Types of treatment for soft tissue sarcoma

Your doctors will plan your treatment taking into account

• The type of sarcoma you have
• How far your cancer has grown or spread (the ' stage')
• Your general health and fitness
• Your age

Cancer treatments can be divided into local and systemic treatments. Surgery and radiotherapy are local treatments. They treat just one area of the body. Systemic treatments are carried in the bloodstream and can reach cancer cells wherever they are in the body, not just at the original tumour site. Chemotherapy and biological therapies are systemic treatments.

An operation to remove the tumour is the main treatment for most soft tissue sarcomas. The aim of the surgery is to remove as much of the cancer as possible. As well as removing the cancer, the surgeon will remove a good border of surrounding healthy tissue. This is to try to make absolutely sure that they take away the whole sarcoma. The healthy border is usually a few millimetres and is called a ‘healthy margin’. This means the cancer is less likely to come back in the same place. At the same time, the surgeon tries to take away as little healthy tissue as possible, so that the impact of the surgery is as small as possible.

In the past, surgery for sarcomas in the arm or leg often meant removing the affected limb completely (amputation). But there have been big improvements in surgical techniques, such as being able to re-attach tiny blood vessels (microvascular surgery). Or being able repair the operation site with muscle from other parts of the body (muscle flap) and skin grafts. These improvements mean that amputation can now be avoided in most people and you may have 'limb sparing' surgery instead. Fewer than 1 in 20 people diagnosed with sarcoma need amputation these days. Unfortunately, the size and position of a soft tissue sarcoma in the arm or leg may still mean that amputation is necessary in some people.

Surgery is used to remove stage 1, 2 and 3 sarcomas. If surgery to remove a sarcoma is too difficult because of its position in the body, you may have radiotherapy instead of surgery. In some areas of the body, radiotherapy may also be difficult because of the risk of damage to vital organs.

Most people have radiotherapy after surgery to try to kill off any remaining sarcoma cells and reduce the risk of the sarcoma coming back. Whether you need radiotherapy or not depends to some extent on the grade and size of your sarcoma. Radiotherapy may not be necessary after surgery if you have

• A low grade sarcoma
• A very small sarcoma
• A sarcoma that is near the body surface (superficial) and not buried deep in the tissues

In some situations, surgery may also be used to remove sarcoma that has spread to other parts of the body (stage 4). This is most often done when the sarcoma has spread to the lungs. You can only have this type of operation if the tumours in the lung are small and there are not too many of them.

Radiotherapy uses high-energy X-rays to kill cancer cells. You may have radiotherapy before or after surgery, or on its own as your main treatment.

Treatment before surgery is called neo-adjuvant treatment. The aim is to to shrink the tumour so that it is easier to remove. If the treatment is successful, you may be able to have a smaller operation than you otherwise would have. Doctors call this 'down-staging' the disease.

But doctors use radiotherapy most often after surgery, to kill off any cancer cells that may have been left behind. They call this adjuvant radiotherapy. If you do have radiotherapy after surgery, you will usually begin your treatment between 6 and 12 weeks after your operation. This gives the area time to heal before the radiotherapy starts. Radiotherapy treatment may last for up to 7 weeks. The exact time will depend on the type, size and position of the sarcoma.

Sometimes, radiotherapy may be the main treatment for sarcoma - for example with Ewings tumours, you have radiotherapy to try to cure the sarcoma. But otherwise radiotherapy is usually used when the position of the cancer makes surgery to remove it too difficult. In this situation, radiotherapy is used to try to control the sarcoma and slow its growth.

Doctors also use radiotherapy to treat symptoms or try to control a sarcoma that has already spread or has come back since it was first treated.

Chemotherapy means having anti-cancer drugs. For sarcoma, chemotherapy is mostly used to treat

• Ewing's sarcomas
• Embryonal or alveolar rhabdomyosarcoma
• Children or young adults with sarcoma
• Sarcomas that have spread

It is not yet clear how helpful chemotherapy is in other situations. So you may be asked to join a clinical trial if you are offered chemotherapy. A recent European study showed that chemotherapy does not help to reduce the chance of most types of sarcoma coming back after surgery. So chemotherapy is not standard treatment after surgery. Your specialist will discuss this with you individually. They are most likely to suggest chemotherapy for people with large, high grade sarcomas, who are most at risk of the cancer coming back.

The chemotherapy drugs that doctors most often use to treat soft tissue sarcomas are all injected into a vein or given through a drip. You may have a single chemotherapy drug or a combination of two or more drugs.

Chemotherapy for soft tissue sarcoma can sometimes be given before surgery to try to shrink the cancer and make it easier to remove but is not standard treatment. This is called neoadjuvant chemotherapy. Occasionally people have chemotherapy to shrink their sarcoma before surgery using a technique called isolated limb perfusion. This is way of giving chemotherapy into just one arm or leg. It is complicated to do and is only available as a treatment for sarcoma at a couple of hospitals in the UK at the moment.

Chemotherapy can be used to treat symptoms or try to slow down a cancer that has already spread or has come back since it was first treated. Doctors call this palliative chemotherapy. Research is continuing to try to improve the success of this type of treatment. Trials for soft tissue sarcoma are listed on our clinical trials database. Choose 'sarcoma' from the dropdown menu of cancer types to find them.

For gastrointestinal stromal tumours (GISTs), you may have a biological therapy drug called called imatinib (Glivec) before or after surgery. Imatinib is a type of drug known as a tyrosine kinase inhibitor. Imatinib works by blocking signals within cancer cells and stopping a series of chemical reactions that make the cells grow and divide. Studies have shown that imatinib can be very effective in stopping gastrointestinal stromal tumours (GISTs) from growing. There is detailed information on our page about biological therapy for soft tissue sarcoma.

For small, localised sarcomas, surgery is the main treatment and may cure you. You are likely to have radiotherapy afterwards unless your surgeon can completely remove the sarcoma, surrounded by a wide border of healthy tissue with no cancer cells. This is to help stop the cancer coming back.

If you have a larger tumour that has not spread, you may have radiotherapy or chemotherapy before surgery. This treatment is designed to shrink the sarcoma so that you won't need so much surgery. This is only done with particular types of sarcoma such as rhabdomyosarcoma and Ewings. Some types do not respond so well and are less likely to shrink.

If your sarcoma has spread, you may still have surgery as this can help to relieve symptoms and keep the cancer under control for longer. For sarcoma that has spread, you may have chemotherapy, radiotherapy or any combination of these three types of treatment.

If your sarcoma has spread to the lungs and you have only a few small lung tumours, your surgeon may be able to remove them.