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I'm Dr. Waddah Al-Refaie, I serve as the chief of surgical oncology
at MedStar Georgetown University Hospital,
I also serve as the surgeon in chief for the Lombardi Comprehensive Cancer Center.
I have the high privilege of caring for patients with GI cancer,
soft tissue sarcoma, gastrointestinal stormal tumors
and malignant melanoma.
To be diagnosed with cancer is a devastating diagnosis, and it impacts
the way you think and it impacts your lifestyle
and all the future decisions that you have.
As a surgical oncologist, I see the glass half full.
There's a treatment option for nearly every individual.
So we're here to help our patients the best that we can
and offer those patients hope at their very vulnerable times of their life.
Surgical oncology is a specialty that evolved over the last 2-3 decades.
Surgeons spend 2-3 years at the major Comprehensive Cancer Center
learning tools and techniques, and I'm a member of a team
and feel intensely committed to this team approach
to individuals with these cancers.
It's challenging, it keeps you thinking all the time
at how can we help our patients and offer them the best outcomes that we can.
The diagnosis itself can be at times challenging and require
our specialized pathologist.
Some of the diseases, you have 50 types of sarcoma different from each other.
So again, you'd like to be at a center where your pathologists, surgeons,
medical oncologists, radiologists are working together,
familiar with these diseases and be able to streamline
the treatment decision for complex diseases.
So this is an environment where we're stimulated challenged constantly
to help our patients, and I thrive in these kinds of environments
where it's research driven based on the latest treatment options
to offer our patients here at MedStar Georgetown University Hospital.
What we offer at MedStar Georgetown University Hospital
is an array of highly specialized physicians in various aspect of
the continuum of cancer care.
We have specialized surgeons with fellowship training in surgical oncology,
you have specialized medical oncologists, you have radiation therapists
who are very familiar with that various typse of disease sites,
and we have a very robust partnership with the Lombardi Comprehensive Cancer Center,
one of the few cancer canters in the nation that has
a Comprehensive Cancer Center designation,
and it's the only one in the D.C metro area. So we feel that we offer our patients
cutting-edge, the latest in access to cancer clinical trials
that very few centers in the country are able to offer
these kinds of treatment options to our patients with cancer.
So sarcomas are rare tumors that occur in the bones,
muscle, fat surrounding the muscle itself, the nerves as well.
So we divide sarcomas into bony sarcoma or soft tissue sarcoma
and the soft tissue sarcoma are tumors that arise from muscles,
nerve sheets, fat, hence the name soft tissue sarcoma.
They're a rare group of tumors, there're about 11,000 cases a year,
they commonly occur in the upper extremities or in the lower extremities.
Less commonly, they occur in the intra-abdominal cavity
or behind the intestines in an area we call Retroperitoneal Sarcomas.
So sarcomas are a wide differences of type. There are about 50 types of sarcomas
that occur due to the wide spectrum and the nature of sarcoma
where they can affect the fat, the muscles or the nerves themselves
and that adds to the complexity of sarcomas themselves and their rarity
because now you have a rare group of tumors
with a wide spectrum of types of diagnosis
and here comes the importance of having a good pathologist who...
to be able to make a diagnosis for you in those kinds of specific types of sarcomas.
They're a rare group of tumors, there're about 11,000 cases a year
in the United State, so they're not a common cancer such as
colon cancer or breast cancer.
Typically, patients present with an increased swelling in their arms or shoulder
or in the thigh or in the legs themselves.
I notice of the course of time that I have a bump, it's getting harder,
it may or may not hurt, but it's getting bigger in size.
At other times, patients may be complaining of pain in their extremities
and then an MRI is done or a CT scan and the mass is found.
But the vast majority of patients will present with a mass
that has increased over the course of time
and that leads to the diagnosis of sarcoma.
At other times, if it's located at the abdomen,
those patients will present with a large mass that their
primary care physician has found or a CT scan was done
and then a mass is identified.
The stage of sarcoma is a bit different from other cancers.
So here it depends on the size of the sarcoma,
where is it located, in other words, the depth.
So is it a superficial sarcoma that involves the skin and the muslce
or is it deep sarcoma that involves deeper components of the muscle
or in the abdomen. Another factor that determines the stage is
what we call "grade", and that's an evaluation that the pathologist
will make by assessing the specimen itself under the microscope.
Whether lymph nodes are involved or not and whether other organs
have been affected by the sarcoma itself.
So it's a combination of size, depth, grade, involvement of lymph nodes
and whether it has spread to distant organs or not.
So treatment option depends on the stage of the sarcoma itself
and individuals who do not have any evidence of sarcoma spreading to other organs
or what we call, no evidence of distant metastatic disease,
surgical resection is a main treatment option.
And what we want to achieve is a margin-negative resection, that is,
we'd like to remove the sarcoma itself with a complete resection,
not leaving any tumor behind.
The other treatment option is radiation therapy
and that's either offered before surgery or after surgery,
and each option has its pros and cons as well.
Unlike other disease sites, soft tissue sarcoma
may have a tendency to respond or not to systemic chemotherapy.
So systemic chemotherapy is not offered all the time
for individuals with soft tissue sarcoma.
But again, we approach this disease in a team approach,
we discuss all the cases in our tumor board
and decide what is the best treatment approach in terms of surgery,
radiation, with or without systemic chemotherapy.
You do not need chemotherapy for all cases of soft tissue sarcoma.
The main treatment option is surgical resection,
at times we offer radiation therapy before or after surgery.
Systemic chemotherapies help for certain types of sarcomas,
whether sarcoma has spread to other organs, in other words a metastatic disease,
or we believe that certain types of sarcoma may respond better
to systemic chemotherapy, and those are the group of patients
that after a discussion on our tumor board, we offer them systemic chemotherapy.
There is a role for radiation therapy for most but not all patients with sarcoma.
It's either given before or after surgery. This discussion is based on
where is the sarcoma located. If it's a sarcoma that's located
in the extremities, in the arms or in the legs and thighs,
we typically have a discussion with a patient
and go over the risks and benefits of offering radiation therapy
before surgery versus after surgery.
So if we were to offer radiation therapy before surgery,
the benefit of doing that is you offer less radiation.
You want to shrink the tumor, you want to preserve the limb,
but the drawback of giving radiation upfront is
you have a higher risk of surgical site infection.
If we offer it after surgery, you give a larger dose of radiation,
more edema, more swelling,
because of the large field of radiation that's offered.
In exchange, you have lower doses of... Excuse me, lower risk
of surgical site infection.
So it's a risk balance. We personalize the decision,
we see what the cancer is, what the patient has
and then make the decision for when to offer radiation.
And again, this is a team approach decision,
we make the decision with our radiation therapist,
we discuss it on our tumor board and see what's the best option.
Now, whereas if the sarcoma's located in the intra-abdominal cavity, again,
there're certain scenarios that we offer radiation before surgery,
other scenarios - it's offered later on, after surgery.
Here at MedStar Georgetown University Hospital
Lombardi Comprehensive Cancer Center we offer a multi-specialty team approach
where surgeons are very familiar and have expertise
in soft tissue sarcoma given their training.
Medical oncologists have dealt with this disease
and have various lines of systemic chemotherapy
for patients who believe will benefit from systemic chemotherapy.
At MedStar Georgetown University Hospital we have CyberKnife facility
that's been offered to patients with soft tissue sarcoma
either before or after surgery, and we have access to clinical trials
for individual soft tissue sarcoma as well.
So the decision is a team-based approach based on discussing the case itself,
personalizing the decision
and offering the best treatment options that they deserve.
The changes in lifestyle depends where the sarcoma is located.
If it's a large sarcoma in the extremity requiring a fair amount of muscle removed
and joint involvement, obviously the ability to move, ambulate,
carry things - will be impacted. And that's when we have a discussion
with the patient and we offer them radiation therapy to shrink the tumor up front.
If it's a sarcoma that's located in the abdomen or the area
behind the abdomen that's called the retroperitoneum,
it depends pretty much on how many organs we will re-sect
and how they will recover from that.
So if it's one sarcoma with one organ,
the recovery is faster than re-secting multiple organs
or muscle involved as well.
Most patients with soft tissue sarcoma are at risk of recurrence of their sarcoma.
Again, we personalize their risk of recurrence based on
where is hte sarcoma located, what type of sarcoma
does an individual have,
and what type of grade and the size of the sarcoma itself.
So for example, if an individual has or develops a sarcoma on the thigh,
that's a small sarcoma less than 5cm in size,
a low-grade that has been re-sected with negative margin,
their risk of recurrence is much lower than another individual
who developed a high-grade sarcoma inside the abdomen
that required removing it along with other organs.
In other words, we follow all our patients with sarcoma
because of the risk of recurrence.
Patients who develop sarcoma in their extremity
tend to develop their recurrence elsewhere.
They tend to develop recurrences in their lung or in the bone.
So we watch... we follow them closely by either performing
a chest X-ray or a CT scan. Individuals who have a sarcoma re-sected
from their intra-abdominal or the retroperitoneum area
tend to reoccur in that area itself again
and therefore the CT scans and imaging we do are more focused
on a local reoccurrence phenomenon.
Soft tissue sarcoma is a rare group of tumors and cancers
that affects patients in various parts of the body.
The complexity is further confounded by the nature of sarcoma
to involve surrounding organs.
So if a patient has intra-abdominal or retroperitoneum sarcoma,
typically the resection in most of the times is above 40%-50% of instances
the sarcoma needs to be re-sected with other organs,
including the colon, the kidney and part of the muscles.
In about 20% of cases the sarcoma may be involving nerves and vessels
that need to be removed and reconstructed again.
So given the complexity of the disease itself
and the impact of surgery on their short and long-term survival,
we believe that, I mean... the surgical oncologists
are trained to deal with those types of complex tumors
that are also rare as well
and work in a team manner with other medical oncologists
and radiation oncologists who offer those patients the best treatment options.