Orthopedic oncologist describes multidisciplinary care

Norton Cancer Institute offers many cutting-edge clinical trials for patients with advanced cancer.

Specialists at Norton Orthopedic Institute and Norton Cancer Institute work together in a team approach for treatment of bone and soft tissue tumors. As an orthopedic oncologist, I work closely with medical and radiation oncologists, musculoskeletal radiologists, and surgical pathologists to determine the best course of treatment for each patient.

Timing of the various treatments is important, and together we develop an individualized plan based upon the patient’s specific diagnosis, extent of disease, and goals of treatment. Our multidisciplinary sarcoma tumor board meets weekly to discuss all new patients diagnosed with bone and soft tissue sarcoma.

With osteosarcoma and Ewing sarcoma, a patient typically receives intensive inpatient chemotherapy before and after surgery, requiring close collaboration between their orthopedic oncologist and their medical oncologist. Most patients with localized soft tissue sarcoma are treated with a combination of radiation therapy and wide surgical resection of their tumor. Sequencing of the surgery and radiation dramatically influences the risks of early and late complications. This necessitates detailed discussion among the patient, radiation oncologist, and surgeon to develop the optimal treatment plan.

Norton Cancer Institute offers many cutting-edge clinical trials for patients with advanced cancer. Skeletal-related events such as pathologic fracture are among the most common reasons for unplanned patient withdrawal from cancer trials. I work closely with our hematology and oncology clinical investigators to screen and treat patients for bone lesions that may threaten their successful participation in potentially lifesaving trials.

Incidental finding on imaging obtained for non-tumor issues is the most common reason providers refer patients to me. Typically, the imaging report mentions the possibility of cancer, creating great anxiety for the patient. I carefully correlate the patient’s history and physical examination with my personal review of the imaging. Typically, I will order additional imaging or laboratory tests to clarify the diagnosis, schedule repeat imaging at a later date to assure stability of a benign appearing lesion, or perform a biopsy to attain a definitive diagnosis. Most lesions are benign; however, this is the entry point for many patients into their cancer care.

Approximately half of patients with metastatic cancer develop bone metastases. Many patients fear loss of independence, becoming a burden to family, and severe pain associated with pathologic fractures more than death from their cancer. Studies have shown skeletally related events to be one of the greatest drivers of impaired quality of life and costs in cancer patients. Operations for bone metastases are my most frequent surgical procedures.

Prophylactic fixation with metal rods or plates and screws is likely the orthopedic oncology intervention with which most clinicians are familiar. The ability to positively impact overall treatment by obtaining new biopsy tissue of the patient’s progressive metastatic disease is perhaps an underappreciated aspect of these procedures. Next generation sequencing of the metastatic tissue permits my medical oncology colleagues to alter treatment in cases which may have been terminal in the past.

The increasing use of metastasectomy for isolated or oligometastatic disease is another underappreciated aspect of orthopedic oncology. In patients with limited metastatic disease, I often will perform more aggressive resections similar to sarcoma surgery in an effort to remove all macroscopic disease — which has been shown to improve overall survival.

Minimally invasive interventions with the use of computer navigation are newer tools in orthopedic oncology, which can be a great benefit to patients unable to tolerate larger, more invasive procedures. Tumors deep within the pelvis or adjacent to joint surfaces — which previously required long incisions and deep dissections — now can be accessed through percutaneous placement of needles, thermal probes, and screws. Function preserving and pain alleviating procedures such as biopsy, thermal ablation, cement injection, and screw fixation can be performed in this manner. Typically, these patients are up walking and return home the next day.

Historically, pathologic fracture was viewed by some as an end-stage event in cancer care. With advances in medical and radiation oncology resulting in dramatically improved survival for many types of cancer, one might conclude that the role of orthopedic oncology has diminished. In fact, my experience has been that patients living longer with cancer has resulted in greater need of orthopedic oncology care. I often tell patients that fixing a symptomatic bone metastasis is not a failure of their cancer treatment. Instead, surgery is an opportunity to improve their quality of life which we expect to be measured in years rather than months as in the past.

Norton Healthcare has a long tradition of providing orthopedic oncology care. It has been my pleasure to return home after training and working at major cancer centers in St. Louis, Missouri; Salt Lake City, Utah; and Los Angeles, California. I have the good fortune of seeing patients from throughout the region, especially Western Kentucky and Southern Indiana. I look forward to continuing to build and refine our orthopedic oncology program with the help of my wonderful Norton Orthopedic Institute and Norton Cancer Institute colleagues.

George T. Calvert, M.D., is an orthopedic surgeon and orthopedic oncologist with Norton Orthopedic Institute.

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