By Bree Eaton, MD, Pediatric Medical Director, Emory Proton Therapy Center
In the spring of 2018, a 55-year-old woman presented to her doctor with symptoms of sinus infection and numbness in the side of her face and lip. Based on a presumed diagnosis of chronic sinusitis, she underwent sinus surgery. Pathology revealed a soft tissue sarcoma, and she was referred to Winship Cancer Institute of Emory University, where a dedicated sarcoma team had experience — more than any other place in Georgia — in diagnosis and treatment of this rare type of tumor in adults.
An Engine of Discovery, Innovation and Collaboration
The diagnosis of rhabdomyosarcoma of the maxillary sinus was confirmed from her appointment with Winship oncologists. After presentation of her case before Winship at Emory’s multidisciplinary tumor board, the patient was recommended to undergo surgical resection. A team of otolaryngology surgeons performed a total maxillectomy for radical resection of the facial tumor, right parotidectomy, and a modified radical neck dissection.
Treatment of Rhabdomyosarcoma
A second team immediately moved into the operating room, performing advanced reconstruction with a left fibular free flap and transosteal bone graft. Final pathology revealed the tumor to be an Alveolar Rhabdomyosarcoma. Rhabdomyosarcoma is one of the most common soft tissue sarcomas in children and adolescents but accounts for less than one percent of all adult malignancies and three percent of all soft tissue sarcomas.
Surgery went well, and all of the tumor was successfully removed. Standard of care for intermediate risk rhabdomyosarcoma includes a sequence of chemotherapy alone, followed by simultaneous chemotherapy and radiation, then more chemotherapy alone. The close proximity of the tumor bed to the patient's right eye and optic nerve and other radiation-sensitive structures, led the team to recommend proton therapy.
Applicability of Proton Therapy Radiation
In December 2018, the patient started proton radiation at Emory Proton Therapy Center. She received 28 treatments of 50.4 Gy to the post-operative resection bed and the right neck, levels one through two. Her appointments took place Monday through Friday and each lasted 30 minutes, including time to prep and the radiation itself. Radiation ended in January 2019 and chemotherapy concluded in March 2019.
Representative de-identified image from the patient’s proton therapy plan (left) compared to IMRT plan (right)
The patient tolerated chemotherapy and radiation well, with no unexpected complications. Midway through radiation she experienced grade 1 radiation-induced dermatitis, mucositis, dry mouth, altered taste, and fatigue, all of which resolved after radiation ended. Her only long-term side effects have been intermittent and occasional clear, watery drainage from her right eye and mild tightness of her skin.
Survivorship and Beyond
One year later, she continues to be followed closely by her team of specialists, including her otolaryngology surgeon, medical oncologist, and radiation oncologist. She also is part of Winship’s survivorship program, designated to prevent medical or emotional problems from unduly impacting patients’ quality of life. She feels well and life has returned to normal. As an enthusiastic cook, she prepared a Thanksgiving meal for her husband and more than 30 friends and family members.
Treatment of this patient’s rare cancer illustrates the wisdom of her physician’s referral to Winship at Emory, not only for the experience of its head and neck surgeons and sarcoma team, but also for its expertise in proton therapy. That has made a tremendous difference in her outcome. Her tumor was dangerously close to her eyes, brain, inner ears, parotid gland, and endocrine structures, including the pituitary hypothalamus. Intensity modulated proton therapy with pencil beam scanning was able to precisely target the tumor bed while minimizing and, in this case, eliminating radiation exposure to nearby healthy tissues. This significantly reduces both acute and long-term side effect risks.
The radiation oncologist worked closely with the patient’s referring physician, before, during and after care, something in which Winship at Emory’s physicians take special effort and pride. Our radiation oncologists frequently confer about the appropriateness and potential of proton therapy with physicians considering referral of a patient. For patients who are referred, intake is rapid, with ongoing communication with the local physician. And although this Atlanta-based patient received all her treatment and support services at Winship Cancer Institute of Emory University, the team works collaboratively with referring physicians across Georgia and the region so that eligible patients are able to receive treatment at Emory Proton Therapy Center, but receive chemotherapy closer to home under the care of their local physician if needed.
Expertise in Proton Therapy for Your Patient
As the only proton therapy center in the state of Georgia, we specialize in the most advanced radiation technologies and treatments for patients with specific cancers. We are an integral part of Winship Cancer Institute of Emory University, a National Cancer Institute-Designated Comprehensive Cancer Center. Together, our teams of world-renowned experts deliver the most effective treatments and achieve the best outcomes for your patients.
Emory Proton Therapy Center is committed to the continued health and safety of all patients. During this time, we are taking all necessary precautions to screen for coronavirus (COVID-19) and to prevent its potential spread. We continue to monitor the evolving COVID-19 pandemic and are working with experts throughout Emory Healthcare to keep your patients safe. For the most up-to-date information for our referring partners, click here.