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RADIATION THERAPY
SOFT TISSUE SARCOMA
Elizabeth H. Baldini MD, MPH
Radiation Oncology Director
Center for Sarcoma and Bone...
Soft Tissue Sarcoma
Management by Multimodality Team
Radiology
Pathology
Surgery: Oncologic/Orthopedic; Plastic
Radiation ...
Management at Experienced Center
•Associated with better outcome
Guadagnolo, A J Clin Onc 2011
Gutierrez, Ann Surg 2007
Pa...
Treatment
Localized Disease
• Surgery
• Radiation Therapy
Metastatic Disease (beyond local site)
• Systemic therapy
Treatment of Localized
Soft Tissue Sarcoma of the
Extremity or Trunk
Decades ago: Amputation
Now: Limb-Sparing Surgery & R...
Surgery and Radiation
Sequencing
Pre-operative Radiation  Surgery
OR
Surgery  Post-operative Radiation
• Efficacy: Simil...
Surgery and Radiation Sequencing
PRE-OP RT
Lower Dose:
50 Gy
5 weeks
Smaller Irradiated
Volume: tumor
plus margins
POST-OP...
Surgery and Radiation Sequencing
PRE-OP
• More acute wound
complications
(35% vs 17%)
• Usually reversible
POST-OP
• More ...
Surgery and Radiation Sequencing
• Equivalent efficacy
• Different Toxicities
• Treatment approach should be
individualize...
RADIATION PLANNING
PROCESS
SIMULATION
• Decide on patient position on
treatment table
• Make custom immobilization device
to reproduce position on a ...
Radiation Simulator
Treatment
couch
CT scan
Immobilize hand for tumor of arm
Custom cast molded to hand
•
Immobilize foot for tumor of leg
Custom cast molded to foot
Tattoos
• Permanent marks placed on skin
• Used for set up of daily treatments
Radiation Treatment Volumes
Physician contours
tumor on the
planning CT scan
Adds “margin”
around tumor to
treat possible
...
Radiation Planning Process
• MD works with physicist
• Iterative process, takes about a week
• Goal: to devise a plan to
–...
Radiation Graphic Plan
Pink: tumor; Green: ovaries
Dose Lines:
100% Yellow
90% Blue
40% Brown
6% Green
Treatment Begins
Most common regimen:
• Daily treatment Monday – Friday
• 5 weeks
Each treatment takes ~ 20 minutes
• most...
Treatment Machine:
Linear Accelerator
Laser Lights Lined up on Tattoos
Or Lasers Lined up on Mask
Verification X-rays or CT scan
• Taken prior to
each treatment to
confirm patient is
set up correctly
• Adjustments are
ma...
Radiation Techniques
External Beam Radiation Therapy
Photons
• 3D
• IMRT (Intensity Modulated Radiation Therapy)
Electrons...
Comparison of Dose Distributions
Isodoses
Red: 100%
Light blue: 20-30%
3D IMRT
Radiation Therapy Side Effects
Acute
• Skin reddening
• Fatigue
• Delayed wound
healing
• Hair loss in
treatment area
• Mu...
Dana-Farber/Brigham & Women’s Cancer Center:
Center for Sarcoma and Bone Oncology
• Surgical Oncology
Monica Bertagnolli, ...
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How Radiation Therapy is Used to Treat Soft Tissue Sarcoma

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Learn about the process of radiation therapy to treat soft tissue sarcoma, and how new radiation technology has improved treatment of the disease.

This presentation was given by Elizabeth H. Baldini, MD, MPH, radiation oncology director for the Center for Sarcoma and Bone Oncology at Dana-Farber Cancer Institute. It was originally presented as part of the "15 Years of GIST/Soft Tissue Sarcoma Symposium," held on Sept. 12, 2015 at Dana-Farber in Boston, Mass.

Published in: Health & Medicine

How Radiation Therapy is Used to Treat Soft Tissue Sarcoma

  1. 1. RADIATION THERAPY SOFT TISSUE SARCOMA Elizabeth H. Baldini MD, MPH Radiation Oncology Director Center for Sarcoma and Bone Oncology Dana Farber Cancer Institute Associate Professor of Radiation Oncology Harvard Medical School
  2. 2. Soft Tissue Sarcoma Management by Multimodality Team Radiology Pathology Surgery: Oncologic/Orthopedic; Plastic Radiation Oncology Medical Oncology Physical Therapy Social Work Case Review at Multi-disciplinary Tumor Board
  3. 3. Management at Experienced Center •Associated with better outcome Guadagnolo, A J Clin Onc 2011 Gutierrez, Ann Surg 2007 Paszat, Sarcoma 2002 Clasby, Br J Surg 1997 Gustafson, Acta Orthop Scand 1994
  4. 4. Treatment Localized Disease • Surgery • Radiation Therapy Metastatic Disease (beyond local site) • Systemic therapy
  5. 5. Treatment of Localized Soft Tissue Sarcoma of the Extremity or Trunk Decades ago: Amputation Now: Limb-Sparing Surgery & Radiation
  6. 6. Surgery and Radiation Sequencing Pre-operative Radiation  Surgery OR Surgery  Post-operative Radiation • Efficacy: Similar – Excellent Local Control Rates 85-100% • Toxicities: Different
  7. 7. Surgery and Radiation Sequencing PRE-OP RT Lower Dose: 50 Gy 5 weeks Smaller Irradiated Volume: tumor plus margins POST-OP RT Higher Dose: 60-66 Gy 6-7 weeks Larger Irradiated Volume: entire operative bed + margins
  8. 8. Surgery and Radiation Sequencing PRE-OP • More acute wound complications (35% vs 17%) • Usually reversible POST-OP • More long-term swelling, stiffness, skin thickening • Usually irreversible TOXICITIES DIFFERENT
  9. 9. Surgery and Radiation Sequencing • Equivalent efficacy • Different Toxicities • Treatment approach should be individualized • We prefer Pre-op RT for most situations – lower dose, smaller treatment volume  less irreversible long-term toxicity
  10. 10. RADIATION PLANNING PROCESS
  11. 11. SIMULATION • Decide on patient position on treatment table • Make custom immobilization device to reproduce position on a daily basis for treatment • Obtain CT scan in treatment position
  12. 12. Radiation Simulator Treatment couch CT scan
  13. 13. Immobilize hand for tumor of arm Custom cast molded to hand •
  14. 14. Immobilize foot for tumor of leg Custom cast molded to foot
  15. 15. Tattoos • Permanent marks placed on skin • Used for set up of daily treatments
  16. 16. Radiation Treatment Volumes Physician contours tumor on the planning CT scan Adds “margin” around tumor to treat possible microscopic disease 4 cm 1.5 cm Red: tumor Green, Orange: margins
  17. 17. Radiation Planning Process • MD works with physicist • Iterative process, takes about a week • Goal: to devise a plan to – treat contoured volume to desired dose – maximize normal tissue sparing
  18. 18. Radiation Graphic Plan Pink: tumor; Green: ovaries Dose Lines: 100% Yellow 90% Blue 40% Brown 6% Green
  19. 19. Treatment Begins Most common regimen: • Daily treatment Monday – Friday • 5 weeks Each treatment takes ~ 20 minutes • most of the time is getting the patient in position X-rays are taken prior to each treatment • to confirm patient position
  20. 20. Treatment Machine: Linear Accelerator
  21. 21. Laser Lights Lined up on Tattoos
  22. 22. Or Lasers Lined up on Mask
  23. 23. Verification X-rays or CT scan • Taken prior to each treatment to confirm patient is set up correctly • Adjustments are made as necessary and new films are taken for set-up confirmation
  24. 24. Radiation Techniques External Beam Radiation Therapy Photons • 3D • IMRT (Intensity Modulated Radiation Therapy) Electrons Protons Brachytherapy • Radioactive seeds placed in the tumor bed • Temporary or permanent
  25. 25. Comparison of Dose Distributions Isodoses Red: 100% Light blue: 20-30% 3D IMRT
  26. 26. Radiation Therapy Side Effects Acute • Skin reddening • Fatigue • Delayed wound healing • Hair loss in treatment area • Muscle aches Chronic • Swelling • Skin thickening • Joint stiffness Rare • Bone fractures • Sterility • Second tumors
  27. 27. Dana-Farber/Brigham & Women’s Cancer Center: Center for Sarcoma and Bone Oncology • Surgical Oncology Monica Bertagnolli, MD Chandrajit Raut, MD, MSc Jiping Wang, MD • Medical Oncology George Demetri, MD Suzanne George, MD Priscilla Merriam, MD Jeffrey Morgan, MD Andrew Wagner, MD, PhD • Pathology Christopher Fletcher, MD Jonathan Fletcher, MD Jason Hornick, MD, PhD • Radiation Oncology Elizabeth Baldini, MD, MPH Philip Devlin, MD Clair Beard, MD • Orthopedic Oncology Marco Ferrone, MD John Ready, MD ebaldini@partners.org

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