Our Treatment Approach

Musculoskeletal Cancers

Aggressive, Multidisciplinary Approach
About Bone and Soft-Tissue Sarcomas
Expert Treatment Planning
Focus on Limb-Sparing Surgery
The Role of Radiation Therapy
The Role of Chemotherapy

Aggressive, Multidisciplinary Approach
Bone and soft-tissue sarcomas, also known as musculoskeletal cancers, are relatively rare forms of cancer. In contrast to the large number of patients affected by lung or breast cancer, sarcomas represent only 0.7 percent of all cancers diagnosed annually in the United States. Some 5,600 new cases develop each year. And although the prognosis differs depending on several factors – including the kind of sarcoma, its size and the stage of the disease – patients often can look forward to a 60 percent to 80 percent cure rate.

The Siteman Cancer Center has strong expertise in treating this form of cancer. A multidisciplinary team of specialists made up of surgeons, a medical oncologist, a radiation oncologist and a physical therapist work together to improve patient survival and functional outcome. And they achieve this result using an aggressive treatment plan that often includes chemotherapy and radiation therapy, which allows more patients to undergo limb-sparing surgery.

About Bone and Soft-Tissue Sarcomas
Sarcomas arise in either bone or soft tissue, including muscle, fat, blood vessels or other supporting tissues anywhere in the body. Bone sarcomas often appear in the long bones of the body or around the knee, shoulder or pelvis. Half of all soft-tissue sarcomas occur in the limbs, and 40 percent are located in the trunk and abdomen. They also can emerge in more visible places, such as the face or fingers.

Some bone sarcomas are even more common in children than in adults, representing 6.5 percent of all pediatric tumors. Ewing’s sarcoma and osteosarcoma, generally cancers of childhood, emerge in the first few decades of life. Overall, sarcomas represent the fifth-leading cause of death in children below the age of 15.

Sarcomas most often arise sporadically for reasons that are not yet understood, but occasionally they are linked to genetic factors, especially abnormalities of either the P53 or retinoblastoma gene. Some sarcomas may develop after exposure to certain herbicides, dioxin or vinyl chloride. Others occur in women with chronic lymphedema after breast cancer surgery.

Whatever their origin, the symptoms often are similar. Both children and adults come to their doctor with a lump or mass, sometimes visible and often painful. In adults, most soft-tissue masses are benign; however, it is critical to identify sarcomas as early as possible in the course of the disease.

Expert Treatment Planning
Sarcomas vary in size and location, and they require different approaches to biopsy and surgery. Because an improperly performed biopsy can compromise an operation, Siteman’s experienced, multidisciplinary team meets early to plan an approach to each new case. A very thorough knowledge of anatomy is necessary to determine precisely what kinds of incisions can be made and what type of surgery will yield the best result. In fact, when referring physicians have a patient with a suspected diagnosis of bone or soft-tissue sarcoma, they may wish to refer the patient to Siteman physicians for evaluation even before the initial biopsy is performed.

In the case of soft-tissue sarcoma, for example, this evaluation usually includes a biopsy for accurate diagnosis as well as staging of the primary tumor with magnetic resonance imaging (MRI). Distant disease must be assessed using computerized tomography (CT). These imaging tools help physicians more accurately determine where tumors are and what their location is in relation to surrounding body structures. With that information, they can measure what tissues and length of bone are involved and decide what they have to remove and what they can spare.

A Siteman coordinator works to make sure that patient visits take place as smoothly and efficiently as possible. Typically, that means back-to-back consultations with a surgeon, radiation oncologist and medical oncologist for the patient’s convenience.

Focus on Limb-Sparing Surgery
Our surgeons believe strongly in trying to save patients’ limbs. Most Siteman patients with a soft-tissue sarcoma have surgery to remove the cancer or some form of limb-sparing surgery plus radiation therapy. These highly specialized procedures for very rare tumors are best performed at a center like Siteman, where experts in this area can take an integrated approach to care.

Historically, the situation was quite different. Only a few decades ago, some 90 percent of children with osteosarcomas faced amputation. Now, 90 percent undergo limb salvage, in which surgeons remove the bone or segment of bone involved with the cancer then reconstruct the limb.

Today, Siteman surgeons can replace any joint in the body – knee, hip, shoulder, elbow – with custom-designed artificial prostheses or bone grafts. To replace structurally significant segments of bone, they often use bone grafts. The choice of technique depends upon the situation of the patient.

The Role of Radiation Therapy
Radiation therapy is a major component of treatment whenever surgery would be too disfiguring, would lead to amputation or cannot be performed at all. Some sarcoma patients may undergo only radiation treatment, while others will have radiation therapy before surgery. Still others will have radiation following surgery, especially if the tumor was large or all cancer cells at the edge of the tumor could not be removed.

Radiation oncologists are vitally important members of the treatment team. They deliver therapy through external radiation beams or brachytherapy, internal treatment with radioactive sources laid in or against the tumor location. In general, their goal is to give radiation therapy that targets tumor cells and has little effect on surrounding healthy tissue, minimizing side effects.

The Role of Chemotherapy
In some cases, patients receive chemotherapy for several weeks before they undergo surgery. Then, when the tumor is removed, pathologists examine it to see how much is “dead” and how much is “alive.” If the tumor is largely dead, then the patient is responding well to the chemotherapy and has a better prognosis.

Sarcomas in children – particularly osteosarcomas and rhabdomyosarcomas – led the way in establishing a role for chemotherapy. Initially, physicians used chemotherapy to buy time for children and avoid amputation until sophisticated, customized prosthetics became available. From that experience came an increasing appreciation that chemotherapy was improving patients’ survival.

Now chemotherapy is used for two purposes: to enhance the patient’s response to local therapy or to eliminate any cancer cells in the body that may have already metastasized, or spread. In general, adult sarcomas have not proved to be as sensitive to chemotherapy as childhood sarcomas.