Heterogeneity in response to neoadjuvant radiotherapy between soft tissue sarcoma histotypes: associations between radiology and pathology findings

Objective

To investigate imaging biomarkers of tumour response by describing changes in imaging and pathology findings after neoadjuvant radiotherapy (nRT) and exploring their correlations.

Materials and methods

Tumour diameter, volume, and tumour-to-muscle signal intensity (SI) ratio were collected before and after radiotherapy in a cohort of 107 patients with intermediate/high-grade STS and were correlated with post-radiotherapy pathology findings (percentage of necrosis, viable cells, and fibrosis) using Spearman Rank test. Pathological complete response (pCR) was defined as no residual viable cells present, whereas the presence of < 10% viable cells was defined as near-complete pathologic response (near-pCR).

Results

Median amount of necrosis, viable cells, and fibrosis after nRT were 10%, 30%, and 25%, respectively. 7% of patients achieved pCR and 22% near-pCR. No changes in tumour volume were found except for subtypes myxoid liposarcoma (mLPS) −Δ54.47%, undifferentiated pleomorphic sarcoma (UPS) +Δ24.22% and dedifferentiated liposarcoma (dLPS) +Δ35.91%. The median change of tumour-to-muscle SI ratio was −19.7% for the entire population, whereas it was −19.55% and −36.26% for UPS and mLPS, respectively. Correlations (positive and negative) were found between change in volume and the presence of necrosis or fibrosis (r_s = 0.44; r_s = −0.44), as well as between tumour-to-muscle SI ratio and viable cells (r_s = 0.33) or fibrosis (r_s = −0.28).

Conclusion

STS displays extensive heterogeneity in response patterns after nRT. In some subgroups, particularly UPS and mLPS, tumour size changes or tumour-to-muscle SI ratio are significantly linked with the percentage of viable cells, fibrosis, or necrosis.

Key Points

Question How do primary soft tissue sarcomas (STS) respond to neoadjuvant therapy, and what correlations exist between pathological findings and imaging characteristics in assessing treatment response?

Findings mLPS shrank post-nRT; undifferentiated pleomorphic and dLPSs enlarged. Volume increase correlated with higher necrosis and lower fibrosis; tumour-to-muscle intensity ratio correlated with viable cells.

Clinical relevance These findings emphasise the extensive heterogeneity in STS response to nRT across different subtypes. Preoperative correlations between tumour volume and SI changes with necrosis, fibrosis, and viable cells can aid in more precise treatment assessment and prognostication.

Graphical Abstract