Sarcomas Cancer

These are cancers of the skeletal system-- the tendons, muscles and bones. They can be dangerous cancers and must be treated aggressively these cancers can occur in any part of the body. Any unfamiliar lump or bump found under the skin could be a sarcoma. Treatment can be either surgery alone or combined with radiation therapy. Chemotherapy is sometimes needed to stabilize the tumor and is seldom curative. Sarcoma of Bone Cancers arising in bone are rare. They make up a small percentage of all cancers. Osteogenic sarcomas and Ewing’s sarcoma are the most prevalent types and these commonly occur in children and young adults. Tumors of the marrow are discussed elsewhere (Multiple Myelomas and Lymphomas); Ewing’s Sarcoma is also discussed elsewhere. Osteogenic tumors grow slowly in the beginning, causing very little pain and are often confused with arthritis. Consequently, they are often ignored. As they grow locally, they compress the surrounding bone and give a characteristic view on x-rays. When the cancer spreads from the bone, it must metastasize in the blood stream, as bone has no lymphatic vessels. The cancer will often spread locally within the bone from which it starts, by migrating along the inside of the bone. Almost all Osteogenic sarcomas have spread before they are diagnosed. A diagnosis can often made from the appearance of the cancer on the X-ray but a definite diagnosis is made from the pathological biopsy. A chest x-ray and a bone scan are often done to stage the cancer, as lung and bone are frequently the first locations of spread. An MRI of the bone will give a better definition of the cancer and demonstrated extra-osseous extension. An angio-gram of the end of the bone will display the cancer’s blood supply and this information is essential, if a limb-sparing procedure is considered. PET scan are now being done and demonstrate hidden metastases. A diagnosis should be made with a core biopsy needle. This can be more accurate if done by a radiologist, using CAT-Scan guidance. Open surgical biopsies should be avoid as they tend to cause local recurrences. Treatment A surgeon, a radiation therapist and a medical oncologist must evaluate all patients with this disease. Each sub specialist has a significant amount to offer. The treatment of Osteogenic Sarcoma is divided into the treatment of the system disease and treatment of the local disease. The old treatments of Osteogenic sarcomas – resection of the primary cancer - were dismal, less than a twenty percent chance of a five-year survival. Now with neoadjuvent chemotherapy, using drugs such as Adriamycin, cis-platinum, carboplatin, high dose methotrexate and others, followed by aggressive management of the primary cancer, is giving five- year survival rates of more than sixty percent. This is a much-desired improvement because it is now realized that most patients with Osteogenic sarcomas have already metastasized before they are diagnosed. So the systemic disease must always be controlled before the primary is attacked. The primary cancer is treated with a combination of either intraarterial chemotherapy or radiation therapy or both. These treatments may be given concurrently or sequentially as determined by the therapists. All efforts are made to spare the limb involved with the cancer so the patient will remain whole after all therapies have been administered. At the end of systemic and local therapy, the surgeon may have to remove dead tumor from the treated bone and then strengthen it again with different types of fillings or replace bone with prosthetic devises. The treatment of bone cancer has become an art form and is a highly specialized area of medicine. The treatment of Osteogenic sarcomas is complex and difficult. The discussion here is meant to be educational and no decisions about treatment should be made on this short discussion. If you wish to know more about the treatment of this cancer or the drugs that are used to treat it, call my office for an appointment. Sarcomas of Fibrous Tisues, Muscle or Bone. Sarcomas are malignant tumors arising from the skeletal system. They can arise from bone, muscle, fibrous tissue or fat. Their cause has remained a mystery. They can arise in any part of the body. About forty percent of them arise in the upper extremity; fifteen per cent in the lower extremity and thirty percent in the abdomen, along the backbone. They present as painless enlarging lumps under the skin or as masses in the abdomen. They will sometimes present as a constant pain in a localized part of the body, which cannot easily be explained. A careful MRI of that painful part of the body should be done to rule out an early progressive cancer. There are four types of sarcoma: Malignant Fibrous Histiocytomas. Liposarcomas. Rhabdomyosarcomas. Osteogenic sarcomas. Malignant Fibrous Histiocytomas. These tumors present as a painless mass, mostly on the lower extremity, but can also show up in the arms or back. They grow slowly at first and as they get larger, they can become painful. They may start as benign lesions but can then become malignant and can spread to the near by lymph node. The diagnosis is made with a biopsy and under the microscope; the cancer is classified as being either low grade or high grade. The former tends to grow slowly; the latter has a high tendency to metastasize. Treatment The best treatment for this disease is surgery. The surgeon should make sure to remove the cancer totally and to do that he may have to take a wide margin of healthy tissue around the tumor. Depending on where the cancer is, this may be difficult. These tumors tend to re-occur locally so if the tumor is greater than two centimeters in size, external radiation therapy is often given. The external radiation kills any residual cancer cells that may be left behind after surgery so the cancer does not re-occur. If the cancer spreads away from the primary site, then it is very difficult to cure it afterwards. This cancer is not very responsive to chemotherapy so surgery and radiation are the two best mainstays of treatment. New drugs are being sought to better control this disease. Liposarcomas Liposarcomas are malignant tumors that start in normal fat cells. Some of these malignancies start in benign lipomas and therefore any benign lipoma that begins to grow should be held in suspicion for becoming malignant and should be removed. Most Liposarcomas start in the retroperitoneal space (by the backbone, behind the abdomen) and can become quiet large before they are detected. They are usually painless and are usually slow growing. Treatment Surgery is usually the best and only treatment for this cancer. It is not always possible to remove it completely because it tends to infiltrate around vital, and unrespectable organs like the kidneys, the spleen and the liver. So after the cancer has been debulked with surgery, it may grow back again and this type of management (repeated resections) may be the best treatment. The cancer is not very responsive to radiation therapy and chemotherapy, so far, has not been very successful. Newer drugs are being sought to better control this disease. Rhabdomyosarcomas These are malignancies that start in muscles, usually in the legs but can also occur in the arms or in the back. They are painless lumps that grow slowly in the beginning. Because they cause no pain, they are allowed to become large because the patient does not suspect that they are serious. As they get larger, they can infiltrate around the nerves and blood vessels and therefore can be difficult to remove without causing injury to a nerve or can reduce the blood flow to an organ. As these cancers age and grow large, they can spread to the surrounding areas and to the local lymph nodes. The diagnosis is made with a biopsy and the cancer is graded, dependent on the number of growing cells (mitosis) that are, microscopically, seen in the biopsy. It is classified as being high grade, if many mitotic figures are seen and low grade if a few are seen. Treatment Surgery is again the best treatment. However sometimes, because of the location of the cancer, it is difficult to resect the cancer without interfering with some vital part and therefore presurgical treatment with either radiation therapy or chemotherapy may have to be done. If this cancer involves an arm or leg, then attempts are made to spare the limp. Chemotherapy can be infused into the artery supplying the cancer in an attempt to decrease the cancer’s size. Radiation therapy, either external or brachiotherapy, can be used to further decrease the size of the cancer. When the cancer has been made small, then it is more easily to resect it without losing a limb. The treatments for all these different types of sarcomas are complex and difficult. If you wish to know more about the disease or the treatments, we use to control them, please call my office for an appointment.