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Treatment for soft tissue sarcomas

Treatment planning
Types of treatment
Second opinion
Giving your consent
Benefits and disadvantages of treatment
Treatment decisions

Treatment planning

As sarcomas are rare cancers, you should always be referred for treatment at a specialist sarcoma unit where a team of specialist doctors and others work together. This is known as a multidisciplinary team (MDT) and may include:

a surgeon
a clinical oncologist Ė a doctor who treats cancer with radiotherapy
a medical oncologist Ė a doctor who treats cancer with chemotherapy
a pathologist Ė a doctor who specialises in how disease affects the body a radiologist Ė a doctor who analyses x-rays and scans
a specialist nurse who gives information and support to people with sarcoma.

The multidisciplinary team may also include other healthcare professionals, such as:

a dietitian
occupational therapist
psychologist or counsellor.

In order to plan the best treatment for you, your doctors will take into account your age, general health, and the type, stage and grade of the sarcoma.

Types of treatment

Surgery is the most common treatment. If the soft tissue sarcoma is small and it is possible to remove it completely, surgery may be used on its own.

For larger sarcomas, and where there may be a possibility of cancer cells being left behind, radiotherapy is usually used as well as surgery. Radiotherapy may be given before the operation to shrink the tumour and make it easier to remove, or afterwards to try to destroy any cancer cells that may not have been removed.

Sometimes radiotherapy is used on its own or in combination with chemotherapy to treat more advanced sarcomas that canít be removed.

Chemotherapy may sometimes be given before surgery, to shrink the tumour. It is sometimes given after surgery, to try to destroy any cancer cells that have not been removed or which may have spread to other parts of the body.

For gastrointestinal stromal tumours a drug called imatinib (Glivec®) may be used before or after surgery.

It often helps to make a list of the questions you want to ask your doctor, and to take a close friend or relative with you.

Second opinion

Usually a number of cancer specialists work together as a team and they use national treatment guidelines to decide on the most suitable treatment for a patient. Even so, you may want to have another medical opinion. Either your specialist, or your GP, will be able to refer you to another specialist for a second opinion if you feel it will be helpful. The second opinion may cause a delay to the start of your treatment, so you and your doctor need to be confident that it will give you useful information.

If you do go for a second opinion, it may be a good idea to take a friend or relative with you, and have a list of questions ready, so that you can make sure your concerns are covered during the discussion.

Giving your consent

Before you have any treatment, your doctor will explain the aims of the treatment to you. They will usually ask you to sign a form saying that you give your permission (consent) for the hospital staff to give you the treatment. No medical treatment can be given without your consent, and before you are asked to sign the form, you should have been given full information about:

the type and extent of the treatment you are advised to have
the advantages and disadvantages of the treatment
any other types of treatments that may be appropriate
any significant risks or side effects of the treatment.

If you do not understand what you have been told, let the staff know straight away so that they can explain again. Some cancer treatments can be very complex, so it is not unusual for people to need repeated explanations.

It is often a good idea to have a friend or relative with you when the treatment is explained, to help you remember the discussion more fully. You may also find it useful to write down a list of questions before you go to your appointment.

Patients often feel that the hospital staff are too busy to answer their questions, but it is important for you to be aware of how the treatment is likely to affect you. The staff should be willing to make time for you to ask questions.

You can always ask for more time to decide about the treatment if you feel that you canít make a decision when it is first explained to you.

You are also free to choose not to have the treatment. The staff can explain what may happen if you do not have it. It is essential to tell a doctor, or the nurse in charge, so that they can record your decision in your medical notes. You do not have to give a reason for not wanting to have treatment, but it can be helpful to let the staff know your concerns so that they can give you the best advice.

Benefits and disadvantages of treatment

Many people are frightened at the idea of having cancer treatments, because of the potential side effects that can occur. Although many of the treatments can cause side effects, these can often be well controlled with medicines. Some people ask what would happen if they did not have any treatment. Treatment can be given for different reasons and the potential benefits will vary depending upon the individual situation.

Early-stage sarcoma

In people with early-stage sarcoma, surgery is often done with the aim of curing the cancer, and additional treatments may also be given to reduce the risks of it coming back.

Advanced-stage sarcoma (metastatic)

If the cancer is at a more advanced stage, the treatment may only be able to control it Ė leading to an improvement in symptoms and a better quality of life. However, for some people the treatment will have no effect upon the cancer and they will get the side effects with little benefit.

Treatment decisions

If you have been offered treatment that is intended to cure your cancer, the decision whether to accept it may not be a difficult one. However, if a cure is not possible and the treatment is being given to control the cancer for a period of time, it may be more difficult to decide whether to go ahead with treatment or not.

Making decisions about treatment in these circumstances is always difficult, and you may need to discuss in detail with your doctor whether you wish to have treatment. If you choose not to, you can still be given supportive (palliative) care, with medicines to control any symptoms.

It is important that you ask your doctors and nurses any questions you have about your treatment. It is true that the hospital staff are busy, but the more you understand about your treatment, the easier it is for you and them.

Surgery for soft tissue sarcomas

Soft tissue sarcomas are very rare cancers, so once a sarcoma is diagnosed you will usually be referred to a surgeon in a large cancer hospital, who specialises in the treatment of these types of cancer. Sometimes surgery may have been done before the surgeon realised that the lump was a soft tissue sarcoma. In this situation you will then normally be referred to a sarcoma specialist. Sarcoma specialists often treat other types of cancer as well as sarcoma.

The aim of most sarcoma surgery is to remove as much of the tumour as possible. Usually, an operation called a wide local excision is done. This means removing the cancer with a border (margin) of healthy, cancer-free tissue all around it. The border of healthy tissue is removed to try to stop the cancer coming back in that area.

It is difficult to give general information about sarcoma surgery because the type of operation you have will depend on where in your body the sarcoma is. Many sarcomas are in the arm or leg, but they can grow anywhere.

Your surgeon will discuss the operation with you in detail before any choice is made about your treatment.

Surgery to the chest or abdomen
Surgery to the arms or legs
Plastic surgery

Surgery to the chest or abdomen

Surgery is usually the main treatment for soft tissue sarcomas of the trunk (the chest and abdomen). The extent of the operation will depend on the exact position of the sarcoma in the body. Your doctor will discuss this fully with you before the operation.

After your operation, you will have a tube (drip) going into a vein in your arm. This will give you fluids and nutrients for 2Ė3 days until you are able to eat and drink properly. The nurses on the ward will then take the drip out. Your doctor will let you know when you can start to eat again.

Radiotherapy may also be used after operations for sarcomas in the chest or abdomen to try to make sure that any remaining cancer cells are destroyed.

Surgery to the arms or legs

Major improvements have been made in surgery for soft tissue sarcomas of the arms and legs over the past few years. In the past, it was usually necessary to remove the limb (amputation) if cancer was found. A false limb (prosthesis) would then be made to replace the limb that had been removed. Amputation is still sometimes necessary, but it is now usually possible to just remove the cancer and some of the tissue around it. This is known as limb-sparing surgery and is done by using a combination of surgery, radiotherapy and chemotherapy.

Plastic surgery

Depending on the size and position of your tumour, the surgeon may have to remove a large area of tissue. This may mean that you need to have some reconstructive/cosmetic (plastic) surgery to repair the area. If this kind of surgery is needed it will be done at the same time as your operation.

The aim of plastic surgery is to make the area look and function as naturally as possible. The exact type of surgery you have will depend on where in your body the sarcoma is and how much tissue the surgeon needs to remove. If only a small area has been removed, the surgeon may be able to join the two edges together again. For larger areas a skin graft may be needed. This involves taking some skin from a different part of the body (known as the donor site) and using it to repair the operation site. Both sites will gradually heal over a few weeks after the operation.

Occasionally itís necessary to repair the operation site with a specialist technique using skin and tissue. This is known as a tissue flap and there are several different types. The surgeon will explain your operation to you and answer any questions you may have.

Limb-sparing surgery for soft tissue sarcomas

Before your operation
After your operation
Prostheses for growing children

Before your operation

Before your operation, your doctor and the nurses on the ward will discuss your treatment with you in detail to make sure that you fully understand what it involves. It is often helpful to talk to someone who has had the same operation, and the medical staff should be able to arrange this for you. On some wards a clinical nurse specialist may be available to discuss any worries that you or your carers may have.

If you have had chemotherapy, your body will need some time to recover before the surgery can be done. Usually it takes at least a couple of weeks after chemotherapy before you are ready to have your operation.

Your doctor and anaesthetist will come to see you to make sure you understand what is going to happen. They will answer any questions you may have. You will have to sign a form agreeing to the surgery. This is the time to make sure you ask all the questions you need to. Many people find that the more they know about what is going to happen, the less frightening it seems. Donít worry if you think of more questions later; just speak to your nurses again. If they canít answer your questions, they can contact the doctor to come and talk to you again.

If you have body hair on the surgery area, you will need to be shaved before your operation. This is done to reduce the risk of infection. You may be shaved in the operating theatre after you have had your anaesthetic.

After your operation

At first your limb will be firmly bandaged. This is to give the area time to heal. You will probably have a drainage tube in the wound to remove any fluid that collects in the area of the operation. It will be removed once it has stopped draining, usually after a few days.

Swelling around the wound

Sometimes fluid can build-up around the wound, especially following surgery to a buttock or limb. The swelling should gradually reduce over a few weeks. Sometimes a lot of fluid builds up around the wound; this is known as a seroma. It may need to be drained by a doctor or nurse.


You may have a drip (infusion) of fluids going into a vein in your arm. This will give you fluids and nutrients for 2Ė3 days until you are able to eat and drink properly. The nurses on the ward will then take the drip out.


You will have some pain and discomfort after your operation. Painkillers will be prescribed for you and these are usually very effective in keeping pain under control. To start with you will probably need a strong painkiller such as morphine. This will be given to you either as injections (given by the nurses), or through a small pump attached to a needle in your arm (which you control yourself). It is important to let the nurses know if your painkillers donít seem to be working.

If you have had surgery on your leg, a different method of pain relief (called an epidural) may be used. A fine tube is inserted through your back into the fluid between the membranes around your spinal cord; a local anaesthetic can then be continuously given into the fluid to numb the nerves that run to your legs.


Your nurses or the physiotherapist will teach you breathing and leg exercises. You can help yourself to get better by doing the exercises as often as you are told you need to. Breathing exercises will help to stop you getting a chest infection. Leg exercises will help to stop clots forming in your legs. Chest infections or blood clots can happen if you are not moving around as much as you would normally be. Your nurses will encourage you to get up and about as soon as possible. However, limb- sparing surgery or amputation is major surgery, and you may have to stay in bed for some time afterwards; this may be from a couple of days up to a week.

Your physiotherapist will show you some exercises to keep the muscles in the limb strong and supple. This is so that as soon as it is strong enough you can use it normally. The physiotherapist will also help you to move the limb once you are able to be up and about again. Sometimes you will need a brace or support for your limb. If the operation was on your leg, you may be given crutches to use at first. This is to protect your leg while you are learning to walk again. You will probably be left with a slight limp.

Sometimes trying to walk normally with a limp puts pressure on the leg and causes pain elsewhere in the body. Although it is important to have any continuing pain checked by your doctor, it does not necessarily mean that the cancer has come back.

Going home

Most people are able to go home once their wound is well healed, usually from 7Ė10 days after their operation.


After limb-sparing surgery, radiotherapy treatment is usually given to the area of the operation, to destroy any cancer cells that may still be in the area. This is done because it is very difficult to be completely certain that all the cancer cells have been removed during the operation.

Prostheses for growing children

If a child has limb-sparing surgery while they are still growing it may be possible for them to have an internal prosthesis (false part of the limb) fitted that can be lengthened at a later date. The lengthening is done during a fairly minor operation, which may mean a short stay in hospital.

Amputation as a treatment for soft tissue sarcomas

It is not always possible to do limb-sparing surgery and occasionally amputation may be necessary. This may be because itís the only way to get rid of the cancer. Very occasionally, after discussion with their specialist doctor and family, people choose to have an amputation instead of limb-sparing surgery.

The preparation for amputation is similar to that for limb-sparing surgery. Psychological support for people who are about to have an amputation is very important. The nursing and medical staff looking after you will be able to offer help and support. It may also be helpful to talk to someone who has had the same operation and can give you practical advice.

After your operation
Artificial limb (prosthesis)

After your operation

You will usually have a drip for a few days to give you fluids. A bandage will be applied over the affected site to help shape the area. You'll have a tube in the wound to drain off any fluid that builds up.

You will be given painkillers to deal with any pain and discomfort. Some people have a pain that appears to come from the part of the limb that has been amputated. This is known as phantom pain or sensation. Although this pain will gradually fade, there may be some discomfort in the area for a while after the operation.

About two to three days after surgery, you will be encouraged and helped to move around. The physiotherapist will visit you shortly after your operation and show you how to do exercises to keep the muscles around the operation site strong and supple, making it easier to use an artificial limb. The physiotherapist will also show you how to do the breathing and leg exercises described above.

Artificial limb (prosthesis)

Following an amputation, most people can be fitted with an artificial limb called a prosthesis. Modern technology means that artificial limbs are now very effective, enabling people to walk, run and play sport.

A person who fits artificial limbs will visit you before or after your operation to show you the different types of prosthesis and how they work. Careful measurements have to be taken so that the prosthesis fits properly. It may take several weeks for your prosthesis to be made and, in the meantime, you may be fitted with a temporary one so that you can begin to get used to it. The fitting of artificial limbs is usually arranged through the ward where you are being treated. Your doctor or nurse can give you more information about this.

Once your wound has healed, probably after a couple of weeks, you will be able to go home.

Radiotherapy for soft tissue sarcomas

About radiotherapy
Planning your treatment
Treatment sessions
Side effects

About radiotherapy

Radiotherapy treats cancer by using high-energy x-rays to destroy cancer cells, while doing as little harm as possible to normal cells.

Radiotherapy is an important part of the treatment for soft tissue sarcomas, particularly those affecting the arms or legs. It is usually given after surgery to destroy any remaining cancer cells. Sometimes radiotherapy may be given before an operation (neo-adjuvant radiotherapy), either to shrink the tumour and make it easier for the surgeon to remove it successfully, or to avoid having to amputate the limb. If the radiotherapy is given after surgery, the wound from the operation must be healed before radiotherapy treatment is started.

Radiotherapy is sometimes given on its own and may be the only treatment needed.

Radiotherapy is also given to relieve symptoms and control sarcomas that canít be removed.

Radiotherapy for sarcomas is normally given as a series of short daily treatments in the hospital radiotherapy department. High-energy x-rays are directed from a machine at the area of the cancer. The treatments are usually given from Monday to Friday, with a rest at the weekend. The number of treatments will depend on the type, size and position of the cancer within your body, but the whole course of treatment for early cancer will usually last a few weeks. Each treatment takes about 10Ė15 minutes. Your doctor will discuss the treatment and possible side effects with you.

Planning your treatment

To make sure that the radiotherapy is as effective as possible, it has to be planned carefully. If your sarcoma is in an arm or a leg, you may have a plastic mould made. The mould helps to keep you still during radiotherapy treatment sessions and is fitted over the affected part of your body. It is made in the mould room, on your first few visits to the radiotherapy department.

You will also be asked to lie under a large machine called a simulator, which takes x- rays or CT scans of the area to be treated. Sometimes a CT scanner can be used for the same purpose. Treatment planning is an essential element of radiotherapy and it may take a few visits. The planning sessions during your first few visits will take longer than the actual radiotherapy treatment sessions.

Marks may be drawn on your skin to help the radiographer, who gives you your treatment, to position you accurately and to show where to direct the rays. These marks must stay visible throughout your treatment but they can be washed off once the course of treatment is over. Sometimes small permanent marks (like tattoos) may be made on your skin. At the beginning of your treatment, you will be given instructions on how to look after your skin in the area being treated, as radiotherapy can make the skin sore.

Treatment sessions

Before each session of radiotherapy, the radiographer will position you carefully on the couch and make sure that you are comfortable. During your treatment, which only takes a few minutes, you will be left alone in the room, but you will be able to talk to the radiographer who will be watching you carefully.

Radiotherapy is not painful, but you do have to lie still for a few minutes while your treatment is being given. The treatment will not make you radioactive and it is perfectly safe for you to be with other people, including children, after your treatment.

Positioning the radiotherapy machine

Side effects

Radiotherapy can cause general side effects such as feeling sick and tiredness. The side effects you get will depend on the area of the body being treated and the length of your treatment. The clinical oncologist and radiographer will advise you what to expect.

Hair loss

Hair will only fall out in the area being treated by radiotherapy, so the treatment for soft tissue sarcomas will not make the hair on your head fall out. The hair that is lost may grow back after the treatment has ended, but is often lost permanently.

Skin care

During radiotherapy, the skin in the treated area may become darker or red and sore. Your radiotherapist will give you advice about skin care at the start of your treatment. Your doctor can prescribe a special cream to soothe sore skin if necessary.

Tiredness and fatigue

As radiotherapy can make you tired, try to get as much rest as you can, especially if you have to travel a long way for treatment each day.

Feeling sick

If nausea and vomiting occur they can usually be effectively treated with anti- sickness drugs (called anti-emetics), which your doctor can prescribe. If you donít feel like eating, you can replace meals with nutritious, high-calorie drinks which are available from most chemists and can be prescribed by your GP. Our section on diet has some helpful hints on how to eat well.

All these side effects should disappear gradually once the course of treatment is over, but it is important to let your doctor know if they continue.

Long-term side effects

After radiotherapy, some people may develop swelling known as lymphoedema. This happens because the lymph glands and vessels can become damaged by the radiotherapy. Lymph fluid (which circulates around the lymphatic system) is unable to pass along the vessels and builds up, causing swelling.

If lymphoedema develops it canít be cured, but it can often be treated and managed.

To help prevent lymphoedema you should try to avoid getting any infection or inflammation in the area that has been treated with radiotherapy. You should try to avoid cuts or grazes in the area and help to look after your skin by using moisturisers if it gets dry.

Radiotherapy to a joint, such as the knee or elbow, may cause it to become stiff. To help prevent stiffness, it is important to keep the joint mobile by using it and doing regular exercise.

Our section on radiotherapy gives more detail about this treatment and side effects.

Chemotherapy for soft tissue sarcomas

Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells. As the drugs are carried in the blood, they can reach cancer cells all over the body.

Chemotherapy may sometimes be given before surgery, to shrink the tumour and make it easier to remove. This is known as neo-adjuvant treatment.

Chemotherapy may also sometimes be used after surgery, to try to destroy any cancer cells that were too small to be removed, or which may have spread to other parts of the body. This is known as adjuvant treatment.

Certain types of soft tissue sarcomas are always treated with chemotherapy. For other types it is very rarely used. Your doctor can tell you whether chemotherapy will be used to treat your type of soft tissue sarcoma.

Giving chemotherapy
Side effects

Giving chemotherapy

Chemotherapy drugs are usually given by injection into a vein (intravenously) but sometimes can be given as tablets. The most commonly used chemotherapy drugs for soft tissue sarcomas are doxorubicin and ifosfamide.

Chemotherapy is given as a session (or cycle) of treatment, which usually lasts a few days. This is followed by a rest period of a few weeks to allow your body to recover from any side effects of the treatment.

The number of cycles you have will depend on the type of sarcoma you have and how well it is responding to the drugs. If doxorubicin is given on its own you will be given it as an outpatient. You will usually be given any other types of chemotherapy as an inpatient, which means spending a few days in hospital.

Side effects

Chemotherapy can cause unpleasant side effects, but it affects everyone differently and any side effects that do occur can often be well controlled with medicines.

Lowered resistance to infection

Chemotherapy can reduce the production of white blood cells by the bone marrow, making you more likely to get an infection. This effect can begin about seven days after treatment has been given and your resistance to infection usually reaches its lowest point 10Ė14 days after chemotherapy. Your blood cells will then increase steadily and will usually have returned to normal before your next course of chemotherapy is due.

Contact your doctor or the hospital straight away if:

your temperature goes above 38ļC (100.5ļF)
you suddenly feel unwell (even with a normal temperature).

You will have a blood test before each cycle of chemotherapy, to make sure that your cells have recovered. If necessary, you may be given antibiotics to treat any infection. Occasionally it may be necessary to delay your treatment if your blood count is still low. We can send you information about how to avoid an infection if you have reduced immunity.

Bruising or bleeding

The chemotherapy can also reduce the production of platelets, which help the blood to clot. Let your doctor know if you have any unexplained bruising or bleeding, such as nosebleeds, blood spots or rashes on the skin, and bleeding gums.

Anaemia (low number of red blood cells)

While having chemotherapy, you may become anaemic. This may make you feel tired and breathless.

Feeling sick

Some of the drugs used to treat soft tissue sarcomas may make people feel sick (nauseous) and vomit. There are now very effective anti-sickness drugs (anti- emetics) to prevent or greatly reduce nausea and vomiting. Your doctor can prescribe these for you. Let your doctor know if you still feel sick, as they can prescribe other types of anti-sickness drugs for you.

Sore mouth

Some chemotherapy drugs can make your mouth sore and cause small ulcers. Regular mouthwashes are important and your nurse will show you how to do these properly.

Taste changes

You may notice that your food tastes different. Your taste will usually go back to normal after the treatment finishes. If you donít feel like eating during treatment, you could try replacing some meals with nutritious drinks or a soft diet Ė our section on eating well has some useful tips on coping with eating problems.

Hair loss

Unfortunately, hair loss is a common side effect of some chemotherapy drugs. You can ask your doctor whether the drugs you are taking are likely to make your hair fall out.

It may be possible to reduce the amount of hair that you lose by using scalp cooling. Cooling the scalp during chemotherapy means that fewer chemotherapy drugs reach the hair follicles, and so the hair is less likely to fall out. We can send you information about scalp cooling.

People who lose their hair often cover up by wearing wigs, hats or scarves. Your nurses can arrange for you to see a wig-fitter to help you choose a style and colour that suits you. If your hair falls out, it will grow back over a period of 3Ė6 months once your treatment has finished.


You may feel tired and have a general feeling of weakness. It is important to allow yourself plenty of time to rest.

Although they may be hard to bear at the time, these side effects will disappear over a few months once your treatment is over.


Your ability to become pregnant or father a child may be affected by some of the chemotherapy drugs used to treat sarcomas. It is important to discuss fertility with your nurse or doctor before starting treatment as it may be possible for men to store sperm and women to store eggs or embryos for use in the future.

Some women may find that the chemotherapy treatment causes an early menopause, and they may have the signs of the menopause, such as hot flushes and sweats. In many cases, HRT (hormone replacement therapy) can be given to replace the hormones that are no longer being produced. Women with gynaecological sarcomas may not be able to have HRT because the cancer may be sensitive to hormones.

You may find it helpful to talk all this through with your doctor or one of the support organisations.


It is not advisable to become pregnant or father a child while having any of the chemotherapy drugs used to treat sarcomas, as they may harm the developing foetus. It is important to use effective contraception during your treatment and for up to a year afterwards. You can discuss this with your doctor or specialist nurse.

Condoms should be used during sex within the first 48 hours after chemotherapy, to protect your partner from any of the drug that may be present in semen or vaginal fluid. Again, you can discuss this with your doctor.

It is important to remember that chemotherapy affects different people in different ways. Some people find they are able to lead a fairly normal life during their treatment, but many become very tired and have to take things much more slowly. Just do as much as you feel like and try not to overdo it.

Biological therapies for soft tissue sarcomas

Biological therapies are treatments based on substances that are produced naturally in the body to destroy cancer cells.

Imatinib (Glivec®)
Sunitinib (Sutent®)

Imatinib (Glivec®)

Imatinib is a type of drug known as a tyrosine kinase inhibitor. It is sometimes used to treat gastrointestinal stromal tumours (GISTs). Imatinib works by blocking (inhibiting) signals within cancer cells and preventing a series of chemical reactions that make the cells grow and divide. The chemical it blocks is called tyrosine kinase. The effects of imatinib are very specific to GISTs. It is taken once a day as tablets.

Imatinib can cause side effects including feeling sick (nausea), vomiting, diarrhoea, a skin rash and puffiness, especially around the eyes. Some of the side effects can be reduced with other medicines.

Imatinib can sometimes control GISTs for several years.

Sunitinib (Sutent®)

Sunitinib is another tyrosine kinase inhibitor. It is sometimes used to treat GISTs that donít respond to imatinib, or if the side effects of imatinib are too much. As well as blocking signals within the cancer cells and preventing a series of chemical reactions that make the cell grow and divide, it helps to prevent the tumour developing new blood vessels. Without blood vessels the tumour canít get the nutrients it needs to survive.

Sunitinib has recently been licensed as a treatment for GISTs, but it may not be widely available. Your doctor can advise you if sunitinib is suitable for you.

Side effects of sunitinib include tiredness, diarrhoea, sore hands and feet, a sore mouth, taste changes and a loss of appetite.