Pulmonary Metastasectomy Versus Stereotactic Beam Radiation Therapy for Sarcoma Pulmonary Metastasis: A Retrospective Cohort Study

Background Sarcomas are a diverse group of malignancies that most commonly metastasize to the lungs. Surgical metastasectomy has been considered the gold standard for oligometastatic disease that is technically resectable in medically appropriate patients, while stereotactic body radiotherapy (SBRT) offers a non-surgical alternative that has been shown to be safe and effective. The current literature remains limited in direct comparisons between these treatments. Methodology A retrospective cohort study was performed at a single academic center between 2005 and 2024 that included 99 patients with metastatic sarcoma to the lungs. Patients received metastasectomy only (n = 34), SBRT only (n = 28), or both modalities (n = 37). The primary endpoint was overall survival from metastatic diagnosis. Secondary endpoints included treatment-related complications. Multivariable Cox proportional hazards modeling adjusted for treatment modality, age, number of nodules, chemotherapy use, and other prognostic factors. Results Before controlling for confounding, metastasectomy was associated with the greatest median survival at 45.5 months, followed by both at 37.5 months and SBRT at 24.5 months. On multivariable analysis, metastasectomy was associated with significantly reduced mortality (hazard ratio (HR) = 0.40, 95% confidence interval (CI) = 0.20-0.82, p = 0.012). SBRT may reduce the risk of mortality, but significance was not reached (HR = 0.86, p = 0.648). Age >70 years (HR = 2.39, p = 0.015) and ≥3 nodules (HR = 2.27, p = 0.008) predicted worse survival. Wide resection of metastases, including microscopic margins, was not associated with statistically significantly reduced mortality when compared to non-wide metastasectomy, with residual microscopic disease (HR = 0.693, p = 0.328). Complication rates were similar between SBRT (17.2%) and metastasectomy (13.4%). Conclusions Metastasectomy should remain the preferred, first-line treatment for oligometastatic sarcoma to the lungs in appropriately indicated patients. SBRT remains a safe and effective alternative for patients with unresectable disease or those who are medically inoperable.