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.

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. 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. 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. Treatment
Localized Disease
• Surgery
• Radiation Therapy
Metastatic Disease (beyond local site)
• Systemic therapy

5. Treatment of Localized
Soft Tissue Sarcoma of the
Extremity or Trunk
Decades ago: Amputation
Now: Limb-Sparing Surgery & Radiation

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. 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. 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. 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. RADIATION PLANNING
PROCESS

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. Radiation Simulator
Treatment
couch
CT scan

13. Immobilize hand for tumor of arm
Custom cast molded to hand
•

14. Immobilize foot for tumor of leg
Custom cast molded to foot

15. Tattoos
• Permanent marks placed on skin
• Used for set up of daily treatments

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. 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 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. Treatment Machine:
Linear Accelerator

21. Laser Lights Lined up on Tattoos

22. Or Lasers Lined up on Mask

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. 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. Comparison of Dose Distributions
Isodoses
Red: 100%
Light blue: 20-30%
3D IMRT

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. 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