Comparison of preoperative and postoperative radiation therapy for extremity soft-tissue sarcoma: a randomized clinical trial

Background: The optimal sequencing of radiotherapy and surgery for the treatment of soft-tissue sarcoma (STS) is an ongoing source of controversy. In this study, the authors compared preoperative and postoperative radiotherapy in patients with extremity STS. Methods: Eighty patients with localized extremity STS were randomly assigned to either preoperative or postoperative radiotherapy group. Baseline characteristics of the patients were not significantly different between the two study groups. Primary outcome measures were pain, acute complications (wound dehiscence and infection), and late complications (limb edema, subcutaneous fibrosis, and joint stiffness). The severity of late complications was evaluated using the radiation therapy oncology group criteria. Secondary outcome measures were oncologic outcomes, including local recurrence and distant metastasis. Results: The mean pain level was not significantly different between the two groups ( P =0.1). Infection was not seen in any of the patients. The rate of wound dehiscence and infection was not significantly different between the two groups ( P =0.32 for both). Of the late complications, the rate of limb edema and subcutaneous fibrosis was similar in the two groups ( P =0.16 and P =0.35, respectively). In contrast, the rate of joint stiffness was significantly more in the postoperative radiotherapy group ( P <0.001). The severity of all three late complications also was more in the postoperative radiotherapy group at 6 and 12 mo. There were no significant differences between the two groups regarding local recurrence and distant metastasis ( P =0.99 and P =0.77, respectively). Conclusions: The authors suggest preoperative radiotherapy in patients with localized extremity STS because of its lower rate of and less severe complications, particularly joint stiffness. Level of Evidence: Level I.