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dr james c wittig, orthopedic oncologist, new york, new jersey
Patient Education

Whenever radiation is prescribed, the benefits of radiation must be weighed against the risks. The complications include stiffness and scarring, burns, muscle contractures, chronic swelling and lymphedema, muscle atrophy, muscle weakness, hair loss in the exposed area, skin burns, radiation induced cancers of bone and soft tissue, malignant degeneration of benign tumors, nerve damage, nerve pain, nerve paralysis. Radiation induced changes and damage continue to progress with time and compound year after year. The severity of these complications varies according to the dose of radiation administered and varies between patients. Most patients experience minor radiation induced changes or complications. Precautions are taken to minimize these complications. Physical therapy is required during and after radiation. Specific exercises should be continued for the rest of the patients life. The entire course of radiation depends upon the dose that is administered. Typically 3-4 weeks of treatment is required. The patient goes for the treatment daily, 5 days per week.

Radiation can also be delivered to the wound by catheters that are planted in the wound at the time of surgery. This is referred to as brachytherapy. I do not prefer to use brachytherapy because of the high wound complication rates that occur with its use. Additionally, in my opinion, it does not reliably deliver the radiation to all areas of the surgical bed where it is needed. I prefer external beam radiation delivered postoperatively. The required field is most reliably treated and since the radiation is administered when the wound is healed, wound complications are rarely an issue.

The decision to administer radiation however must weigh the benefits against the risks. That is the risk of the tumor coming back and what problems it can cause if it comes back against the complications associated with radiation. In some instances, it may be beneficial to not administer radiation and monitor the patient closely and perform a second procedure if the tumor comes back. In these instances the chance of requiring a second surgery are usually low and the complications associated with a second surgery may be less severe than the complications associated with radiation. Radiation treatment of the extremities can cause complications or problems such as stiffness, joint contractures, muscle atrophy, fractures that do not heal, severe swelling and lymphedema, neurogenic pain, nerve problems leading to paralysis, limb length discrepancy as well as second malignancies. Thus, there is always a risk benefit ratio.

External beam refers to the method of administration of the radiation by means of a device that targets the patient through an external source. It can cover a very specific target area and wide field. Generally, the patient receives daily doses (5 days a week) for 3-4 weeks. In my opinion, it is the most reliable method of administering radiation to the required field. This is in contrast to catheters that can be placed at the time of surgery and loaded with radiation pellets. I do not prefer this method because, the decision as to administer radiation must be made early, prior to studying the tumor response to the chemotherapy. Thus, many patients who have had a good response to the chemotherapy regimen who may be able to be spared from radiation and its untoward complications would be treated unnecessarily. Also, there are excessive wound complications associated with these catheters and the area that must be treated may not reliably be treated because of technical reasons. Some surgeons prefer to give radiation preoperatively by external beam, I do not prefer this approach and do not find it necessary when chemotherapy is given preoperatively.

In my opinion, many patients who could be spared from radiation (those who have had a good response to the chemotherapy regimen) may be unnecessarily treated. Additionally, radiation given before surgery leads to a higher number of wound complications and more severe wound complications that often require extensive plastic surgery procedures such as free flaps to close the wound. This can lead to substantial problems with use of the extremity postoperatively and can delay resumption of chemotherapy.

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