For extremity rhabdomyosarcomas (hand) with positive epitrochlear and axillary lymph nodes, do you treat the lymph nodes or just the primary?

Treatment of extremity RMS (either hand or foot) requires either resection or radiation for local treatment, in the setting of effective systemic therapy. There are good data in the literature showing that the primary tumor can be effectively irradiated, while retaining function and form so to avoid amputation. This tumor most frequently is of the unfavorable, alveolar subtype. Patterns of spread have shown a high incidence of lymph node spread, so that draining lymph nodes, as well as the in-transit nodes need to be imaged adequately in staging. PET has proven to be useful in picking up subclinical disease. If nodal disease is present it should be irradiated for local control. Radical node dissections are not appropriate in the setting of ...