Sarcoma Surgery

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 Surgery 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.

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 TreatmentSurgery 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

  1. extremity adjacent to major nerves, blood vessels, bones, and joints
  2. abdomen (intra-abdominal and retroperitoneum) adjacent to major organs, blood vessels, nerves, ureters, and bone
  3. 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.

  • Intraoperative 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 ServicesAll 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, intraoperative 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.