12.2.10Therapy

12.2.10.1 Overview

•Multidisciplinary approach according to location, primary presentation (resectability, staging), and histology

•Examples:

–Orbital, parameningeal, female genitals, biliary tract, or prostate: primary biopsy followed by chemotherapy, radiotherapy, rarely surgery necessary or possible; second-look biopsy due to false-negative results

–Local tumor of the trunk, extremities, or paratesticular area: surgical total excision, chemotherapy, eventually irradiation

–In other locations without metastases: initial chemotherapy followed by surgery (debulking only) of the remaining tumor; depending on the result: radiotherapy and/or additional chemotherapy should be given

12.2.10.2Surgical Procedure

• Total resection:

– If surgery is possible without major functional deficits

– If irradiation can be avoided or reduced

– If the field of irradiation can be reduced

– If group III stage is likely to become group I or II stage after initial chemotherapy

• Lymph node involvement: biopsy of tumors involving the extremities, the genitourinary tract, and in metastatic lymph node involvement; total regional lymph node resection is not necessary in combined chemoand radiotherapy and surgery

12.2.10.3Radiotherapy

•Stage I: no irradiation

•Stages II–IV: radiotherapy after initial chemotherapy eventually after surgery with microor macroscopic residual disease indicated

•Therapy using less than 40 Gy results in a higher rate of local relapses

•Pulmonary metastases: 14–18 Gy total pulmonary irradiation and an additional 30 Gy of residual metastases

•In solitary bone metastases, 50–60 Gy

•In multiple metastases, individualized irradiation may be delivered for control of symptoms; it is unclear whether irradiation of metastases alters overall outcome

•In hepatic involvement, 25–30 Gy

12.2.10.4 Chemotherapy

•Highly chemotherapy-sensitive tumor, especially in combined procedure (surgery and irradiation and chemotherapy)

•Improved results after combined chemotherapeutic drugs with minimal overlapping resistance patterns and toxicities