Sarcoma Treatment

From M. D. Anderson Sarcoma: What Can You Expect, part 3
Date: February 11, 2008
Duration: 19:30

Doctor (entering room):
Hi, how are you?

Narrator:
Because sarcoma can occur in any soft tissue or bone in the body, it is treated with a variety of therapies…often chemotherapy, radiation therapy and surgery or combinations of all three.

Dr. Benjamin:
One of the things that’s interesting about sarcomas compared with many other cancers is there are far fewer of them that are treated by just one modality or another.

Dr. Benjamin:
The question of what can a patient expect in the treatment of sarcoma depends very much on how advanced the tumor is, so early stage tumors have a much greater likelihood of being cured by local therapy, surgery or surgery and radiation, and the more advanced cancers…the farther advanced you get the more likely chemotherapy gets into the picture. And the farther advanced you get… the less likely cure is one of the possibilities.

Dr. Patel:
If patients have a localized stage of disease that is relatively favorable that we call stages 1 and 2 disease, these are patients that will typically be treated with what we call local therapy... So stage 1 and 2 patients are typically treated with surgery with or without the help of radiation therapy, because the intent is to make that tumor disappear and control it locally.

Dr. Patel:
We get to the controversial area of what we call Stage 3 disease. This is what we call high-risk disease, and it’s high risk for metastases and recurrence. These are patients with greater than 5 centimeters in size high-grade tumors.

Dr Patel:
Even when they are treated by experts with adequate and appropriate surgery and radiation therapy, they still run approximately 50% risk of recurrence and spread of the tumor somewhere between three to five years from the time of the original diagnosis.

Dr. Benjamin:
But interestingly, there have been… and continue to be… patients even with the most advanced stages of sarcoma who actually are cured either by chemotherapy or by chemotherapy together with surgery.

Narrator:
High-risk patients often are treated aggressively, with multiple therapies, including chemotherapy, radiation and surgery. It’s important to remember that there are exceptions to the treatment guidelines. Sometimes, even if your tumor is less than five centimeters, your doctor may still recommend chemotherapy. On the other hand, many patients with even larger tumors may not have chemotherapy at all. Various imaging techniques are used throughout the treatment process to assess how the treatments are working. Depending on the results of the imaging techniques, the treatments are adjusted accordingly.

Narrator:
Chemotherapy…using drugs to kill cancer cells…is the major treatment for many cancers.
Chemotherapy may involve one drug, or a combination of two or more drugs, depending on the type of cancer. Although some chemotherapy drugs are available as pills, and some others are given as injections, most chemotherapy is given intravenously… through a needle that is inserted into a vein.

Brenda Hagan:
Most patients will have to have a catheter placed…a Central Venous Catheter which is a catheter that is placed under the collarbone or in the arm, and that catheter stays in place for the duration of their chemotherapy.”

Narrator:
The drugs are injected directed into the Central Venous Catheter, or CVC, each time the patient is treated. Using the CVC keeps the patient from being stuck by a needle every time chemotherapy is administered. Some patients receive the drugs through an artery. Arterial chemotherapy is usually given to patients with osteosarcoma in an extremity. These tumors need a substantial blood supply to grow, and large arteries form to provide that blood supply. Arterial chemo is also used to control tumors in the liver. Unlike other solid tumors, sarcomas respond to higher doses of chemotherapy drugs. The higher the dose, the more response you will get in sarcoma.

Brenda Hagan:
“We’ve found that giving the higher doses of chemotherapy is what works. A lot of outside oncologists may try to give lower doses of chemotherapy, and we know from our experience that the higher doses are effective.”

Narrator:
Patients who are having arterial chemotherapy as well as some patients who are on very high dose chemotherapy and need close monitoring are hospitalized for their treatments. The majority of chemotherapy regimens, however, can be given on an outpatient basis. The patient comes into one of the Ambulatory Treatment Centers for several hours, receives the chemotherapy, and then leaves. When sarcoma patients are just beginning treatment, they generally receive two cycles of chemotherapy. They then undergo reevaluation and restaging by the medical team to determine how effective the chemotherapy has been.

Brenda Hagan:
“Restaging means that we re-look at any of the areas that the tumor is present, and we have them undergo scans; we have them come back to the clinic and we decide…’Is the chemotherapy working, or is it not working?’

Tami Barnes:
Cancer and chemotherapy…you can kind of think of it in the same way you think of a bacterial infection with an antibiotic. Not everybody responds to chemotherapy, and we don’t know why that it, so we don’t really know in the beginning what your odds are. We can give you global statistics, but we never know. Some tumors are simply resistant to treatment.

Narrator:
Chemotherapy regimens can sometimes be rough on the patient. Side effects might include low blood counts, fatigue, and bruising or bleeding more than usual. You may also become more susceptible to infection. But it’s important to remember that, unlike several years ago, there are now good medications available to control side effects like nausea. You are not alone. You have an entire medical team supporting you in your fight against this disease.

Tami Barnes:
You have to get through the treatments, and it’s not easy, and we’re here, and we’ll take care of you and do what we can, but really you have one shot at beating this disease, and you have to go full force into it and really do everything that’s required, so you have a chance...You have to do that, and it’s not convenient, but it is the sole focus…you’re fighting for your life, and it’s gotta be the prime focus of everything that you do.

Dr. Benjamin:
I think the single most important thing for patients is to put into perspective what the goals of treatment are, and if the goals of treatment are curative, they need to be willing to put up with a lot of misery over what seems like a long period of time in order to be cured after they finish.
If they’re palliative… maybe they shouldn’t have such intensive treatment. But it’s critical to define the difference.

Title:
Radiation Therapy

Narrator:
Another primary cancer treatment is radiation therapy…sometimes called radiotherapy. This treatment uses high-energy beams such as x-rays to pinpoint and destroy cancer cells. It damages their internal chemistry and causes them to stop multiplying. Your treatment plan may call for radiation therapy alone or in combination with other treatments, such as chemotherapy or surgery. Often, radiation will be used to shrink a tumor to make surgery or chemotherapy more effective. Before you begin receiving radiation treatment, you will meet with your radiation oncologist…a doctor who specializes in radiation therapy…along with a radiation oncology nurse. They will examine you and explain the treatment process.

Maurice Crissmon:
They were very polite, and they were very professional, and I trusted their word, and I felt comfortable about going through with the situation.

Narrator:
An appointment will be scheduled for a treatment-planning session, called simulation. The entire simulation process may take up to one hour.

Leann Clark:
When you first start your radiation treatment there’s people there that you don’t know, and you have to go in and disrobe and all of this, and it’s really intimidating, and we can be a little shy about it and everything, but the radiation team is just so used to doing it, and they kind of get to know you and what kind of goes on in your life. So when you go in there, they make you feel so at ease.”

Narrator:
During the simulation your doctor and radiation therapist will locate the exact areas to be treated. A special immobilization device…either a mask for your face or a cradle for your body, leg or arm…will be made to help keep you very still during your radiation treatments.

Leann Clark:
I just remember my arm had to be up above my head, and my arm just got so tired of being in that position. And then a break…and they give you a few minutes…arm down…they wanted to be so precise, because that was how the radiation was going to be lined up, so they wanted to make sure they got everything in the correct position, so when you went to lay in that cradle every single time, you were in the exact spot you needed to be.

Narrator:
During this first simulation session, you will be positioned on the table in the cradle or immobilization device while you undergo imaging procedures, including a CT scan and x-rays.
Your doctor will study these scans to pinpoint the exact area to be treated, as well as the areas of healthy tissue that need to be protected from the radiation. The radiation therapists then will mark the exact treatment areas either directly on your skin or on the immobilization device, depending on where the cancer is located. The marks on your body ensure that the radiation targets the correct area each time you receive treatment. When you begin actual treatments, you will usually come once a day, Monday through Friday, over a course of five to six weeks. The length of treatment varies depending on the type of cancer. After positioning you on the table, your therapist will use lasers to line up the marks on your skin or treatment mask. After lining up the marks, the therapist will leave the room.

Maurice Crissmon:
They have to position you, so that when the radiation and machine comes and hits you just right, and they have to leave the room, it’s just the idea that you’re laying on the table, and you have to be still.

Narrator:
From a control room, the therapist can see and talk to you at all times by closed circuit TV and two-way intercom. The first treatment session lasts 30 to 40 minutes, because the therapist will take X-rays to verify the accuracy of the treatment area. The following treatment sessions each will last about 15 to 20 minutes. You will receive only one to two minutes of radiation to each treatment area.

Leann Clark:
You just get up there and lay down. They get you in position. And they just give you the radiation treatment. It takes seconds…like 15 seconds. It took much longer to come in, get dressed, and leave, than it did to actually do the procedure.

Mitzi:
As far as radiation therapy, you’re not going to feel any pain. The main side effects are just skin reaction…once again… a redness to even blistering, and I tell them as far as care of the skin, we have different ways of treating it depending on what stage of skin breakdown they have, but that’s very manageable, and if they have pain, we will give them pain medicine in order for them to get through their treatments.

Title:
Surgery

Narrator:
Surgery is the oldest treatment for cancer. Some patients may have it more than once during their treatment. After a cancer diagnosis, it sometimes takes weeks or months, before a patient is ready for surgery. During that time, chemotherapy and / or radiation therapy is often given to shrink the tumor and eradicate any microscopic disease in other parts of the body. New and improved imaging techniques, including MRIs, CTscans and PETscans allow surgeons better views of both bone and soft tissue tumors.

Dr. Hunt:
Certainly one of the things that has improved is our imaging capability, so again, understanding the true extent of the involvement of the soft tissues helps us to know how much tissue we need to remove.

Narrator:
When a cancer is removed surgically, the goal is to remove the entire tumor … as well as a “margin” of healthy surrounding tissue. A pathologist will examine the removed tissue under a microscope, and will ensure that the margins are “clear” …meaning they do not contain any cancer cells. Sometimes this is done during the operation, and sometimes it’s done later.

Dr. Hunt:
Our pathologists work very carefully and closely with us…at the time of surgery, so that we can look at the tissues and understand what the extent of the tumor is and know whether or not we need to sacrifice more tissue or whether we can preserve that tissue.

Dr. Hunt:
And the more complex the resection, the more often we need some additional—help with reconstruction. And that’s where often the plastic surgeons or vascular surgeons will help us and—and that gives—again, that offers the patient the best outcome.

Dr. Robb:
Sometimes, in order to eradicate cancer, it may be necessary to remove an entire organ, but there are many new surgical techniques that help to avoid bodily deformity or loss of limb… and, of course, there is reconstruction to help restore normalcy. We certainly believe that restoration of function such as restoring a bladder for a patient or restoring the patient’s outward appearance as in the reconstruction of a breast is a vitally important and critical part of treating cancer.

Narrator:
In most cases, when sarcomas involve the bone, the M. D. Anderson surgeon will perform limb-sparing surgery. During a limb-sparing procedure, the surgeon removes the bone from the arm or leg which contains the tumor and then replaces the bone with either a metal prosthesis or an allograft or an allograft prosthetic composed.

Dr. Lewis:
As far as limb salvage, I would say the options we do here are same as options elsewhere. We just see more and do more. So while someone in a non-tumor center may see five, you know, or three a year, we’ll do, you know, five every three months. So it’s… once again… you want to go to the place where they’re doing…they have the most experience.

Dr. Lewis:
I mean… with bone sarcomas, the average survival used to be 20%—and now it’s clearly greater than 70.

Narrator:
Several years ago, amputation was the surgery most often performed. Now, the goal is to preserve the normal structures and thereby preserve function while at the same time removing all the cancer. Amputation is often avoided, and the patient can regain function of the limb. However, there are some cases in which the best oncologic outcome requires amputation.

Doctor (entering room):
Are you doing OK today?

Patient:
Yeah, I’m doing fine.

Dr. Lewis:
Depending on where the lesion is—we talk pretty much in depth about the reconstructive options—and I do emphasize that amputation is still a life saving procedure, so even though I’m a surgeon, and I’m a limb salvage surgeon, I’m foremost an oncologist, so I want to save their life more than I want to save their limb, but we have excellent technique for limb salvage.

Dr. Lewis:
I think one of the things patients have to remember is that the recovery doesn’t end with surgery, and really how much effort they put into their rehabilitation will be reflected in how good their functional outcome is.

Dr. Lewis:
The key is follow the directions or follow the instructions of your surgeon, because things that we suggest or we do or do not let you do is really only for your benefit. So if we ask you not to walk until something heals, really once it heals, we’ll let you start walking. And it’s not because we're—especially with children; it’s not because we're mean, it’s just because we want your outcome to come out the best it possibly can.

Narrator:
Surgeries can range from 2 to 10 or 12 hours, and in many cases, several teams work together to remove the tumor and perform reconstruction. Volunteers, many of whom are cancer survivors themselves, work in the hospital surgical waiting areas, updating the family as the surgery progresses.

Dr. Hunt:
Especially with some of the more complex resections and reconstructions where we have multiple teams of surgeons involved…usually what we tell the patients is that they should plan to be in the hospital for the length of time for that type of surgery. Seven to 10 days is often the time frame that we would utilize.

Narrator:
Patients are asked to stay in town at least another week or two, after they're discharged from the hospital. This allows them to become comfortable with any incision care or drain care they need to manage and also with pain management techniques. If physical therapy is recommended they can begin it before traveling back home. The patient will be asked to come back periodically for checkups.

Dr. Hunt:
We know that if a patient is going to have a recurrence of their tumor, we would most often see that within the first two years. And so we see them very closely…at close intervals within the first two years, and then after that we spread out the follow-up appointments to twice a year or once a year, depending on the type of tumor.

Dr. Hunt:
You know—we really have made major strides in the outcomes of our patients, and patients do very, very well.

Dr. Lewis:
I think you're in great hands here at M.D. Anderson. We have great medical oncologists. We have great radiation oncologists…and, as long as you have faith in your treatment and faith in yourself, I think that you’ll do very, very well.