Image-Guided Radiation Therapy in Treating Patients With Primary Soft Tissue Sarcoma of the Shoulder, Arm, Hip, or Leg

RATIONALE: Image-guided radiation therapy uses high-energy x-rays to kill tumor cells. Specialized radiation therapy that delivers a lower dose of radiation directly to the tumor may kill more tumor cells and cause less damage to normal tissue.

PURPOSE: This phase II trial is studying the side effects and how well image-guided radiation therapy works in treating patients with primary soft tissue sarcoma of the shoulder, arm, hip, or leg.

OBJECTIVES:

Primary

* To determine the effect of reduced radiation volume using image-guided radiotherapy (IGRT) on lymphedema ≥ grade 2, subcutaneous fibrosis, and joint stiffness at 2 years in patients with primary soft tissue sarcoma of the extremity.

Secondary

* To estimate the rates of other grade 3-5 adverse events as measured by Common Toxicity Criteria for Adverse Effects (CTCAE) v3.0.
* To determine the pattern of first failure, including local failure (in-field, marginal, and outside-field failure), regional failure, distant failure, and death without disease progression.
* To estimate the rates of local failure, local-regional failure, distant failure, distant disease-free survival, disease-free survival, overall survival, and second primary tumor.
* To estimate the rate of wound complications.
* To correlate the degree of late radiation morbidity (defined as any lymphedema, subcutaneous fibrosis, or joint stiffness) at 2 years with scores on the clinical measure, Musculoskeletal Tumor Rating Scale (MSTS).

OUTLINE: This is a multicenter study.

* Neoadjuvant radiotherapy: Patients are assigned to 1 of 2 treatment groups (group 1 closed to accrual as of 01/08/10).

  * Group 1 (closed to accrual as of 01/08/10): Patients undergo 3-D conformal radiotherapy (3D-CRT) or intensity-modulated therapy (IMRT) once daily, 5 days a week, for 4½-5 weeks. Patients also receive up to 6 courses of neoadjuvant, adjuvant, concurrent, or interdigitated chemotherapy.
  * Group 2: Patients undergo 3D-CRT or IMRT once daily, 5 days a week, for 5 weeks.
* Surgery: At 4-8 weeks after completion of neoadjuvant radiotherapy, patients undergo surgical resection of the tumor. Patients with positive tumor margins (residual tumor) undergo intraoperative radiotherapy boost or proceed to adjuvant radiotherapy within 2 weeks after surgery.
* Adjuvant radiotherapy: Patients undergo either external-beam radiotherapy (EBRT) once daily for 8 fractions or brachytherapy.

After completion of study treatment, patients are followed at least every 3 months for 2 years, every 6 months for 3 years, and then annually thereafter.

Eligibility Criteria:
DISEASE CHARACTERISTICS:

* Histologically confirmed primary soft tissue sarcoma of the upper extremity (including shoulder) or lower extremity (including hip)

  * Incisional or core biopsy required within the past 8 weeks
* No histopathological diagnosis of any of the following:

  * Rhabdomyosarcoma
  * Extraosseous primitive neuroectodermal tumor (PNET)
  * Soft tissue Ewing sarcoma
  * Osteosarcoma
  * Kaposi sarcoma
  * Angiosarcoma
  * Aggressive fibromatosis (desmoid tumor)
  * Dermatofibrosarcoma protuberans
  * Chondrosarcoma

    * Extraskeletal myxoid chondrosarcoma allowed
* Tumor must be surgically resectable, as determined by a surgeon within the past 8 weeks

  * Limb-preservation surgery alone would not provide adequate local control, as determined by the surgeon
* No sarcoma of the hand, foot, head, neck, or intra-abdominal or retroperitoneal region or body wall
* No sarcoma ≥ 32 cm in any direction
* No lymph node or distant metastases, according to the following within the past 8 weeks:

  * History/physical examination, including a detailed description of the location, size, and stage of the sarcoma
  * MRI with contrast of the primary tumor

    * The maximum dimension of the primary tumor is measured in MRI images
  * CT scan of the chest

    * Multiple pulmonary nodules \< 8 mm without a histological diagnosis detected incidentally on a non-screening CT scan may be allowed
  * CT scan with contrast of the abdomen and pelvis in patients with intermediate- or high-grade sarcoma of the upper thigh
* No recurrent tumor after prior potentially curative therapy

PATIENT CHARACTERISTICS:

* Zubrod performance status 0-1
* Absolute neutrophil count ≥ 1,500/mm\^3
* Platelet count ≥ 100,000/mm\^3
* Hemoglobin ≥ 8.0 g/dL (transfusion or other intervention allowed)
* Bilirubin ≤ 1.5 mg/dL\*
* Aspartate aminotransferase (AST) or alanine aminotransferase (ALT) ≤ 2 times upper limit of normal\*
* Serum creatinine ≤ 1.6 mg/dL OR creatinine clearance ≥ 55 mL/min\*
* Left ventricular ejection fraction (LVEF) ≥ 50% by multiple gated acquisition scan (MUGA) or echocardiogram\*
* Not pregnant or nursing
* Negative pregnancy test
* Fertile patients must use effective contraception
* No other invasive malignancy within the past 3 years, except nonmelanomatous skin cancer or carcinoma in situ of the breast, oral cavity, or cervix
* No severe, active co-morbidity, including any of the following\*:

  * Unstable angina and/or congestive heart failure requiring hospitalization within the past 6 months
  * Transmural myocardial infarction within the past 6 months
  * Acute bacterial infection or fungal infection requiring intravenous antibiotics
  * Acquired Immune Deficiency Syndrome (AIDS) or immunocompromised patients

    * HIV testing not required
* No NCI CTCAE v 3.0 grade 3-4 electrolyte abnormalities, including any of the following\*:

  * Calcium \< 7 mg/dL or \> 12.5 mg/dL
  * Glucose \< 40 mg/dL or \> 250 mg/dL
  * Magnesium \< 0.9 mg/dL or \> 3 mg/dL
  * Potassium \< 3mmol/L or \> 6 mmol/L
  * Sodium \< 130 mmol/L or \> 155 mmol/L NOTE: \*Applies to group 1 only, which was closed to accrual as of 01/08/10)

PRIOR CONCURRENT THERAPY:

* See Disease Characteristics
* No prior excisional biopsy in which the majority of the tumor (≥ 50%) is removed
* No prior radiotherapy to the region of the study cancer that would result in overlap of radiotherapy fields
* No other concurrent investigational agents