Radiation Therapy

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Radiation therapy alone is rarely successful in achieving local control of STSHN. Some authors have advocated a preference for preoperative radiation for extremity STS citing lower dose and smaller tumor volumes with results equivalent to postoperative radiation as reasons.62 The problem with using this approach in the head and neck is the proximity of many of these lesions to bone and/or major neural structures and the very real concern of wound complications following radical radiation therapy.

In contrast, the beneficial role of adjuvant postoperative radiotherapy (PORT) in improving local control after surgery has been demonstrated in a number of retrospective studies of STSHN. At the University of California, Los Angeles, local control after surgery (52%) improved to 90 percent with the addition of postoperative radiation. As would be expected, the impact of PORT was even greater in patients with positive surgical margins: 75 percent local control versus only 26 percent if no additional treatment was given.63 Almost all major retrospective series have reported equivalent survival rates for surgery alone and surgery with PORT: the addition of radiation therapy to surgery improves local control in the selected group of poor prognosis patients who are offered PORT because of adverse features

Figure 17-7. A, An 86-year-old woman presented with a malignant fibrous histiocytoma of the left infraorbital region that had recurred following previous excision. B, CT scan was suspicious of intraorbital extension. C, The lesion and the lower eyelid were excised down to the infraorbital rim which was grossly uninvolved, and the wedge-shaped soft-tissue defect was reconstructed using a Mustarde type advancement flap. D, Six months following surgery the patient maintained good function of the left eye with an acceptable cosmetic result.

Figure 17-7. A, An 86-year-old woman presented with a malignant fibrous histiocytoma of the left infraorbital region that had recurred following previous excision. B, CT scan was suspicious of intraorbital extension. C, The lesion and the lower eyelid were excised down to the infraorbital rim which was grossly uninvolved, and the wedge-shaped soft-tissue defect was reconstructed using a Mustarde type advancement flap. D, Six months following surgery the patient maintained good function of the left eye with an acceptable cosmetic result.

of their tumors.

A prospective randomized trial from the MSKCC has shown the benefit of adding brachytherapy to surgery for high-grade lesions of the extremity and superficial trunk.64 This may be a useful approach in selected patients with STSHN who have minimal postoperative residual disease in areas such as the skull base. Good results have been reported for neutron therapy in the treatment of gross residual disease after resection of extremity STS.65 The major disadvantages of fast neutrons are the increased risk of complications and the technical inability to shape and control the beam, which limits their safe use in critical areas of the head and

Figure 17-8. A, The clinical appearance of a 30-year-old man presenting with an extensive osteosarcoma of the left maxilla that had not responded to chemotherapy and radiation. B, The patient underwent radical surgical excision of the tumor including orbital exenteration, total maxillectomy and hemimandibulectomy. C, The specimen included the tumor with the contents of the left orbit and the maxilla and left hemi-mandible. D, The extensive surgical defect was reconstructed with microvascular tissue transfer using the rectus abdominis muscle with its overlying subcutaneous tissue and skin.

Figure 17-8. A, The clinical appearance of a 30-year-old man presenting with an extensive osteosarcoma of the left maxilla that had not responded to chemotherapy and radiation. B, The patient underwent radical surgical excision of the tumor including orbital exenteration, total maxillectomy and hemimandibulectomy. C, The specimen included the tumor with the contents of the left orbit and the maxilla and left hemi-mandible. D, The extensive surgical defect was reconstructed with microvascular tissue transfer using the rectus abdominis muscle with its overlying subcutaneous tissue and skin.

neck. In contrast, techniques such as intensity modulated beam radiotherapy (IMRT) can deliver very precisely controlled dosages of photons to the tumor or its bed while minimizing radiation to vital structures such as the optic chiasm.66 Improved local control using adjuvant radiation therapy has, however, not translated into better survival as patients succumb to distant metastases. This fact underscores the need to develop more effective systemic treatment.

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