Abstract
BACKGROUND: Pulmonary metastases (PM) develop in ∼ 30 % of sarcoma patients after curative therapy and confer poor prognosis. Surgery and stereotactic body radiotherapy (SBRT) are viable local ablative options, but direct comparative data is limited. This systematic review evaluates oncologic outcomes and toxicities of surgery versus SBRT for sarcoma-derived PM. MATERIALS AND METHODS: We systematically reviewed Medline and references for studies of sarcoma-PM treated with surgery or SBRT according to PRISMA, including publications up to 13th May 2025. Outcomes included local control (LC), progression-/disease-free survival (PFS/DFS), overall survival (OS), and toxicities, with OS data harmonized for pooled analysis. RESULTS: Fifty-eight mostly retrospective studies comprising 4,787 patients were included. LC, PFS, and DFS were heterogeneously reported but generally similar. Three-year weighted median LC was 89.6 % (surgery, 2 studies) vs. 87.8 % (SBRT, 15 studies). Reporting on PFS/DFS was limited: Four-year-PFS 21 % (SBRT) vs. 28 % (surgery, 1 study each); 5-year-DFS 12 % (SBRT, 1 study) vs. 19 % (surgery, 9 studies). SBRT toxicities were generally ≤ CTCAE grade 3, while surgery occasionally caused grade 4-5 events. 5-year-OS showed no significant difference: 31.6 % for SBRT [95 %-CI 23.9-41.5 %], 37.8 % for surgery [95 %-CI 30-41.9 %]. CONCLUSION: Evidence indicates SBRT and surgery provide comparable outcomes for sarcoma- PM, with SBRT offering a more favorable toxicity profile. Though heterogeneous indications and incomplete reporting limit comparability, SBRT should not be viewed solely as fallback for surgically ineligible patients. Treatment should be individualized within a multidisciplinary expert team, integrating patient- and modality-specific factors. Well-designed prospective trials are needed to define relative safety and efficacy.