Preoperative hypofractionated radiotherapy in soft tissue sarcomas: institutional experience and clinical implications

Background: Conventional preoperative radiotherapy (RT) with 50 Gy in 25 fractions improves local control in soft tissue sarcomas (STS) but entails prolonged treatment and high rates of wound complications. Hypofractionated regimens may offer a shorter, more patient-convenient alternative while maintaining comparable outcomes, although they are not yet standard. Materials and methods: We conducted an observational study of a prospective cohort of 24 patients with localized STS of the extremities or superficial trunk treated with preoperative hypofractionated RT between December 2021 and January 2025. Two regimens were used: moderately hypofractionated RT (MHFRT, 42.75 Gy/15 fx) and ultra-hypofractionated RT (UHFRT, 30 Gy/5 fx). Outcomes included acute toxicity, wound complications, pathological response, local control, and postoperative limb function using the Musculoskeletal Tumor Society (MSTS) and Toronto Extremity Salvage Score (TESS) scales. Results: The median age was 68 years, and median tumor size 11.6 cm. All patients completed RT without interruption. A favorable pathological response (≥90% necrosis and/or ≤ 10% viable tumor) was achieved in 66.7%. Grade 1-2 dermatitis occurred in 66.7%, with no grade ≥ 3 toxicity. Major wound complications developed in 29.2%. Median MSTS and TESS scores were 26/30 (86.7%) and 88%, respectively. At 18 months median follow-up, 1- and 2-year local control rates were 100%. Conclusions: Preoperative hypofractionated RT demonstrated excellent tolerance, high pathological response, and outstanding local control with acceptable wound-complication rates. Functional outcomes were favorable, supporting hypofractionated RT as a safe, efficient, and function-preserving alternative for localized STS in experienced centers. These findings provide real-world evidence supporting shorter preoperative RT schedules as a feasible and function-preserving approach in multidisciplinary sarcoma care.