Inl. J Radialron Oncoh~gy Em/ Phys Vol. Printed in the U.S.A. All rights reserved.
23, pp.
6 15-6
0360.3016/92 $5.00 + .OO Copyright 0 1992 Pergamon Press Ltd.
I9
??Brief Communication
POSTOPERATIVE
RADIOTHERAPY
FOR MALIGNANT
FIBROUS
HISTIOCYTOMA
H. M. FAGUNDES, M.D.,’ P. P. LAI, PH.D., M.D.,’ L. P. DEHNER, M.D.,2 C. A. PEREZ, M.D.,’ D. M. GARCIA, M.D.,’ B. N. EMAMI, M.D.,’ J. R. SIMPSON,M.D., PH.D.,’ W. G. KRAYBILL, M.D.3 AND N. A. KUCIK’ ‘Radiation Oncology Center, Mallinckrodt Institute of Radiology; and ‘Department of Pathology, ‘Department Washington University, School of Medicine, St. Louis, MO
of Surgery,
Between 1974 and 1989, 49 patients with histologically confirmed malignant fibrous histiocytoma received postoperative radiotherapy at the Mallinckrodt Institute of Radiology for primary (41) or recurrent (8) disease. Median age of the patients was 63 years, and the median follow-up period was 41 months. Patients were grouped according to the 1988 AJC staging classification: stage IA (one patient), stage IIA (4 patients), stage IIB (9 patients), stage IDA (15 patients), stage IIIB (18 patients), and stage IVA (2 patients). Eight tumors (16%) were in the pelvis, 8 (16%) in the trunk, 4 (8%) in the head and neck, and 29 (60%) in the extremities. Primary surgical procedures included incisional biopsy (4 patients), excisional biopsy (19), narrow margin excision (14), wide local excision (9), and removal of the entire compartment (3). Based on pathology reports, the margins of resection were classified as positive in 23 (5 gross, 18 microscopic), 5 close, 11 negative, and 10 unknown. Patients were irradiated with shrinking field technique; the median radiation dose was 6000 cGy, with more than 95% of patients receiving at least 4500 cGy. In addition, seven patients received postoperative chemotherapy. The 5-year overall survival rate was 62%, disease-free survival 64%, local control 68%, and freedom-from-distant metastasis 85%. Thirteen patients had local recurrences, with > 75% recurring within 3 years. Sites of local recurrence were as follows: trunk (3), pelvis (3), lower extremities (4), and head and neck (3). There appears to be a correlation of local failnre with positive surgical margin: of 23 patients with positive margins, 9 (39%) had local recurrences, whereas 1 of 11 patients (9%) with negative margins had local recurrence. Three of 13 patients with persistent or recurrent disease were salvaged by additional treatment, rendering ultimate local control in 80% (39/49). Thirty-four of 36 patients with local control obtained good to excellent function. Two patients were found to have grade 3 complications: 1 patient had edema of the extremity, and the other developed necrotic skin ulcer that was successfully treated with hyperbaric oxygen. Five patients developed distant metastases, with 80% occurring within 2 years. In summary, adequate but conservative surgery with postoperative radiotherapy for malignant fibrous histiocytoma can achieve local tumor control as well as preservation of functional limbs with acceptable morbidity in a large proportion of patients. Radiotherapy,
Soft tissue sarcoma, Malignant fibrous histiocytoma.
In 1964, in a review of 15 16 cases of fibrous histiocytoma, O’Brien and Stout (10) reported 53 cases with malignant potential (i.e., high mitotic rate, infiltrative growth, or known metastases). Since then, the term malignant fibrous histiocytoma (MFH) has gained general acceptance and is now the most frequently diagnosed soft tissue sarcoma in adults ( 1, 8). In a recent Scandinavian histopathology review of high-grade soft tissue sarcomas, 40% of the cases were MFH, followed by synovial sarcoma (15%) leio-
myosarcoma (9%), liposarcoma (8%) and malignant schwannoma (6%) (1). Malignant fibrous histiocytoma manifests a broad range of histologic appearances. Essentially five subtypes have been described: storiform-pleomorphic, myxoid (myxofibrosarcoma), giant cell (malignant giant cell of soft parts), inflammatory (xanthosarcoma, malignant xanthogranuloma), and angiomatoid (22). Mixed morphologic types may also be found. The majority of malignant fibrous histiocytomas are cellular neoplasms with mixed storiform and pleomorphic areas.
Presented at the 32nd Annual Scientific Meeting of the American Society for Therapeutic Radiology and Oncology, Miami, FL, 1S-20 October 1990. Reprint requests to: Peter P. Lai, Ph.D., M.D., Mallinckrodt Institute of Radiology, Radiation Oncology Center, 4939 Audubon Ave., Suite 5500, St. Louis, MO 63 110.
Acknowledgements-The authors wish to thank Ms. Gwendolyn Jackson and Ms. Marlene Taylor for their secretarial help in the preparation of this manuscript. Dr. Lai is a recipient of the American Cancer Society Clinical Oncology Career Development Award. Accepted for publication 6 January 1992.
INTRODUCTION
615
616
1. J. Radiation Oncology 0 Biology 0 Physics
Current management of primary soft tissue sarcoma of the extremities and trunk consists of any of the following: conservative surgery combined with irradiation (preoperative or postoperative) ( 17, 18); combined intraarterial or intravenous chemotherapy, irradiation, and surgery (5); radical surgery alone, either radical compartmental resection or amputation ( 13, 15); or irradiation alone (2 1). Although MFH is considered the most common soft tissue sarcoma in adult patients, its management as a separate entity with conservative surgery and postoperative irradiation has not been well documented. This report describes the treatment and results of 49 patients with localized MFH managed with surgery and postoperative radiotherapy. METHODS
AND MATERIALS
Patient characteristics Between 1974 and 1989, 49 patients with localized, histologically confirmed malignant fibrous histiocytoma received postoperative irradiation at the Radiation Oncology Center, Mallinckrodt Institute of Radiology. Available histopathology slides were reviewed and the diagnosis of MFH confirmed by a pathologist (LPD) in 40 of the patients. There were 3 1 males and 18 females, with ages ranging from 13 to 90 years (median 63 years). Thirtyseven patients were white and 12 were black. The followup period ranged from 4 to 192 months (mean 41 months). Most patients had a painless nodule or mass present for several weeks or months. Work-up included chest X ray, routine blood chemistry, and complete blood count. Most patients had a CT scan of the involved area, and in more recent years an MRI scan was obtained. Tumor sites included lower extremity (37%), upper extremity (23%), pelvis (16%), trunk (16%), and head and neck (8%). Tumors were staged according to the American Joint Committee (AJC) staging system and graded on the basis of histopathologic characteristics (2). Patient distribution according to stage was: 2% Stage IA; 8% Stage IIA; 18% Stage IIB; 3 1% Stage IIIA; 37% Stage IIIB; and 4% Stage IVA. Fifty-seven percent of the tumors were storiformpleomorphic, 29% myxoid, 8% mixed morphologic patterns, 4% giant cell, and 2% inflammatory. Two tumors were grade 1, 13 grade 2, and 34 grade 3 lesions. The primary surgical procedures included four incisional biopsies, 19 excisional biopsies, 14 narrow margin excisions, nine wide local excisions, and three compartmental resections. Of the 49 patients, 23 had positive surgical margins, five had close margins, and 11 had negative surgical margins; in 10 patients the margin status was unknown. Radiation technique All patients were treated with external beam megavoltage irradiation to a median dose of 6000 cGy given at 180 to 200 cGy daily fractionation. Most patients with tumors in the extremities were treated with 4 MV photons,
Volume 23, Number 3. 1992
whereas patients with tumors in the trunk were treated with high-energy photons (18 or 25 MV). Individual immobilization devices were used for reproducible positioning. The “shrinking field” technique was used to deliver 4000 cGy with initial large parallel opposed AP-PA, lateral, or oblique fields, followed by an initial field reduction for 1000 cGy, and a further shrinkage in field size for an additional 1000 to 1600 cGy boost. A generous margin of 10 to 15 cm beyond the initial tumor edge was used for lesions in the extremities, and whenever possible, no more than two-thirds of the cross section of the extremity was irradiated, sparing a strip of tissue to decrease the probability of late edema of the distal extremity. No attempt was made to include the entire anatomic compartment. For tumors localized in the head and neck region, trunk, or pelvis, a generous margin was not always feasible. About 50% of patients were treated using scar bolus. Statistical methods All survivals and survival functions use the actuarial life-table as applied by Cutler and Ederer (4), and test statistics provided are Generalized Wilcoxon (Breslow), Generalized Savage (Mantel-Cox), and Tarone-Ware (9, 20). Trend analysis was performed by the Tarone Method ( 19). RESULTS
The actuarial 5-year local tumor control and diseasefree survival rates and patterns of failure by stage for these 49 patients are presented in Table 1. Ten patients failed locally only; two patients had distant metastasis only, and three patients experienced both local and distant failure. Six patients died of intercurrent disease. The overall 5year local control rate was 68%; the disease-free survival rate was 64%, and the overall survival rate was 62%. All patients with Stage IA and Stage IIA tumors were free of disease at last follow-up. Four of nine patients with Stage IIB disease failed locally. In this group three patients died of intercurrent disease. Two of 15 patients with Stage IIIA disease had local failures, one concomitant with distant disease. Eight patients with Stage IIIB disease had recurrence: five local only, two local and distant, and one distant only. One of two patients with stage IVA disease failed distantly only. Analysis of patterns of failure according to type of surgery is shown in Table 2. All four patients who had incisional biopsy only failed locally. When excisional biopsy was performed, 6 of 19 (32%) had local recurrences. In patients who had narrow margin excision, 2 of 14 (14%) had local failures. No patient who underwent wide local excision had a recurrence. One of three patients with massive disease treated with compartmental resection recurred 1ocalIy with concomitant distant metastasis. A total of 13 patients experienced local recurrence, three of whom also developed distant metastasis.
Postoperative radiotherapy for MFH 0 H. M. FAGUNDES etal.
617
Table I. Five-year local control, disease-free survival, and patterns of failure for patients with malignant fibrous histiocytoma after postoperative radiotherapy by stage Syear actuarial results
AJC stage
No. of patients
Local failure only
Local and distant failure
IA IIA IIB IIIA IIIB IVA Total
1 4 9 15 18 2 49
0 0 4 1 5 0 10
0 0 0 1 2 0 3
Distant failure only 0 0 0 0 1 1 2
Died of intercurrent disease 0 0 3 1 1 1 6
Local control
Disease-free survival
l/l 414 48% 76% 59% 212 68%*
l/l 414 48% 76% 53% l/2 64%
* 3/ 13 patients were salvaged with further surgery, resulting in an ultimate local control of 80%.
Of the 11 patients with negative margins, only one recurred locally (9%). This patient was treated to only 2800 cGy. Of the 23 patients with positive surgical margins, nine (39%) recurred locally. Forty percent of the patients with close margins and 10% with unknown margins had local recurrences. The 5-year actuarial local tumor control rate was 68%. Of the 10 patients with local recurrence alone, three patients were salvaged with further surgery, rendering an ultimate local control rate of 80%. Analysis of local recurrence rate by site revealed 3 of 4 (75%) in the head and neck, 3 of 8 (38%) in the trunk, 3 of 8 (38%) in the pelvis, and 4 of 29 (14%) in the extremities. Local control according to tumor size for patients with MFH treated by surgery and postoperative radiotherapy is shown in Figure 1. The 5-year local control rate for patients with tumors less than 5 cm was 94% compared with 57% for patients with tumors larger than 5 cm (p = 0.02). Eight of 49 patients had grade 2 or 3 complications (delayed or late). Two patients had grade 3 complications:
one patient had edema of the extremity, while the other had a necrotic skin ulcer successfully treated with hyperbaric oxygen. Five patients had grade 2 edema of the extremity, while one patient had grade 2 complications including skin fibrosis within the treatment field and general complaints involving the gastrointestinal and genitourinary systems.
DISCUSSION
A literature survey disclosed scant information on the management of malignant fibrous histiocytoma with conservative surgery and postoperative radiotherapy. Reagan et al. (11) reported on 17 patients with localized malignant fibrous histiocytoma treated with surgery and postoperative irradiation or irradiation alone for unresectable tumors. The tumor dose ranged from 4594 to 6642 cGy, with a median dose of 6000 cGy. Local control was achieved in 1 I/ 17 (65%) patients. Lindberg et al. (7) reported on a group of 300 patients with soft tissue sarcoma that included 60 patients with malignant fibrous histiocytoma treated with conservative surgery and post-
Table 2. Patterns of failure for patients with malignant fibrous histiocytoma after postoperative radiotherapy by type of surgery
(17)
100
Failure site Type of surgery Incisional biopsy Excisional biopsy Narrow margin excision Wide margin excision Compartmental resection Total
NED
Local
Distant
Local + distant
4
0
3
0
1
19
3
5
0
1
14
0
2
2
0
9
9
0
0
0
3 49
2 34
0 10
0 2
Total
NED = No evidence of disease.
(‘3
_
(‘2
_
(%
90
1”:: ?typ=
23, pp.
6 15-6
0360.3016/92 $5.00 + .OO Copyright 0 1992 Pergamon Press Ltd.
I9
??Brief Communication
POSTOPERATIVE
RADIOTHERAPY
FOR MALIGNANT
FIBROUS
HISTIOCYTOMA
H. M. FAGUNDES, M.D.,’ P. P. LAI, PH.D., M.D.,’ L. P. DEHNER, M.D.,2 C. A. PEREZ, M.D.,’ D. M. GARCIA, M.D.,’ B. N. EMAMI, M.D.,’ J. R. SIMPSON,M.D., PH.D.,’ W. G. KRAYBILL, M.D.3 AND N. A. KUCIK’ ‘Radiation Oncology Center, Mallinckrodt Institute of Radiology; and ‘Department of Pathology, ‘Department Washington University, School of Medicine, St. Louis, MO
of Surgery,
Between 1974 and 1989, 49 patients with histologically confirmed malignant fibrous histiocytoma received postoperative radiotherapy at the Mallinckrodt Institute of Radiology for primary (41) or recurrent (8) disease. Median age of the patients was 63 years, and the median follow-up period was 41 months. Patients were grouped according to the 1988 AJC staging classification: stage IA (one patient), stage IIA (4 patients), stage IIB (9 patients), stage IDA (15 patients), stage IIIB (18 patients), and stage IVA (2 patients). Eight tumors (16%) were in the pelvis, 8 (16%) in the trunk, 4 (8%) in the head and neck, and 29 (60%) in the extremities. Primary surgical procedures included incisional biopsy (4 patients), excisional biopsy (19), narrow margin excision (14), wide local excision (9), and removal of the entire compartment (3). Based on pathology reports, the margins of resection were classified as positive in 23 (5 gross, 18 microscopic), 5 close, 11 negative, and 10 unknown. Patients were irradiated with shrinking field technique; the median radiation dose was 6000 cGy, with more than 95% of patients receiving at least 4500 cGy. In addition, seven patients received postoperative chemotherapy. The 5-year overall survival rate was 62%, disease-free survival 64%, local control 68%, and freedom-from-distant metastasis 85%. Thirteen patients had local recurrences, with > 75% recurring within 3 years. Sites of local recurrence were as follows: trunk (3), pelvis (3), lower extremities (4), and head and neck (3). There appears to be a correlation of local failnre with positive surgical margin: of 23 patients with positive margins, 9 (39%) had local recurrences, whereas 1 of 11 patients (9%) with negative margins had local recurrence. Three of 13 patients with persistent or recurrent disease were salvaged by additional treatment, rendering ultimate local control in 80% (39/49). Thirty-four of 36 patients with local control obtained good to excellent function. Two patients were found to have grade 3 complications: 1 patient had edema of the extremity, and the other developed necrotic skin ulcer that was successfully treated with hyperbaric oxygen. Five patients developed distant metastases, with 80% occurring within 2 years. In summary, adequate but conservative surgery with postoperative radiotherapy for malignant fibrous histiocytoma can achieve local tumor control as well as preservation of functional limbs with acceptable morbidity in a large proportion of patients. Radiotherapy,
Soft tissue sarcoma, Malignant fibrous histiocytoma.
In 1964, in a review of 15 16 cases of fibrous histiocytoma, O’Brien and Stout (10) reported 53 cases with malignant potential (i.e., high mitotic rate, infiltrative growth, or known metastases). Since then, the term malignant fibrous histiocytoma (MFH) has gained general acceptance and is now the most frequently diagnosed soft tissue sarcoma in adults ( 1, 8). In a recent Scandinavian histopathology review of high-grade soft tissue sarcomas, 40% of the cases were MFH, followed by synovial sarcoma (15%) leio-
myosarcoma (9%), liposarcoma (8%) and malignant schwannoma (6%) (1). Malignant fibrous histiocytoma manifests a broad range of histologic appearances. Essentially five subtypes have been described: storiform-pleomorphic, myxoid (myxofibrosarcoma), giant cell (malignant giant cell of soft parts), inflammatory (xanthosarcoma, malignant xanthogranuloma), and angiomatoid (22). Mixed morphologic types may also be found. The majority of malignant fibrous histiocytomas are cellular neoplasms with mixed storiform and pleomorphic areas.
Presented at the 32nd Annual Scientific Meeting of the American Society for Therapeutic Radiology and Oncology, Miami, FL, 1S-20 October 1990. Reprint requests to: Peter P. Lai, Ph.D., M.D., Mallinckrodt Institute of Radiology, Radiation Oncology Center, 4939 Audubon Ave., Suite 5500, St. Louis, MO 63 110.
Acknowledgements-The authors wish to thank Ms. Gwendolyn Jackson and Ms. Marlene Taylor for their secretarial help in the preparation of this manuscript. Dr. Lai is a recipient of the American Cancer Society Clinical Oncology Career Development Award. Accepted for publication 6 January 1992.
INTRODUCTION
615
616
1. J. Radiation Oncology 0 Biology 0 Physics
Current management of primary soft tissue sarcoma of the extremities and trunk consists of any of the following: conservative surgery combined with irradiation (preoperative or postoperative) ( 17, 18); combined intraarterial or intravenous chemotherapy, irradiation, and surgery (5); radical surgery alone, either radical compartmental resection or amputation ( 13, 15); or irradiation alone (2 1). Although MFH is considered the most common soft tissue sarcoma in adult patients, its management as a separate entity with conservative surgery and postoperative irradiation has not been well documented. This report describes the treatment and results of 49 patients with localized MFH managed with surgery and postoperative radiotherapy. METHODS
AND MATERIALS
Patient characteristics Between 1974 and 1989, 49 patients with localized, histologically confirmed malignant fibrous histiocytoma received postoperative irradiation at the Radiation Oncology Center, Mallinckrodt Institute of Radiology. Available histopathology slides were reviewed and the diagnosis of MFH confirmed by a pathologist (LPD) in 40 of the patients. There were 3 1 males and 18 females, with ages ranging from 13 to 90 years (median 63 years). Thirtyseven patients were white and 12 were black. The followup period ranged from 4 to 192 months (mean 41 months). Most patients had a painless nodule or mass present for several weeks or months. Work-up included chest X ray, routine blood chemistry, and complete blood count. Most patients had a CT scan of the involved area, and in more recent years an MRI scan was obtained. Tumor sites included lower extremity (37%), upper extremity (23%), pelvis (16%), trunk (16%), and head and neck (8%). Tumors were staged according to the American Joint Committee (AJC) staging system and graded on the basis of histopathologic characteristics (2). Patient distribution according to stage was: 2% Stage IA; 8% Stage IIA; 18% Stage IIB; 3 1% Stage IIIA; 37% Stage IIIB; and 4% Stage IVA. Fifty-seven percent of the tumors were storiformpleomorphic, 29% myxoid, 8% mixed morphologic patterns, 4% giant cell, and 2% inflammatory. Two tumors were grade 1, 13 grade 2, and 34 grade 3 lesions. The primary surgical procedures included four incisional biopsies, 19 excisional biopsies, 14 narrow margin excisions, nine wide local excisions, and three compartmental resections. Of the 49 patients, 23 had positive surgical margins, five had close margins, and 11 had negative surgical margins; in 10 patients the margin status was unknown. Radiation technique All patients were treated with external beam megavoltage irradiation to a median dose of 6000 cGy given at 180 to 200 cGy daily fractionation. Most patients with tumors in the extremities were treated with 4 MV photons,
Volume 23, Number 3. 1992
whereas patients with tumors in the trunk were treated with high-energy photons (18 or 25 MV). Individual immobilization devices were used for reproducible positioning. The “shrinking field” technique was used to deliver 4000 cGy with initial large parallel opposed AP-PA, lateral, or oblique fields, followed by an initial field reduction for 1000 cGy, and a further shrinkage in field size for an additional 1000 to 1600 cGy boost. A generous margin of 10 to 15 cm beyond the initial tumor edge was used for lesions in the extremities, and whenever possible, no more than two-thirds of the cross section of the extremity was irradiated, sparing a strip of tissue to decrease the probability of late edema of the distal extremity. No attempt was made to include the entire anatomic compartment. For tumors localized in the head and neck region, trunk, or pelvis, a generous margin was not always feasible. About 50% of patients were treated using scar bolus. Statistical methods All survivals and survival functions use the actuarial life-table as applied by Cutler and Ederer (4), and test statistics provided are Generalized Wilcoxon (Breslow), Generalized Savage (Mantel-Cox), and Tarone-Ware (9, 20). Trend analysis was performed by the Tarone Method ( 19). RESULTS
The actuarial 5-year local tumor control and diseasefree survival rates and patterns of failure by stage for these 49 patients are presented in Table 1. Ten patients failed locally only; two patients had distant metastasis only, and three patients experienced both local and distant failure. Six patients died of intercurrent disease. The overall 5year local control rate was 68%; the disease-free survival rate was 64%, and the overall survival rate was 62%. All patients with Stage IA and Stage IIA tumors were free of disease at last follow-up. Four of nine patients with Stage IIB disease failed locally. In this group three patients died of intercurrent disease. Two of 15 patients with Stage IIIA disease had local failures, one concomitant with distant disease. Eight patients with Stage IIIB disease had recurrence: five local only, two local and distant, and one distant only. One of two patients with stage IVA disease failed distantly only. Analysis of patterns of failure according to type of surgery is shown in Table 2. All four patients who had incisional biopsy only failed locally. When excisional biopsy was performed, 6 of 19 (32%) had local recurrences. In patients who had narrow margin excision, 2 of 14 (14%) had local failures. No patient who underwent wide local excision had a recurrence. One of three patients with massive disease treated with compartmental resection recurred 1ocalIy with concomitant distant metastasis. A total of 13 patients experienced local recurrence, three of whom also developed distant metastasis.
Postoperative radiotherapy for MFH 0 H. M. FAGUNDES etal.
617
Table I. Five-year local control, disease-free survival, and patterns of failure for patients with malignant fibrous histiocytoma after postoperative radiotherapy by stage Syear actuarial results
AJC stage
No. of patients
Local failure only
Local and distant failure
IA IIA IIB IIIA IIIB IVA Total
1 4 9 15 18 2 49
0 0 4 1 5 0 10
0 0 0 1 2 0 3
Distant failure only 0 0 0 0 1 1 2
Died of intercurrent disease 0 0 3 1 1 1 6
Local control
Disease-free survival
l/l 414 48% 76% 59% 212 68%*
l/l 414 48% 76% 53% l/2 64%
* 3/ 13 patients were salvaged with further surgery, resulting in an ultimate local control of 80%.
Of the 11 patients with negative margins, only one recurred locally (9%). This patient was treated to only 2800 cGy. Of the 23 patients with positive surgical margins, nine (39%) recurred locally. Forty percent of the patients with close margins and 10% with unknown margins had local recurrences. The 5-year actuarial local tumor control rate was 68%. Of the 10 patients with local recurrence alone, three patients were salvaged with further surgery, rendering an ultimate local control rate of 80%. Analysis of local recurrence rate by site revealed 3 of 4 (75%) in the head and neck, 3 of 8 (38%) in the trunk, 3 of 8 (38%) in the pelvis, and 4 of 29 (14%) in the extremities. Local control according to tumor size for patients with MFH treated by surgery and postoperative radiotherapy is shown in Figure 1. The 5-year local control rate for patients with tumors less than 5 cm was 94% compared with 57% for patients with tumors larger than 5 cm (p = 0.02). Eight of 49 patients had grade 2 or 3 complications (delayed or late). Two patients had grade 3 complications:
one patient had edema of the extremity, while the other had a necrotic skin ulcer successfully treated with hyperbaric oxygen. Five patients had grade 2 edema of the extremity, while one patient had grade 2 complications including skin fibrosis within the treatment field and general complaints involving the gastrointestinal and genitourinary systems.
DISCUSSION
A literature survey disclosed scant information on the management of malignant fibrous histiocytoma with conservative surgery and postoperative radiotherapy. Reagan et al. (11) reported on 17 patients with localized malignant fibrous histiocytoma treated with surgery and postoperative irradiation or irradiation alone for unresectable tumors. The tumor dose ranged from 4594 to 6642 cGy, with a median dose of 6000 cGy. Local control was achieved in 1 I/ 17 (65%) patients. Lindberg et al. (7) reported on a group of 300 patients with soft tissue sarcoma that included 60 patients with malignant fibrous histiocytoma treated with conservative surgery and post-
Table 2. Patterns of failure for patients with malignant fibrous histiocytoma after postoperative radiotherapy by type of surgery
(17)
100
Failure site Type of surgery Incisional biopsy Excisional biopsy Narrow margin excision Wide margin excision Compartmental resection Total
NED
Local
Distant
Local + distant
4
0
3
0
1
19
3
5
0
1
14
0
2
2
0
9
9
0
0
0
3 49
2 34
0 10
0 2
Total
NED = No evidence of disease.
(‘3
_
(‘2
_
(%
90
1”:: ?typ=
