Treatment

Newly Diagnosed? We Can Help Getting the correct diagnosis and the most appropriate treatment from the start is crucial more

Surgery remains the primary treatment for soft tissue sarcoma, the goal being to remove the tumor and at least two to three centimeters (approximately one inch) of the surrounding tissue. While amputation of an arm or leg was once a standard treatment for soft tissue sarcomas of the extremities, today amputations are performed in only about five percent of cases nationwide.

Conservative Multimodal Approaches

Treatment approaches pioneered at Memorial Sloan-Kettering feature more conservative operations, combined with radiation therapy or chemotherapy (sometimes both), which offer patients a high rate of tumor control without amputation.

Minimally Invasive Surgery

For years, Memorial Sloan-Kettering surgeons have performed selected abdominal operations using the minimally invasive laparoscopic technique, which involves making several very small incisions (less than half an inch) and inserting robotic surgical tools to remove small amounts of tissue in order to diagnose cancer and determine the spread of disease. Miniature video cameras allow the surgeon to see inside the body while performing surgery. Increasingly, the applicability of minimally invasive surgery extends beyond diagnosis and staging to operations that were previously performed as open procedures. Patients receiving laparoscopic surgery often have faster recoveries and fewer complications, and are able to go home sooner than with open abdominal surgery.

Although small sarcomas can be treated with surgery alone, the majority of sarcomas are greater than five centimeters in size. These sarcomas are routinely managed by a combination of surgery and radiation therapy. Radiation therapy may be used before, during, and after surgery.

Irradiation sterilizes tumor cells, damaging their DNA so they are no longer able to divide and multiply. Tumor cells beyond the reach of surgery may be neutralized by irradiation.

In comparison to other tumors, the margin of normal tissue subjected to radiation in surgery for soft tissue sarcoma is larger. This is because sarcoma can spread along muscles and between them in ways that sometimes cannot be seen or felt. Microscopically sarcoma cells are discrete, but they can trickle out deceptively and be left behind after surgery. The further away from the tumor site, however, the less likely there are to be sarcoma cells. Radiation oncologists typically irradiate tissue five to 10 centimeters (approximately two inches) beyond where the tumor was located.

Brachytherapy

Brachytherapy, which involves delivering radiation therapy locally, can be administered in two different ways to treat soft tissue sarcoma. Memorial Sloan-Kettering has pioneered the use of brachytherapy for the treatment of soft-tissue sarcoma.

In one approach, during surgery, after the surgeon removes the tumor, special tubes called catheters are inserted into the tumor bed. After allowing the surgical wound to heal for five to six days, the radiation oncologist inserts radioactive seeds into each of the catheters. The seeds stay in place for several days (usually five days), delivering a high dose of radiotherapy to the site.

When the treatment is completed, both the radioactive seeds and the catheters are removed. A patient could finish the entire course of treatment within 10 to 14 days. In certain situations, brachytherapy may be administered for two to three days combined with external radiation for five weeks.

A second form of brachytherapy, called high-dose-rate intraoperative radiation therapy, is delivered entirely during surgery. After the surgeon removes the tumor, applicators are placed against the surface from which the tumor has just been removed. The applicators are attached to a radiotherapy machine that is programmed to send a high dose of radiotherapy directly to the site.

External-Beam Radiation Therapy

External-beam radiation therapy uses doses of radiation delivered from outside the body, focusing on the region of the tumor and surrounding tissues. After postoperative recovery, a course of external beam radiation therapy is usually given. This approach is most useful for the retroperitoneum (the area outside or behind the peritoneum, which is the tissue that lines the abdominal wall and covers most of the organs in the abdomen) and chest, where it is not feasible to leave catheters in place. It is typically a seven to eight week process in which the patient comes in five days a week as an outpatient, for a few minutes worth of radiation therapy at each visit. It can be given before or after surgery.

IMRT

Intensity modulated radiation therapy (IMRT), a new sophisticated computer-guided technique that allows safe delivery of much higher doses of radiation to the tumor while sparing the normal surrounding tissues, is now being used to treat soft tissue sarcoma before surgery. The goal is to use IMRT to shrink the tumor, making the surgery more successful and reducing the chance of recurrence. These tumors can sometimes be very close to the spine or major blood vessels, so this targeted therapy can provide benefit.

Soft-tissue sarcoma is a treatable cancer, even when it recurs locally. Local recurrence does not necessarily mean that the first treatment was wrong or inadequate, and it doesn't mean that the person with the recurrence cannot be cured.

At Memorial Sloan-Kettering, treatment of local recurrence is individualized based on several factors. First, a physician generally performs an "extent of disease workup" to ascertain the precise stage of the recurring sarcoma. The workup may include x-rays of the area of local recurrence and chest x-rays, as well as computed tomographic (CT) and magnetic resonance imaging (MRI) scans.

Patients with an isolated local recurrence generally have another operation (re-resection). Results of re-resection are often good; the majority of these patients have long-term survival. Many patients with local recurrence also receive adjuvant (additional) radiation therapy with surgery. The radiotherapy approach depends on the method and extent of previous surgery and radiotherapy, and may include brachytherapy or external beam radiation.

Even after a local recurrence, amputation is usually not necessary to treat sarcoma of the extremities. Although local recurrence can be a frightening event, we can still treat most patients, and most will have long-term survival.

The place at which a sarcoma arises is called the primary site. Surgical removal of a primary sarcoma, sometimes followed by radiation therapy, will cure many patients. In some patients, however, sarcoma spreads through the bloodstream to distant sites such as the lungs or liver. The process of spread is called metastasis, and the sites are called metastases. Today, fewer than 20 percent of all soft-tissue sarcomas have metastasized before they are diagnosed.

Unlike surgery and radiation therapy, which are directed toward specific areas of the body, chemotherapy travels through the bloodstream to all areas and systems of the body. For that reason, chemotherapy is called systemic treatment.

When a patient's tumor is a type that might spread, chemotherapy may be used as an adjuvant (additional) therapy, either before or after surgery. In addition to destroying microscopic areas of metastasis, if they exist, this treatment can reduce the size of the primary sarcoma before the operation.

Even patients who appear to have a primary sarcoma may have microscopic metastases that cannot be detected, even with modern imaging techniques. Although we can never be certain which patients harbor these microscopic deposits of sarcoma, doctors can estimate the chances that a tumor has spread. This estimate is based on the size of a sarcoma and on its appearance under the microscope. Chemotherapy given after surgical removal of the primary tumor might eradicate micrometastases, but the evidence for this is controversial and usually needs to be discussed on a case-by-case basis.

Today, doctors often give chemotherapy before surgery to patients with large, fast-growing sarcomas. The terms "neoadjuvant chemotherapy" and "preoperative chemotherapy" are used to describe this strategy. In addition to destroying microscopic areas of metastasis (if they exist), this approach often reduces the size of the primary sarcoma. This may permit the surgeon to perform a less radical operation, and may save some patients from an amputation. Preoperative chemotherapy may also contribute to better chances of survival. The involvement of a coordinated team of doctors and nurses is critical to the success of this strategy.

Doxorubicin and ifosfamide are the chemotherapy drugs most widely used in the treatment of patients with sarcoma. In certain patients, chemotherapy that includes both doxorubicin and ifosfamide almost doubles the likelihood of shrinking a sarcoma, compared with older treatments. The nausea that can accompany treatment with doxorubicin can now be managed for 90 percent of patients with one or more of the newer anti-nausea drugs. These newer drugs have proven so effective in controlling nausea that patients often can receive chemotherapy for soft-tissue sarcoma in an outpatient setting.

Our Clinical Trials Find out about new research studies for soft-tissue sarcoma more

In the next five years, doctors hope to develop vaccines and immunotherapies (treatments that use the body's own defenses to combat cancer), as well as anti-angiogenic agents (drugs that block the development of blood vessels, thus starving the tumor) to treat soft-tissue sarcomas. Early stage clinical trials testing these concepts are being conducted.