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How Radiation Therapy is Used to Treat Soft Tissue Sarcoma
The document discusses the management of soft tissue sarcoma, emphasizing a multimodal approach involving surgery, radiation, and systemic therapy at experienced centers for better outcomes. It compares pre-operative and post-operative radiation sequencing, noting differences in efficacy and toxicities, and highlights the radiation planning process and techniques used for treatment. Side effects, both acute and chronic, are outlined, along with the expert team at the Dana-Farber/Brigham and Women’s Cancer Center.
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How Radiation Therapy is Used to Treat Soft Tissue Sarcoma
- 1. RADIATION THERAPY SOFT TISSUESARCOMA 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. Soft Tissue Sarcoma Managementby Multimodality Team Radiology Pathology Surgery: Oncologic/Orthopedic; Plastic Radiation Oncology Medical Oncology Physical Therapy Social Work Case Review at Multi-disciplinary Tumor Board
- 3. Management at ExperiencedCenter •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. Treatment Localized Disease • Surgery •Radiation Therapy Metastatic Disease (beyond local site) • Systemic therapy
- 5. Treatment of Localized SoftTissue Sarcoma of the Extremity or Trunk Decades ago: Amputation Now: Limb-Sparing Surgery & Radiation
- 6. Surgery and Radiation Sequencing Pre-operativeRadiation Surgery OR Surgery Post-operative Radiation • Efficacy: Similar – Excellent Local Control Rates 85-100% • Toxicities: Different
- 7. Surgery and RadiationSequencing 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. Surgery and RadiationSequencing 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. Surgery and RadiationSequencing • 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
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- 11. SIMULATION • Decide onpatient position on treatment table • Make custom immobilization device to reproduce position on a daily basis for treatment • Obtain CT scan in treatment position
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- 13. Immobilize hand fortumor of arm Custom cast molded to hand •
- 14. Immobilize foot fortumor of leg Custom cast molded to foot
- 15. Tattoos • Permanent marksplaced on skin • Used for set up of daily treatments
- 16. Radiation Treatment Volumes Physiciancontours 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. 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. Radiation Graphic Plan Pink:tumor; Green: ovaries Dose Lines: 100% Yellow 90% Blue 40% Brown 6% Green
- 19. Treatment Begins Most commonregimen: • 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
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- 21. Laser Lights Linedup on Tattoos
- 22. Or Lasers Linedup on Mask
- 23. Verification X-rays orCT 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. Radiation Techniques External BeamRadiation Therapy Photons • 3D • IMRT (Intensity Modulated Radiation Therapy) Electrons Protons Brachytherapy • Radioactive seeds placed in the tumor bed • Temporary or permanent
- 25. Comparison of DoseDistributions Isodoses Red: 100% Light blue: 20-30% 3D IMRT
- 26. Radiation Therapy SideEffects 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. Dana-Farber/Brigham & Women’sCancer 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