Annals of Surgical Oncology

, Volume 17, Issue 6, pp 1515–1529 | Cite as

Proton-Beam, Intensity-Modulated, and/or Intraoperative Electron Radiation Therapy Combined with Aggressive Anterior Surgical Resection for Retroperitoneal Sarcomas

  • Sam S. Yoon
  • Yen-Lin Chen
  • David G. Kirsch
  • Ugwuji N. Maduekwe
  • Andrew E. Rosenberg
  • G. Petur Nielsen
  • Dushyant V. Sahani
  • Edwin Choy
  • David C. Harmon
  • Thomas F. DeLaney
Bone and Soft Tissue Sarcomas



We sought to reduce local recurrence for retroperitoneal sarcomas by using a coordinated strategy of advanced radiation techniques and aggressive en-bloc surgical resection.


Proton-beam radiation therapy (PBRT) and/or intensity-modulated radiation therapy (IMRT) were delivered to improve tumor target coverage and spare selected adjacent organs. Surgical resection of tumor and adjacent organs was performed to obtain a disease-free anterior margin. Intraoperative electron radiation therapy (IOERT) was delivered to any close posterior margin.


Twenty patients had primary tumors and eight had recurrent tumors. Tumors were large (median size 9.75 cm), primarily liposarcomas and leiomyosarcomas (71%), and were mostly of intermediate or high grade (81%). PBRT and/or IMRT were delivered to all patients, preferably preoperatively (75%), to a median dose of 50 Gy. Surgical resection included up to five adjacent organs, most commonly the colon (n = 7) and kidney (n = 7). Margins were positive for disease, usually posteriorly, in 15 patients (54%). IOERT was delivered to the posterior margin in 12 patients (43%) to a median dose of 11 Gy. Surgical complications occurred in eight patients (28.6%), and radiation-related complications occurred in four patients (14%). After a median follow-up of 33 months, only two patients (10%) with primary disease experienced local recurrence, while three patients (37.5%) with recurrent disease experienced local recurrence.


Aggressive resection of retroperitoneal sarcomas can achieve a disease-negative anterior margin. PBRT and/or IMRT with IOERT may possibly deliver sufficient radiation dose to the posterior margin to control microscopic residual disease. This strategy may minimize radiation-related morbidity and reduce local recurrence, especially in patients with primary disease.


Posterior Margin Clinical Target Volume Gross Tumor Volume Malignant Peripheral Nerve Sheath Tumor Soft Tissue Sarcoma 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



Thomas F. DeLaney received a speaker’s honorarium from IBA Proton Therapy, and David G. Kirsch is a consultant for Guidepoint Global.


  1. 1.
    Brennan MF, Lewis JL. Diagnosis and management of soft tissue sarcoma. London: Martin Dunitz; 2002.Google Scholar
  2. 2.
    Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2009. CA Cancer J Clin. 2009;59:225–49.CrossRefPubMedGoogle Scholar
  3. 3.
    Gronchi A, Lo VS, Fiore M, et al. Aggressive surgical policies in a retrospectively reviewed single-institution case series of retroperitoneal soft tissue sarcoma patients. J Clin Oncol. 2009;27:24–30.CrossRefPubMedGoogle Scholar
  4. 4.
    Bonvalot S, Rivoire M, Castaing M, et al. Primary retroperitoneal sarcomas: a multivariate analysis of surgical factors associated with local control. J Clin Oncol. 2009;27:31–7.CrossRefPubMedGoogle Scholar
  5. 5.
    Pisters PW. Resection of some—but not all—clinically uninvolved adjacent viscera as part of surgery for retroperitoneal soft tissue sarcomas. J Clin Oncol. 2009;27:6–8.CrossRefPubMedGoogle Scholar
  6. 6.
    Yang JC, Chang AE, Baker AR, et al. Randomized prospective study of the benefit of adjuvant radiation therapy in the treatment of soft tissue sarcomas of the extremity. J Clin Oncol. 1998;16:197–203.PubMedGoogle Scholar
  7. 7.
    DeLaney TF, Kepka L, Goldberg SI, et al. Radiation therapy for control of soft-tissue sarcomas resected with positive margins. Int J Radiat Oncol Biol Phys. 2007;67:1460–9.PubMedGoogle Scholar
  8. 8.
    Zagars GK, Ballo MT. Significance of dose in postoperative radiotherapy for soft tissue sarcoma. Int J Radiat Oncol Biol Phys. 2003;56:473–81.CrossRefPubMedGoogle Scholar
  9. 9.
    Lewis JJ, Leung D, Woodruff JM, Brennan MF. Retroperitoneal soft-tissue sarcoma: analysis of 500 patients treated and followed at a single institution. Ann Surg. 1998;228:355–65.CrossRefPubMedGoogle Scholar
  10. 10.
    Stoeckle E, Coindre JM, Bonvalot S, et al. Prognostic factors in retroperitoneal sarcoma: a multivariate analysis of a series of 165 patients of the French Cancer Center Federation Sarcoma Group. Cancer. 2001;92:359–68.CrossRefPubMedGoogle Scholar
  11. 11.
    van Dalen T, Plooij JM, Van Coevorden F, et al. Long-term prognosis of primary retroperitoneal soft tissue sarcoma. Eur J Surg Oncol. 2007;33:234–8.CrossRefPubMedGoogle Scholar
  12. 12.
    DeLaney TF, Trofimov AV, Engelsman M, Suit HD. Advanced-technology radiation therapy in the management of bone and soft tissue sarcomas. Cancer Control. 2005;12:27–35.PubMedGoogle Scholar
  13. 13.
    Brada M, Pijls-Johannesma M, De RD. Proton therapy in clinical practice: current clinical evidence. J Clin Oncol. 2007;25:965–70.CrossRefPubMedGoogle Scholar
  14. 14.
    Willett CG, Czito BG, Tyler DS. Intraoperative radiation therapy. J Clin Oncol. 2007;25:971–7.CrossRefPubMedGoogle Scholar
  15. 15.
    Bossi A, De Wever I, Van Limbergen E, Vanstraelen B. Intensity modulated radiation-therapy for preoperative posterior abdominal wall irradiation of retroperitoneal liposarcomas. Int J Radiat Oncol Biol Phys. 2007;67:164–70.PubMedGoogle Scholar
  16. 16.
    Gieschen HL, Spiro IJ, Suit HD, et al. Long-term results of intraoperative electron beam radiotherapy for primary and recurrent retroperitoneal soft tissue sarcoma. Int J Radiat Oncol Biol Phys. 2001;50:127–31.PubMedGoogle Scholar
  17. 17.
    Petersen IA, Haddock MG, Donohue JH, et al. Use of intraoperative electron beam radiotherapy in the management of retroperitoneal soft tissue sarcomas. Int J Radiat Oncol Biol Phys. 2002;52:469–75.PubMedGoogle Scholar
  18. 18.
    Tzeng CW, Fiveash JB, Popple RA, et al. Preoperative radiation therapy with selective dose escalation to the margin at risk for retroperitoneal sarcoma. Cancer. 2006;107:371–9.CrossRefPubMedGoogle Scholar
  19. 19.
    Kaplan E, Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assoc. 1958;53:457–81.CrossRefGoogle Scholar
  20. 20.
    Cox D. Regression models and life-tables. J R Stat Soc. 1972;34:187–220.Google Scholar
  21. 21.
    Pawlik TM, Ahuja N, Herman JM. The role of radiation in retroperitoneal sarcomas: a surgical perspective. Curr Opin Oncol. 2007;19:359–66.CrossRefPubMedGoogle Scholar
  22. 22.
    Catton CN, O’Sullivan B, Kotwall C, et al. Outcome and prognosis in retroperitoneal soft tissue sarcoma. Int J Radiat Oncol Biol Phys. 1994;29:1005–10.PubMedGoogle Scholar
  23. 23.
    Tepper JE, Suit HD, Wood WC, et al. Radiation therapy of retroperitoneal soft tissue sarcomas. Int J Radiat Oncol Biol Phys. 1984;10:825–30.PubMedGoogle Scholar
  24. 24.
    Fein DA, Corn BW, Lanciano RM, et al. Management of retroperitoneal sarcomas: does dose escalation impact on locoregional control? Int J Radiat Oncol Biol Phys. 1995;31:129–34.PubMedGoogle Scholar
  25. 25.
    van Doorn RC, Gallee MP, Hart AA, et al. Resectable retroperitoneal soft tissue sarcomas. The effect of extent of resection and postoperative radiation therapy on local tumor control. Cancer. 1994;73:637–42.CrossRefPubMedGoogle Scholar
  26. 26.
    White JS, Biberdorf D, DiFrancesco LM, Kurien E, Temple W. Use of tissue expanders and pre-operative external beam radiotherapy in the treatment of retroperitoneal sarcoma. Ann Surg Oncol. 2007;14:583–90.CrossRefPubMedGoogle Scholar
  27. 27.
    Zlotecki RA, Katz TS, Morris CG, Lind DS, Hochwald SN. Adjuvant radiation therapy for resectable retroperitoneal soft tissue sarcoma: the University of Florida experience. Am J Clin Oncol. 2005;28:310–6.CrossRefPubMedGoogle Scholar
  28. 28.
    Ballo MT, Zagars GK, Pollock RE, et al. Retroperitoneal soft tissue sarcoma: an analysis of radiation and surgical treatment. Int J Radiat Oncol Biol Phys. 2007;67:158–63.PubMedGoogle Scholar
  29. 29.
    Youssef E, Fontanesi J, Mott M, et al. Long-term outcome of combined modality therapy in retroperitoneal and deep-trunk soft-tissue sarcoma: analysis of prognostic factors. Int J Radiat Oncol Biol Phys. 2002;54:514–9.PubMedGoogle Scholar
  30. 30.
    DeLaney TF, Kirsch DG. Bone and soft tissue. In: DeLaney TF, Kooy HM, editors. Proton and charged particle radiotherapy. Philadelphia: Lippincott Williams & Wilkins; 2008. p. 172–85.Google Scholar
  31. 31.
    Suit HD, Chu W. History of charged particle radiotherapy. In: DeLaney TF, Kooy HM, editors. Proton and charged particle radiotherapy. Philadelphia: Lippincott Williams & Wilkins; 2008. p. 1–7.Google Scholar
  32. 32.
    Pisters PW, Ballo MT, Fenstermacher MJ, et al. Phase I trial of preoperative concurrent doxorubicin and radiation therapy, surgical resection, and intraoperative electron-beam radiation therapy for patients with localized retroperitoneal sarcoma. J Clin Oncol.2003;21:3092–7.CrossRefPubMedGoogle Scholar

Copyright information

© Society of Surgical Oncology 2010

Authors and Affiliations

  • Sam S. Yoon
    • 1
    • 7
  • Yen-Lin Chen
    • 2
  • David G. Kirsch
    • 6
  • Ugwuji N. Maduekwe
    • 1
  • Andrew E. Rosenberg
    • 3
  • G. Petur Nielsen
    • 3
  • Dushyant V. Sahani
    • 4
  • Edwin Choy
    • 5
  • David C. Harmon
    • 5
  • Thomas F. DeLaney
    • 2
  1. 1.Division of Surgical Oncology, Department of SurgeryMassachusetts General Hospital, and Harvard Medical SchoolBostonUSA
  2. 2.Department of Radiation OncologyMassachusetts General Hospital, and Harvard Medical SchoolBostonUSA
  3. 3.Department of PathologyMassachusetts General Hospital, and Harvard Medical SchoolBostonUSA
  4. 4.Department of RadiologyMassachusetts General Hospital, and Harvard Medical SchoolBostonUSA
  5. 5.Division of Hematology/Oncology, Department of MedicineMassachusetts General Hospital, and Harvard Medical SchoolBostonUSA
  6. 6.Department of Radiation Oncology and Department of Pharmacology and Cancer BiologyDuke University Medical CenterDurhamUSA
  7. 7.Department of Surgery and Department of Cancer BiologyUniversity of Pennsylvania School of MedicinePhiladelphiaUSA

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