Over the past 10 years, tremendous progress has been made in the medical and surgical treatment of bone and connective-tissue cancers, collectively called "sarcomas." Advances in reconstructive surgery, chemotherapy and radiation therapy have made long-term survival with limb-sparing treatment the rule where it once was the exception. Because tumors of bone and soft tissue are relatively rare, a growing number of medical institutions have realized the need to establish multidisciplinary teams to provide appropriate diagnosis and treatment.
In September, 2001, the Division of Musculoskeletal Oncology was established by the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, and the OSU Comprehensive Cancer Center. The OSUCCC/James is the only center in central and southeastern Ohio dedicated to sarcoma research and care. "We are committed to researching cancer in all its forms and in providing the full range of cancer care services," says David Schuller, MD, executive director of The James and deputy director of the OSUCCC. "For a growing field such as sarcoma research and care, in which the number of experts is limited, we knew it would require a national search to find the top physician-researchers to lead our program.”
Leaders at The OSUCCC/ James and the OSU College of Medicine and Public Health recruited two musculoskeletal oncology specialists to coordinate the diagnostic, surgical and multidisciplinary care of patients of all ages with benign and malignant bone and soft-tissue tumors. Gary Bos, MD, and Joel Mayerson, MD, are among a rare breed of orthopaedic surgeons who focus their expertise on sarcoma care and research. Of the more than 10,000 orthopaedic surgeons in the United States, about 100 or so specialize in musculoskeletal oncology.
"We're a pretty subspecialized group of surgeons," says Mayerson, a Johns Hopkins School of Medicine-trained musculoskeletal oncologist and former chief of the Section of Orthopaedic Oncology at the Medical College of Ohio in Toledo. In the year since his appointment, Mayerson has been busy treating patients from central Ohio and surrounding areas, and establishing treatment protocols for sarcoma diagnosis and treatment at The James.
Most of his early referrals came from Lawrence Weis, MD, who, until his retirement last spring, was the region's only musculoskeletal oncologist. Mayerson's arrival ensured that patients in central and southeastern Ohio would continue to have a musculoskeletal oncology specialist in their backyard. "I had a wonderful position at the Medical College, but I was very impressed with the excitement and opportunity for growth here," he says.
Bos joined the OSU staff in September, 2002, as chair of the Department of Orthopaedic Surgery. The 18-year veteran of musculoskeletal oncology and bone reconstruction, who served previously at the University of North Carolina, Oregon Health Sciences University and the Mayo Clinic, is a leading expert on the treatment and removal of soft-tissue sarcomas. Bos' leadership ties together the clinical, academic and research aspects of a truly multidisciplinary strategy to address sarcoma research and care.
"OSU has always been a strong clinical center for orthopaedics and musculoskeletal care," says Bos, who describes his role as a "planner and dreamer" for the department. "The mission of this department is to extend the Medical Center's three-pronged emphasis on clinical care, teaching and research into musculoskeletal oncology. Through this collaborative focus, our goal is to find new treatments and ultimately develop them to patient care, while students learn and carry on the work for future generations."
An Evolving Specialty
Of the approximately 10,000 new cases of sarcoma diagnosed each year in the United States, about 75 percent are soft-tissue sarcomas in adults. The remaining 2,500 are bone sarcomas, which afflict mainly the hip, thigh, knees and upper arms of children. The incidence of sarcomas of the bone and soft-tissue is low compared to other cancers, but each case is serious. If sarcomas metastasize to other organs, the spread of disease is difficult to control.
Before recent advances, amputation was the prevalent solution to stem the spread of malignant sarcomas. But breakthroughs in patient care have made amputations less common and have greatly improved survival rates. New chemotherapy, radiation and surgical techniques have increased the long-term survival rate from only 33 percent 20 years ago to 60 percent today. And like all forms of cancer, the chances of surviving sarcoma improve dramatically when the disease is detected and treated early in its development. Unfortunately, sarcoma's rarity can hinder its discovery. That is why a musculoskeletal oncologist trained in deciphering the telltale signs of sarcoma is an important part of the early-detection process.
To standardize sarcoma treatment in the OSU Department of Orthopaedic Surgery, the Division of Musculoskeletal Oncology has created a multi-disciplinary sarcoma team of care providers. This team comprises medical oncologists, radiation oncologists and radiologists who focus on early detection and treatment. The musculoskeletal oncology specialist ties the team together and stays abreast of the latest treatment protocols and research findings. "An outstanding infrastructure exists at OSU and The James to incorporate new treatment protocols for patients," Mayerson says. "With the team approach to testing and treatment, we're able to coordinate advanced imaging studies, minimally invasive biopsy techniques, and preoperative chemotherapy and radiation therapy to the maximum benefit of our patients."
Preoperative measures include a full workup of X-rays, MRI, CT and, occasionally, PET scans. With a clear picture of the tumor's characteristics and size, the sarcoma team can formulate an effective preoperative plan that can shrink the tumor and save the limb. The Division of Musculoskeletal Oncology also works with Children's Hospital of Columbus to ensure clear communication and maximum help for young patients battling the disease.
Saving Life and Limb
In recent years, treatments for sarcoma have progressed enormously, with significant increases in both life expectancy and quality of life. Powerful new drug treatments and surgical options are rapidly changing how cancer is treated. "We have made enormous strides," Mayerson says, noting that preoperative chemotherapy and minimally invasive surgical techniques combine to save a limb 85 percent of the time.
"In the past, surgeons had no choice but to resort to disfiguring interventions such as amputation of a limb or surgical removal of a significant amount of bone and tissue," he adds. "Thankfully, there are other options now, both in saving limbs and in reconstructing areas of large resection." For example, bone sarcomas in children make surgery problematic because their muskuloskeletal systems are still developing. The advent of the expandable prosthesis in the mid-1980s solved the growth issue. The design has recently been improved to the point where extending the devices can be done nonsurgically on an outpatient basis.
Chemotherapy, once considered a futile effort against soft-tissue tumors, is now proving helpful in controlling growth. Additional research is in progress to determine which chemotherapy treatments will allow surgeons to take less tissue and bone. "Advancements in chemotherapy, radiation therapy and expandable prosthetic devices have had a huge impact on our ability to restore patients to a normal quality of life," says Bos. "We're able to take smaller margins of tissue and bone in surgery. We save more limbs and preserve more function."
On the Research Front
In addition to providing high-level patient care, The OSUCCC/James is also committed to sarcoma research. Researchers are exploring the origins of sarcoma at the genetic level, testing new drugs aimed at slowing or halting the progress of sarcomas, developing treatment strategies with available drugs, and finding ways to help the body's own immune system subdue sarcoma cancer cells.
Krysztof Mrozek, MD, PhD, research scientist in the Division of Hematology and Oncology at the OSUCCC, is a leading expert in cytogenetics in cancer. He is working with the Division of Musculoskeletal Oncology to study the genetic alterations of sarcoma tumors.
Bos is confident that future breakthroughs in cytogenetic research will help uncover the genes that contribute to the origin of tumors. Additionally, he hopes chromosome aberrations are found to help the diagnostic process as well. To that end, the sarcoma program will soon add a new section of molecular genetics to study and develop new treatments. If the great advances of the past decade are any indication, the next 10 years will bring even more and better options for sarcoma diagnosis and care, and physician-researchers at The OSUCCC/James will be leading the way.