PROTOCOL FOR RADIOTHERAPY IN PATIENTS WITH SARCOMA

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					           Scottish Sarcoma Network – Final Radiotherapy Guidelines – September 2008

PROTOCOL               FOR        RADIOTHERAPY                     IN     PATIENTS             WITH
SARCOMA

Patients with Sarcoma in Scotland are discussed at a weekly telelinked MDT attended by a
multidisciplinary team representing the treating centres.
A decision to treat with radiotherapy is made at the weekly meeting and documented in the minutes.
Radiotherapy is planned and delivered according to these guidelines.
Children require special consideration for radiotherapy planning and delivery; some may need a
general anaesthetic or the services of a play specialist.
Children and Young Adults with sarcoma should be treated according to the relevant clinical trial
which includes guidance on the indications for radiotherapy, the dose and volume to be treated.
These protocols should be followed for all patients entered onto these trials and used as a guide for
those others who are not participating.
Where there is no clinical trial protocol the guidance below is appropriate, however discussion with
members of the CCLG radiotherapy group is encouraged. Radiotherapy to children should only be
given in a CCLG radiotherapy centre.

Patients with sarcoma requiring radiotherapy fall into the following groups:
1.     Soft tissue sarcoma
2.     Bone sarcoma
3.     Non sarcomatous soft tissue lesions (e.g. fibromatosis)
4.      Non sarcomatous bone lesions. (e.g. giant cell tumour, chordoma, aggressive osteoblastoma)


Those patients with the following pathological sub types are treated in accordance with guidelines
for radiotherapy in the relevant national or international protocol. In some cases these protocols will
not be active (i.e. local ethics committee approval has not been sought or obtained), however they
represent an international consensus for radiotherapy indications, volume and dose. Those patients
who are ineligible for these trials (but have the specific disease the trial covers can generally still be
planned and treated using the radiotherapy volume/dose/fractionation suggested in the protocol.
Tumour types included in this are: Ewing’s sarcoma of bone or soft tissue, Rhabdomyosarcoma,
Osteosarcoma, Fibromatosis.


General considerations when planning radiotherapy for a patient with a sarcoma
    Consider the indications for treatment and the potential benefit/detriment to the patient.

      What is the ideal position for the patient for radiotherapy? How will the patient be
       immobilised for treatment? Is CT planning needed? – and can they get through the scanner
       in the treatment position? Conventional fluoroscopic planning is possible for many limb
       tumour locations.

      Consider the place and timing of other therapies e.g. surgery, chemotherapy, isolated limb
       perfusion.

      Consider organs at risk and obtaining dose estimates for them. This is mandatory within the
       chest, abdomen, spine, and head and neck. It may be useful for limb sarcomas for large
       nerves and some bones.

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          Scottish Sarcoma Network – Final Radiotherapy Guidelines – September 2008



Obtain informed consent for planning and treatment

All patients are warned to expect:
     Tiredness
     Erythema which may progress to desquamation (especially in groin/perineum/axilla)
     Late skin changes/pigmentation/sensitivity to sunshine
     Small risk of second malignancy many years after irradiation

If bladder, bowel, gonads, liver, heart, lungs, brain, or mucosa are in field:
     Advise patient of specific acute and long term side effects and possible measures to reduce
        these

For a limb sarcoma, patients should expect:
    Fibrosis and thickening of soft tissues over a period of years
    Stiffness of tissues and joints
    Lymphoedema of the limb, may not start for months/years
           o advise about lymphoedema care and refer to specialist service if needed promptly
    Emphasise the need for exercise and use of the limb in order to minimise late effects


Wherever possible the patient should be given written information regarding radiotherapy treatment
and side effects. Specific information leaflets are being developed by the Scottish Sarcoma MCN.
In the absence of these, information intended for another disease (eg chest radiotherapy for lung
malignancy, if this covers the area to be treated) or general information (eg Cancer BACUP
booklets for pelvic radiotherapy in males and females) may need to be used.
SOFT TISSUE SARCOMA
Indications for radiotherapy in soft tissue sarcoma
Any of the following:
    Marginal or incomplete resection (where wider resection is not possible / desirable)
    High grade lesion (e.g. grade 3 and most grade 2)
    Large lesion (more than 10cm)
    Consider if more than 5cm.
    Local recurrence following re-resection e.g. low grade lesions
    Low grade lesion which would be unresectable if it recurred e.g. some head and neck
       sarcomas
    Lesion is not resectable without pre operative treatment
    Preoperative radiotherapy may be helpful in lesions which are difficult to resect without
       mutilation/loss of function.


Radiotherapy planning for Soft Tissue Sarcoma
Pre operative or definitive radiotherapy

      Consider the best position for treatment delivery. This may need to be changed if normal
       tissue cannot be spared (commonest problem is the contra-lateral leg or perineum). Non
       standard positions include recovery position, one leg up on blocks of foam, one leg hip
       flexed and abducted with knee flopped out.
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          Scottish Sarcoma Network – Final Radiotherapy Guidelines – September 2008

      Use a vacuum bag, knee rest or other immobilisation device to ensure a stable comfortable
       position which must be reproducible. Vacuum bags for limb position should include the feet
       and lower leg as this best controls position. BDS needed for head and neck radiotherapy,
       lung board for chest lesions.

      CT planning scan (at least 1cm cuts unless in head and neck location when 0.5cm
       appropriate) with volumes outlined (PTV etc).

      GTV is tumour as defined on MRI (or CT if MRI not possible), other information (e.g.
       EUA) may need to be taken into account.

      CTV is GTV plus a margin of 3-5cm if oedema is well demarcated. A margin of 8cm needs
       to be added to GTV if oedema extent is not clear.

      PTV is CTV plus 5mm – 10mm, this depends upon immobilisation and reproducibility of
       set up.

      When placing volumes, critical structures need to be taken into account.

      Natural barriers to tumour spread may allow PTV to be smaller in some places (e.g. facial
       planes, bone.)

      A strip or corridor of normal / un-irradiated skin and subcutaneous tissue must be left to
       allow lymphatic drainage; this should be as wide as possible without compromising the
       PTV. In those cases where it is not possible an individual decision has to be made about
       whether to compromise the PTV or to treat full width of the limb. The patient needs to be
       involved in this discussion and appropriately counselled and consented.

      Surgery to be planned 2-6 weeks from end of RT, to allow the acute reaction to settle but
       before the process of fibrosis begins


Post operative radiotherapy

      Ensure the wound is healed – in rare cases radiotherapy can be started before the wound has
       completely healed; this needs to be discussed with the patient and the surgeon. In cases of
       delayed wound healing swabs, treatment of infection and wound care advice may help.

      Consider the best position and immobilisation device for treatment delivery as above.



      Wire all scars and drain sites for the planning scan.

      CT planning scan (at least 1cm cuts unless in head and neck location 0.5cm) with volumes
       outlined (PTV etc).

      Preoperative imaging should be employed to reconstruct the tumour location.



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          Scottish Sarcoma Network – Final Radiotherapy Guidelines – September 2008
      GTV is preoperative tumour volume as defined by MRI (or CT if MRI not possible).


Post operative radiotherapy may often be delivered in two phases:


Phase 1


      Limb CTV is pre operative GTV plus a margin of 5cm, and scar and drain sites plus a
       margin of 1cm in cranial-caudal direction of limb. Axial margin of 2cm added to GTV and
       1cm to scar/drain unless there is an intact facial or bony boundary.


      For non limb sites the CTV is GTV plus 2cm, again scars and drain sites need to be
       considered.

      PTV is CTV plus 5mm – 10mm, this depends upon immobilisation.

      Compromises may have to be made in the volume irradiated and the dose delivered, taking
       account of the dose to organs at risk for sarcomas of the trunk, and where the volume
       extends across joints for limb lesions.

      Natural barriers to tumour spread may allow PTV to be smaller in some places (e.g. facial
       planes, bone.)

      Whole compartment may need to be treated – if concern about contamination.

      A strip or corridor of normal / un-irradiated skin and subcutaneous tissue must be left to
       allow lymphatic drainage; this should be as wide as possible without compromising the
       PTV. In those cases where it is not possible an individual decision has to be made about
       whether to compromise the PTV or to treat full width of the limb. The patient needs to be
       involved in this discussion and appropriately counselled and consented.

      If the primary resection is known to be marginal or to have an involved margin, particular
       care needs to be taken at this/these sites to ensure adequate coverage. Discussions in the
       sarcoma MDT at the time of surgery, to try to identify the risk area from the pathology
       report and operation details are very useful here. In some cases clips placed at surgery are of
       assistance.

Phase 2       Where needed

      GTV as for phase 1.

      CTV is GTV plus 2cm in all directions. Scars and drain sites do not need to be covered.

      PTV is CTV plus 5mm – 10mm, this depends upon immobilisation.




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           Scottish Sarcoma Network – Final Radiotherapy Guidelines – September 2008




Doses for soft tissue sarcoma radiotherapy

Pre operative radiotherapy            50Gy in 25#, followed by post operative boost to 60Gy
                                      (reduce fields) if concern about margins, or 66Gy if
                                      macroscopic unresectable disease Surgery to take place at 2-6
                                      weeks from end of radiotherapy (i.e. acute reaction settled,
                                      fibrosis and other changes not started).

Post operative radiotherapy           60Gy in 30# if clear resection margins. 66Gy in 33# if
                                      macroscopic disease. This can be done in 2 phases, phase 1 up
                                      to 50Gy, phase 2 above 50Gy.

Definitive radiotherapy               66Gy in 33# in 2 phases.

Abdominal radiotherapy                45Gy in 25# in 1 phase if bowel in field. 54Gy in 30# in 2
                                      phases if bowel can be excluded at 45Gy.

Palliative radiotherapy               45Gy in 15# if no bowel in field, 45Gy in 20# if bowel/viscera
                                      in field or very large volume.
                                      30Gy in 10#, or 20Gy in 4 or 5#, or single 10Gy

It may be preferable to treat palliative cases with larger doses and fractions than other tumour types.
Especially if they only have localised disease, or have metastatic disease but are PS 0-2. Local
control is vital in the palliative phase and these patients can be very difficult to palliate if or when
local control is lost.


Rhabdomyosarcoma                      Use radiotherapy guidelines from study protocol

Esthesioneuroblastoma                 Treat like a Head and Neck tumour. Consider if neck needs to
                                      be irradiated as part of primary therapy.

Ewing’s sarcoma                       All soft tissue Ewing’s can be irradiated according to the
                                      guidelines in EuroEwing’s protocol for bone Ewing’s. See
                                      below.PRIMARY BONE SARCOMA

Indications for radiotherapy in Primary Bone Sarcoma
There are some specific and well defined indications for radiotherapy.

Ewing’s sarcoma        Here the current Euro Ewing’s protocol gives advice which can be followed
                       even for those patients who are not on study. The protocol covers indications,
                       margins and doses which vary depending upon the situation. They will
                       usually be on concomitant chemo – consider reducing (50%) or omitting the
                       actinomycin D during radiotherapy. Omit if there is bowel or liver in the
                       field.

NB see warning about RT to lung or cord/CNS in patients who have had High Dose
                 Busulphan andMelphalan


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            Scottish Sarcoma Network – Final Radiotherapy Guidelines – September 2008
Osteosarcoma            If it is unresectable or the resection is marginal (and cannot be improved)
                        then radiotherapy should be given concomitantly with post op chemo or after
                        chemo completed. There are few good guidelines and this situation occurs
                        very rarely.
                        Unresectable osteosarcoma will need radiotherapy as local control treatment
                        – usually in a central location (vertebra etc).

Others                  A mixed bag of pathology. Indications for radiotherapy as for osteosarcoma.



Fields and Volume for Primary Bone Sarcoma

This does not include Ewing’s - see protocol

        General sarcoma guidelines hold true (see above).

        Patient position is crucial for comfort, reproducible setup, and optimal beam arrangement.

        Information from appropriate pre- and post-chemotherapy scans and any operative or
         pathological information.

        CT planning as above.

        Entire bone at risk should be considered, but may not need to be treated.

        A margin of 5cm along the length of the bone and 2-3cm radially for long bones. (Providing
         extra osseous soft tissue extension and contaminated field is taken into account).

        Include scar and drain sites with a 1-2 cm margin.

        More difficult is a lesion in the pelvis, limb girdle, trunk or head and neck.

        Vertebral lesions – include at least one (possible 2) vertebral body up and down. (Ensure
         surgery is not possible).




Doses for Bone sarcoma

This does not include Ewing’s - see protocol

Osteosarcoma            Generally thought to need higher doses

                        At least 60Gy after marginal resections, probably 70Gy if possible for
                        unresectable primary. This will depend critically upon location and other
                        structures. It may be an ideal location for IMRT or protons. If so discussions
                        elsewhere are needed.

                        Palliative doses still need to be biologically hotter than other tumour types
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          Scottish Sarcoma Network – Final Radiotherapy Guidelines – September 2008
                      (e.g. as for STS).

Other bone tumours As the indications are generally for inoperable disease, the dose is at least
                  60Gy in 30# for radical treatment

                      Chordoma may need 60Gy or more, possibly better with protons

                      Giant Cell Tumour 45Gy in 25#, where GTV = CTV.

                      Palliative radiotherapy as previously.

                      For a marginal resection 50Gy in 25# with a boost to highest risk area of 10-
                      16Gy in 5-8#.


Surgery (even amputation / radical or mutilating) may be better for local control than
conservative surgery and radiotherapy.


Fibromatosis

There is an EORTC protocol for radiotherapy in the face of progressing disease which is deemed
inoperable. This can be used at a guide, Martin Robinson in Sheffield is involved in this protocol.

Dose 54Gy in 30#.




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