Radiotherapy Raises Risk of Complications After Limb STS Surgery

Radiotherapy increases the risk of short- and long-term complications in patients with high-grade limb soft tissue sarcoma (STS) who undergo surgery, a recent report found.1

The single-center, retrospective study raises questions about the risks associated with radiotherapy in this patient population, but the authors of the report said those risks must be weighed against the oncological benefits of radiotherapy. The study was published in the International Wound Journal.

Surgical wide excision is the main treatment strategy for people with localized STS, but it is recommended that patients with grade 2 or 3 disease also receive neoadjuvant radiotherapy with or without chemotherapy to downstage large tumors and allow for function-sparing radical excision, the authors explained. If not performed prior to surgery, radiotherapy can also be administered postoperatively, they noted.

Neoadjuvant radiotherapy was associated with longer time spent in the hospital and a higher risk of short- and long-term wound complications. | Image credit: cacaroot - stock.adobe.com

“Local control and overall survival are not influenced by the timing of radiotherapy,” the authors wrote, “thus its standardization is not achieved yet.”

Still, radiotherapy can lead to significant adverse events. The investigators said tissues with high cellular remodeling are particularly susceptible to adverse events, which means that surgical wounds are at a particularly high risk.2

Short-term wound complications of radiotherapy can include dehiscence, delayed healing, and infection, the authors said. Long-term complications can include loss of sweat and sebaceous glands, skin atrophy, lymphedema, telangiectasias, movement difficulty, weakness, and pain, they said.

Complications from radio-treated limb surgery are underreported in the literature, even though such complications can have a significant impact on quality of life and healthcare costs. They therefore sought to assess the risk of both short- and long-term wound complications after surgery with or without radiotherapy, using a series of patients treated at their hospital. In addition to wound complications, they also assessed length of hospital stay and outpatient care time in comparison to treatment.

The authors identified patients with limb STS who were treated at the Veneto Institute of Oncology in Padua, Italy, between 2015 and 2022. All of the 243 patients treated during that time frame were included in the analysis. Of those, 87 received neoadjuvant radiotherapy, 64 received adjuvant radiotherapy, and the remaining 92 patients received surgery alone.

They found that patients who received neoadjuvant radiotherapy tended to spend longer in the hospital, with a mean difference (MD) of 6.4 days (95% CI, 3.9-9.0 days). Those patients were also at a higher risk of short-term wound complications (OR, 3.45; 95% CI, 1.82-6.62).

Neoadjuvant radiotherapy was also a risk factor for long-term wound complications (OR, 4.87; 95% CI, 2.48-9.84) and longer outpatient care time (MD 83 days; 95% CI, 41-126 days). Adjuvant radiotherapy also increased the risk of long-term complications (OR, 5.20; 95% CI, 2.57-10.95) for longer outpatient care (MD, 62 days; 95% CI, 19-106).

“Overall, we found that radiotherapy in limb STS was associated with impaired wound healing and longer care time,” the authors wrote.

The authors said they found such complications were more common on proximal lower limb sarcomas, which they said was likely due to the greater depth of subcutaneous fat and the gravitational effects on lymphatic drainage in lower extremities. However, they said the reasons for such differences were not the focus of their analysis and thus will require additional research.

The investigators said their findings should not be seen as negating the potential benefits of radiotherapy in patients with high-grade limb STS. However, they said clinicians should also not underestimate the side effects of radiation on surgical wounds.

“We believe that more efforts should focus on new clinical strategies to contain cutaneous radiogenic side effects,” they concluded. “Negative pressure wound therapy benefits should be further investigated in an oncological setting.”

References

1. Dal Pos S, Mazza M, Gianesini CM, et al. Wound healing complication in radio-treated limb soft tissue sarcoma patients: a single referral center experience. Int Wound J. 2025;22(6):e70175. doi:10.1111/iwj.70175

2. Stone HB, Coleman CN, Anscher MS, McBride WH. Effects of radiation on normal tissue: consequences and mechanisms. Lancet Oncol. 2003;4(9):529-536. doi:10.1016/s1470-2045(03)01191-4