Strass relief.

While the STRASS trial failed to show slam-dunk advantages to pre-op radiation prior to resection for retroperitoneal sarcoma, there are specific scenarios where it may be useful. This review suggests the decision hinges on understanding the relative risks for local versus distant recurrence. In other words, when the most likely failure would be local, such as the classic example of a well-differentiated liposarcoma, incorporating pre-op (not post-op given the excessive toxicity) radiation probably makes a lot of sense. The standard dose is 50-50.4 Gy in 25 to 28 fractions with an option for a simultaneous integrated boost to 63 Gy to at-risk margins using IMRT. Importantly, radiation should only be offered if the tumor is already amenable to gross total resection because it’s unlikely to shrink the low-grade tumors for which it’s indicated, meaning radiation without surgery has little benefit. Finally, a clear understanding of anticipated post-op anatomy is crucial to setting appropriate dose constraints, such as preserving contralateral kidney or liver function with a plan for nephrectomy or partial hepatectomy. | Salerno & Baldini, JNCCN 2022