Original Study Title: ESTRO clinical practice guideline on radiotherapy for adult soft tissue sarcoma of the extremities and trunk wall – Endorsed by ASTRO
Authors: Siyer Roohani, Mateusz Jacek Spałek, Ninna Aggerholm-Pedersen, Franziska Eckert, B. Ashleigh Guadagnolo, David G. Kirsch, Cécile Le Péchoux, Aisha B. Miah, Kilian E. Salerno, Claudia Sangalli, Rita Simões, Renate Walter, Lisette M. Wiltink, Shane Zaidi, Beate Timmermann, Rick L. Haas
ESTRO Guideline Defines Radiotherapy Standards in Adult Soft Tissue Sarcoma
How should radiotherapy be optimally integrated into the management of adult soft tissue sarcoma of the extremities and trunk wall? A new ESTRO clinical practice guideline, endorsed by ASTRO, provides an updated, evidence-based framework to guide decision-making across the entire treatment pathway.
Soft tissue sarcoma management remains complex, requiring careful coordination between surgery, radiotherapy, and multidisciplinary expertise. This guideline, developed by an international task force, addresses 13 key clinical questions covering indications for radiotherapy, sequencing strategies, target delineation, dose and fractionation, and toxicity assessment.
Preoperative Radiotherapy Remains the Preferred Approach
The guideline reinforces that preoperative radiotherapy followed by surgery remains the standard of care for most localized cases, offering comparable oncologic outcomes with a more favorable long-term toxicity profile compared with postoperative treatment.
Radiotherapy indications are primarily driven by the risk of local recurrence, including factors such as tumor size, grade, depth, histology, and expected surgical margins. Multidisciplinary evaluation at expert sarcoma centers is emphasized as essential for individualized decision-making.
Advances in Planning and Delivery
Modern radiotherapy techniques play a central role in treatment optimization. The guideline highlights the importance of MRI-based target delineation, standardized margins, and highly conformal techniques such as IMRT or VMAT combined with daily image guidance to ensure precise dose delivery while minimizing toxicity.
Standard dosing remains consistent, with preoperative radiotherapy typically delivered to 50–50.4 Gy in conventional fractions. Postoperative strategies include dose escalation depending on margin status, while emphasizing careful balance between tumor control and normal tissue protection.
Emerging Strategies Remain Investigational
Despite ongoing innovation, the guideline takes a cautious stance on newer approaches. Preoperative hypofractionation, integration of systemic therapies such as immunotherapy, and histology-specific dose adaptations show promise but should not yet be adopted into routine clinical practice without further evidence.
Clinical Takeaway
This updated ESTRO guideline consolidates current evidence and expert consensus, confirming preoperative radiotherapy as the backbone of treatment while emphasizing precision techniques and multidisciplinary care. Emerging strategies are promising, but standard, evidence-based approaches remain essential for optimal outcomes in soft tissue sarcoma.
Write full article here
Written By Aren Karapetyan, MD