
Immunotherapy
Limb regional therapy

40. Esmo
algorithm

41. Generally accepted guidelines suggest applying preoperative
external beam radiotherapy (RT), conventionally fractionated
in 25-28 fractions of 1.8-2 Gy to a total dose of 50-50.4 Gy in 5-
6 weeks
This regimen aims to increase the local control probability as
compared to surgery alone.

42. NCCN recommendations for early-stage tumors

43. NCCN recommendations for mid-stage tumors

44. NCCN recommendations for locally advanced
tumors

46. Recommendations
NCCN
• Stage II, III resectable
extremity,
• Superficial trunk, or
head/neck STS with
acceptable functional
outcomes
ESMO
• High-grade (G2–3),
• Deep, >5 cm STS

49. REVIEW AND METAANALYSIS

50. FINDINGS
Eleven studies (n = 2140), including one
RCT, compared preoperative and
postoperative radiotherapy.
LR was less frequent following
preoperative EBRT in retroperitoneal
STSs (OR 0.03, p = 0.02).
Other tumor locations (OR 0.67, p =
0.01).
While wound complications in extremity
sarcoma were more frequent following
preoperative EBRT (OR 2.92, p0.0001)

51. LOCAL RECURRENCE

52. OVERALL SURVIVAL

53. WOUND
HEALING

55. Summary pre op RT
Good evidence
Better with local advanced tumors
Those with less or no edema and decrease in volume they
have good outcome
Functional outcomes are better

59. Is radiation required after limb
salvage surgery?
• The efficacy of postoperative EBRT following limb-sparing surgery was demonstrated in a prospective
randomized study (91 patients with high-grade lesions and 51 patients with low-grade lesions)
• Postoperative RT significantly reduced the 10-year LR rate among patients with high-grade lesions
(no LRs in patients who underwent surgery plus RT vs. 22% in those who underwent surgery alone; P
= .0028).
• Among patients with low-grade lesions, the corresponding recurrence rates were 5% and 32%,
respectively.
• The probability of reduction in the LR rate in patients receiving EBRT was not significant in patients
with low-grade lesions, suggesting postoperative RT after limb-sparing surgery may not be necessary
for this group of patients.
• Outcomes at 20-year follow-up favored patients who received EBRT, but differences were not
statistically significant.
• Ten-year OS was 82% and 77% for patients who received surgery alone versus surgery plus EBRT, and
20-year OS was 71% and 64% for these groups, respectively (P = .22).

60. EWING’S
SARCOMA

67. ECRT

68. Conclusion
Adjuvant RT has a role
•Margin positive/close
•High gradeG2/G3
•Deep
•>5cm
Preop RT
•Stage II, III resectable extremity,
•Superficial trunk, or head/neck STS with acceptable functional outcomes
•High-grade (G2–3),
•Deep, >5 cm STS
Limb salvage surgery should be offered with the help of
•Preop RT
•IORT
•ECRT

69. THANKS