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
stromal 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 is a treatment option for
nearly every individual. So, we're here to help our patients the best that we can in offering
those patients hope, but there are very vulnerable times of their life. Surgical oncology
is a specialty that evolved over the last two to three decades. Surgeons spend two to three years
at 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 as 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 specialized pathologists.
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 pathologist, 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 and challenged constantly to help
our patients, and I and I thrive in these kind 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 University Hospital is a cadre of highly specialized physicians
and various aspects of the continuum of cancer care. You have specialized surgeons
with fellowship training in surgical oncology. You have specialized medical oncologists. You
have radiation therapists who are very familiar with the various types of disease sites. And, we
have a very robust partnership with the Lombardi Comprehensive Cancer Center, one
of a few cancer centers 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, and 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 the tumors that arise from muscles, nerve sheets, fat, and hence the name soft tissue
sarcoma. They're a rare group of tumors. They'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 behind the intestines in an area we call retroperitoneal sarcoma.
So sarcomas are wide differences of type. They're about nearly 50 types of sarcomas
that occurs due to the wide spectrum and the nature of sarcoma where that can
affect the the fat, the muscles, or the nerves themselves. And that adds to the complexity of
sarcoma themselves and the 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
to able to make a diagnosis for you in those kind of specific types of sarcomas.
They're a rare group of tumors. There are about eleven thousand cases a year in the United
States, so they're not common cancers such as colon cancer or breast cancer.
Typically, patients present with an increased swelling of in their arms or a shoulder or in
the thigh or on the leg themselves. They notice over the course of time that I have a bump. It's
getting harder. It may or may not hurt, but it's getting bigger and in size. At other
times, patients may be complaining of pain in their extremities and then an MRI is done or
CAT scan and a 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 diagnosis of sarcoma.
At other times if it's located in the abdomen, those patients will present with a large mass
that their primary care physician has found or a CAT 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 muscle or is it a 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 that's a 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 it's a combination of
size, depth, grade, involvement of lymph nodes, and whether it has spread to a distant organ or not.
So treatment option depends on the stage of the sarcoma itself. So in individuals who do
not have any evidence of sarcoma spread to other organs, or what we call no evidence of
distance metastatic disease, surgical resection is a main treatment option. And, what we want to
achieve is a margin negative for section that is would 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 softer systemic chemotherapy is
not offered all the time for individuals with softer sarcoma. But again, we approach this
disease and 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 chemotherapy is held 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 discussion at our tumor boards 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 extremity as in arms or in the legs and thighs, we typically
have a discussion with the 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 risks and 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 therapists. We discuss it in tumor boards and see what's the best option. Now
whereas if the sarcoma is located in the intra-abdominal cavity, again, there are certain
scenarios that we offer radiation before surgery. Other scenarios offered later on after surgery.
Here at MedStar Georgetown University Hospital Lombardi Comprehensive Cancer Center, we offer a
multispecialty 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 the 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 individuals with
soft tissue sarcoma as well. So the decision is a team-based approach based on discussing the
cases itself, personalizing the decision and offering them the best treatment options that they deserve.
The changes in lifestyle depends where the sarcoma is located. If it's a large sarcoma and the extremity requiring a
fair amount of muscle remove 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, do we offer them
radiation therapy to shrink the tumor upfront. 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 that were resect and how do they recover from that. So if it's one sarcoma with one
organ, the recovery is faster than resecting 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 the sarcoma located, what type of
sarcoma do an individual have, and what type of grade and the size of the sarcoma itself.
So for example if an individual has or develop a sarcoma on the thigh that's a small sarcoma less
than 5 centimeters in size, a low grade that has been resected 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 chest X-ray or CAT scan. Individuals who have a sarcoma resected from
their intra-abdominal or the retroperitoneum area tend to recur in that area itself again,
and therefore, we the CAT scans and imaging we do are more focused on a local recurrence phenomena.
The soft tissue sarcoma is a rare group of tumors and cancers that affects patients in various
parts of the body. The complexity is is further confounded by the the nature of sarcoma to
involve surrounding organs. So if a patient has an intra-abdominal or retroperitoneum sarcoma, typically,
the resection and most of the times about 40 to 50 percent of instances the sarcoma needs to be
resected with other organs including the colon, the kidney, or part of the muscles. And 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 type of complex tumors that are also rare as well nd work in a team manner with other
medical oncologists and radiation oncologists to offer those patients the best treatment options.