Miscellaneous: Soft-tissue sarcoma: neoadjuvant vs adjuvant RT
Free question published 29 July 2026
A 54-year-old man has a 9 cm high-grade (FNCLCC grade 3) myxofibrosarcoma deep in the posterior compartment of the left thigh, abutting the femur. The sarcoma MDT plans limb-sparing wide local excision and recommends perioperative radiotherapy to optimise local control. The patient is fit and his main concern is preserving long-term limb function. Compared with delivering radiotherapy postoperatively, what is the principal trade-off of giving the radiotherapy preoperatively?
- AA higher rate of acute wound-healing complications but less late fibrosis, oedema and joint stiffness
- BA higher total radiotherapy dose to a larger tissue volume
- CA lower rate of acute wound-healing complications during recovery but substantially worse long-term local control of the sarcoma in the treated limb
- DA higher risk of radiation-induced second malignancy within the treated field
- EAn improvement in overall survival driven by tumour downstaging
Why A is correct
In the NCIC SR2 trial, preoperative radiotherapy (50 Gy) caused roughly twice the rate of acute wound complications as postoperative radiotherapy (60 to 66 Gy), especially in the lower limb (43% versus 21%), but the postoperative arm had more late grade greater than 2 fibrosis, oedema and joint stiffness because it treats a larger volume to a higher dose. ESMO guidelines reflect this and favour preoperative radiotherapy when functional preservation is the goal. Local control, progression-free survival and overall survival were equivalent between the arms.
And why the others are not
- BThe reverse is true: preoperative RT uses a lower dose (50 Gy) to a smaller volume than postoperative RT (60 to 66 Gy), which is why late effects are less.
- CIncorrect: preoperative RT has more, not fewer, acute wound complications, and local control was equivalent between the arms in SR2.
- DSecond-malignancy risk is not the principal or established difference between preoperative and postoperative timing in this setting.
- ESR2 showed no overall survival difference between preoperative and postoperative radiotherapy; survival is not the trade-off being asked about.
Source ESMO-EURACAN-GENTURIS Clinical Practice Guidelines - Soft tissue and visceral sarcomas — Gronchi A, Miah AB, Dei Tos AP, et al. Soft tissue and visceral sarcomas: ESMO-EURACAN-GENTURIS Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2021;32(11):1348-1365.
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