Hemithorax Irradiation for High-Risk Chest Wall Sarcomas: Current Evidence, Clinical Practice and Future Directions

Hemithorax irradiation (HT‑RT) is a cornerstone multimodal treatment for high‑risk chest wall bone and soft tissue sarcomas, particularly Ewing sarcoma in children and young adults. Current non‑randomized evidence consistently shows HT‑RT reduces systemic relapse-especially lung metastases-without compromising local control or causing unmanageable acute toxicities, and modern techniques (IMRT, VMAT, proton therapy) further improve its therapeutic ratio by lowering late toxicity. Major gaps remain: no prospective randomized controlled trials (RCTs) confirm independent efficacy, the biological mechanisms are unclear, and long‑term pulmonary function and survivorship data in children are insufficient. Future research must prioritize prospective RCTs, pediatric‑specific dose constraints, advanced technique validation, and mechanistic studies to refine patient selection and optimize outcomes for this high‑risk population.

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