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Radiotherapy before surgery for limb sarcoma doubled the rate of wound complications compared with radiotherapy after surgery, but gave the same tumour control with lower doses and less late fibrosis, leaving the timing as a trade between early and late side effects.
Phase 3 trial of 190 patients with extremity soft tissue sarcoma randomised to preoperative radiotherapy (50 Gy) or postoperative radiotherapy (66 Gy).
Major wound complications occurred in 35 percent after preoperative radiotherapy versus 17 percent after postoperative; local control and survival were similar (with a small non-significant survival advantage for preoperative), and later reports showed less fibrosis, oedema and joint stiffness with preoperative treatment.
Both sequences are standard; preoperative radiotherapy is favoured for large deep tumours because of better long-term function, with postoperative radiotherapy where wound risk is high.