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Soft tissue sarcomas are uncommon cancer
tumors and significant expertise is required
for optimal treatment. In addition,
these tumors are often treated with
multi-modality therapy combining sarcoma
cancer surgery with radiation therapy
and chemotherapy. Thus it is important
to be treated by a team of specialists.
The Massachusetts General Hospital has
a dedicated team of surgical oncologists,
orthopedic oncologists, plastic surgeons,
radiation oncologists, medical oncologists,
radiologists, and pathologists with a
specific interest in the treatment of
patients with sarcoma.
Sarcoma Cancer Treatment Modalities
Surgery
Surgery remains the primary treatment
modality for these tumors. Ideally,
sarcoma cancer tumors should be removed
with a margin of normal tissue of about
2 centimeters (one inch). However, soft
tissue sarcomas often arise in difficult
anatomic locations and may require extensive
surgical expertise to remove in their
entirety with the best possible margin.
Difficult anatomic locations include
the
- extremity adjacent to major nerves,
blood vessels, bones, and joints
- abdomen (intra-abdominal and retroperitoneum)
adjacent to major organs, blood vessels,
nerves, ureters, and bone
- trunk requiring reconstruction of
the abdominal or chest wall.
The use of multiple modalities to treat
sarcoma has allowed surgeons to alter
the operative approach to these tumors.
For example, in the past sarcomas occurring
in the extremity were routinely treated
with amputation. Currently, limb-sparing
surgery is often combined with radiation
and chemotherapy so that now only about
5% of these cases require amputation.
Surgical oncologists at Massachusetts General
Hospital are also experienced in the use
of minimally invasive surgery (or laparoscopic
surgery) techniques to confirm diagnosis
and offer alternative types of surgery.
For example, gastrointestinal stromal
tumors (GIST) are sarcomas that occur
on the bowel wall and are often amenable
to laparoscopic resection. Minimally invasive
surgery offers the advantages of less
post-operative pain, shorter hospital
stay, and earlier return to normal activity.
Another advantage of having surgery at
Massachusetts General Hospital is the
breadth of excellent surgeons in all surgical
specialties who can provide assistance
in complex situations. Thus, large tissue
defects can be managed with rotational
and free-tissue flaps by plastic surgeons
and pulmonary metastases from sarcoma
can be resected by thoracic surgeons.
Radiation Therapy
Radiation therapy has been shown in prospective
randomized studies of sarcomas to
reduce the local recurrence rate
of these sarcoma cancer tumors.
Radiation therapy can be given before
or after definitive surgical resection,
and in some cases can be given during
the operation. Traditionally, external
beam radiation therapy is delivered
by for a few minutes a day, 5 days
a week, over a 6-8 week period.
- Intra-operative Radiation
Therapy (IORT)
Massachusetts General Hospital is
one of only a handful of centers
to have a dedicated intra-operative
radiation treatment facility in
a specially built operating room.
This facility combines both an operating
room and a radiation treatment room.
The treatment machine is a Siemens
ME linear accelerator that can deliver
electron beams of 6, 9, 12, 15 and
18 MeV through field sizes ranging
from 4 to 10 cm. Operating at a
dose rate of 900 monitor units per
minute, each treatment lasts no
more than a few minutes.
- Francis
H. Burr Proton Therapy
Center
Massachusetts General Hospital is
one of only two centers in the country
to offer proton beam radiation therapy
rather than traditional high-energy
x-ray radiation therapy. The Francis
H. Burr Proton Therapy Center
has been designed specifically to
provide proton cancer treatment in
a hospital setting. The aim of radiation
therapy is to deliver a high dose
of radiation to the tumor and minimal
or no radiation to normal tissues
and organs. The physical properties
of proton beams can be used to achieve
superior dose distributions compared
to conventional high-energy x-rays,
allowing a higher dose to be delivered
to the target volume while sparing
adjacent critical structures as much
as possible. The program at the NPTC
builds on the experience gained at
the Harvard Cyclotron Laboratory
(HCL), Harvard University by physicians
using 160 MeV proton beams to treat
both benign and malignant disease.
Since 1961, 9115 patients
were treated at HCL before the medical
program was completely transferred
to NPTC in April 2002.
- Brachytherapy
In certain circumstances, radiation
therapy is best delivered by brachytherapy.
This technique involves placing special
catheters at the time of surgical
resection in the bed of the surgical
wound. The surgical incision is then
allowed to heal for about 5 days and
then radioactive seeds are loaded
into the catheters to deliver radiation
therapy. The seeds are left in place
usually for another 5 days and then
the catheter and seeds are removed.
This is a particularly useful modality
for recurrent sarcomas in which external
beam radiation has already been administered
in the past.
Chemotherapy Treatment
Certain sarcomas have the ability to spread
to distant sites, most frequently to the
lung and liver. Chemotherapy may be beneficial
to patients with these types of sarcomas
even if no sites of distant disease are
identified in order to kill microscopic
foci of tumor cells. If macroscopic distant
disease is identified, chemotherapy may
be beneficial in decreasing the growth
and spread of disease.
Like radiation therapy, chemotherapy treatment
can be given before and after surgical
resection of the sarcoma. In certain
cases, patients with large, aggressive
sarcomas in difficult anatomic locations
my benefit from pre-operative chemotherapy
that may decrease tumor size and make
surgical resection less difficult. Such
pre-operative chemotherapy can also be
combined with pre-operative radiation
therapy.
The most widely used chemotherapeutic drugs
for sarcoma are doxorubicin (adriamycin)
and ifosfamide. In addition to these traditional
agents, our sarcoma program participates
in all clinical trials run through the
Dana-Farber/Partners Cancer Care member
institutions (Dana-Farber Cancer Center,
Massachusetts General Hospital, and the
Brigham and Women’s Hospital). Thus
patients may be offered promising investigational
drugs as part of their treatment. In the
recent past, a drug called Gleevac was
found to be highly effective against a
particular type of sarcoma called gastrointestinal
stromal tumors, producing very high response
rates. Newer agents currently in various
phases of clinical trials include Avastin
(bevacizumab), a promising angiogenesis
inhibitor, and ET743, a natural sea organism
product with activity against liposarcomas
and leiomyosarcomas.
Our Services
All of the surgical oncologists
who treat soft tissue sarcomas participate
in the Center
for Sarcoma and Connective Tissue Oncology
where the patients benefit from a collabortive
team approach to their care and management.
- Consultation on all types of imaging
studies including computerized tomography,
magnetic resonance imaging, and PET
scan. Images sent or delivered with
a request for consultation will be
returned with a letter offering our
interpretation within 48 hours, or
sooner in the case of urgent problems.
- Radiation therapy delivered with a
variety of techniques. These include
external beam x-rays and electrons.
Radiation may also be delivered by
brachytherapy, intra-operative radiation
therapy, and proton beam radiation
therapy. Proton beam radiation therapy
is a high technology particle therapy
that allows for precision targeting
of tumors while minimizing normal
tissue irradiation. These techniques
can allow for the escalation of radiation
dose beyond what can be achieved with
conventional external beam techniques.
- Chemotherapy offered to certain patients
with sarcomas who are at moderate
or high risk of tumor spread to distant
sites. At the Massachusetts General
Hospital Cancer Center, there are
also a number of combined chemotherapy-radiation
therapy-surgery protocols for the
treatment of high risk soft tissue
sarcomas.
Clinical Trials
& Research
Finding new and better ways to
prevent or treat sarcomas and other soft
tissue cancers is an important goal of
the Cancer Center. Through various clinical
research trials, researchers at Massachusetts
General Hospital are investigating therapies
involving new agents as well as new multi-modality
strategies.
To find a clinical
trial >>>
Surgical Oncology
Team
Surgeons in the Division of Surgical
Oncology who specialize in sarcoma cancer
surgery are faculty members of Harvard
Medical School and regularly teach other
physicians in Continuing Medical Education
courses.
Specialists in sarcoma surgery
include:
James C. Cusack, Jr., MD
Sam S. Yoon, MD
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