The Work of the Musculoskeletal Tumor Society

If you were diagnosed with bone cancer in the 1970s or earlier, it was a foregone conclusion that you would lose your limb and you probably would not live long past the amputation. Because of a dedicated cadre of orthopedists, however, things have changed substantially in the last 40 years for those who don’t hear the word “benign.”

One of those steadfast orthopedic surgeons is Dr. Richard Lackman, President of the Musculoskeletal Tumor Society. He states, “Prior to the 1970s almost all patients diagnosed with a bone sarcoma had to undergo an amputation…it was all we could do for patients. In addition, 90% of those patients who were told they had osteosarcoma or Ewing’s sarcoma—the two most common high grade bone sarcomas—died from their disease. In the early 1980s things were looking up, with more treatment options becoming available. The efficacy of chemotherapy was improving, and new drugs such as doxorubicin, methotrexate, and cis-platinum changed things radically. These drugs allowed us to pre-treat high grade bone sarcomas which then facilitated limb sparing surgery.”

Ewing's Sarcoma Source: National Cancer Institute/Unknown photographer/artist/Wikimedia Commons

Pushing for these and other developments were 16 orthopedists who got together in the 1970s to change the then status quo for bone cancer patients. Dr. Lackman recalls those early days:

 “Notable orthopedic surgeons from major academic institutions joined forces and crafted what would become the Musculoskeletal Tumor Society. Because of these and other devoted orthopedists, over the years we began to have more options other than just amputation or watching our patients die.”

It wasn’t until the 1980s that surgeons had something concrete (actually, metal or bone) to offer patients for reconstruction. Dr. Lackman: “Even though we were able to pretreat patients with these sarcomas, we still lacked good prostheses…those did not emerge for another couple of years. It was also at that time that bone and tissue banking gave us a good supply of allograft bone, meaning that we had another reconstructive option.”

Not a perfect option, but an option. “In the U.S., prostheses became the standard of care because we found that the complication rate for allografts was too high, ” recalls Dr. Lackman. “Interestingly, in South America, because prostheses are too expensive, they have refined the techniques of allograft reconstruction and have lowered the complication rate associated with this technique. Over time, things have shifted in this country, and reconstruction, rather than amputation, has become the standard of care because we can do it with a reasonable expectation for durable function and a local recurrence rate of less than 10%. At ten years follow-up 80% of patients who underwent proximal femoral reconstruction have required no further surgery in most series. This drops to 70% for the distal femur and 60% for the proximal tibia. This is not as good as regular reconstructive surgery, but these are large operations with substantial stress on the joints.”

The MSTS, a coterie of super specialists, contains roughly 200 members. They struggle against sarcomas and for funding. Sarcomas are only about 2% of all cancers…but if you’re in that number, it is 110% traumatic. “Those patients with the most severe tumors are going to have to endure a cancer that will spread elsewhere in their bodies. We still lose about a third of patients with primary bone sarcomas. They die from disease in the lungs—we really need better drugs to kill the tumors that we can’t remove in the lungs. There is just not enough funding.”

Despite this, says Dr. Lackman, there is progress. “Chemotherapy has evolved to the point where the cure rate for osteocarcoma is 70%; for Ewing’s sarcoma it is 60%. If patients come in and they already have a tumor in the lung we can still cure them but the prognosis is not as good—about 15% of patients come in with disease in the lung…for them the cure rate is only 30%.”

“With regard to soft tissue sarcomas, over the years we have learned that a combination of surgery and radiation can control the local tumor in 90% of patients. The total cure rate is 70% or better even without chemotherapy though most large centers are currently pursuing chemotherapy for large, high grade lesions in an attempt to increase the cure rate for these patients at highest risk. Also, radiation has become more sophisticated, with 3D conformal treatment that spares the adjacent tissue such that complications from radiation are less frequent than they used to be.”

So where are the signs of hope for tumor patients in the orthopedic labs? Dr. Lackman states,

I believe that some of the most promising research in the field of sarcoma treatment has to do with non-surgical advances. For example, targeted drug therapies aimed at a specific tumor metabolic pathway will hopefully over time replace our current drugs that have a lot of associated toxicity.

"Also, developments in the technology of radiation therapy (Intensity-Modulated Radiation Therapy, proton beam radiation, stereotactic radiation) allow for more selective treatment of the tumor with a smaller dose going to normal tissues. Percutaneous treatments such as radiofrequency ablation to heat kill tumors and cryotherapy to freeze kill tumors will also continue to develop. Finally, 3D imaging and surgical navigation currently play a small role in tumor surgery but hopefully this will increase as these systems become more sophisticated and user friendly. All of these will help us take better care of our tumor patients.”

For those who take up the challenge of caring for these very ill patients, this is good news. But who are these orthopedists and why do they choose this path? “As an orthopedic oncologist you can have a very stimulating practice, ” notes Dr. Lackman. “The surgeries are extremely interesting and diverse, something that is especially enjoyable because orthopedics has become so subspecialized. We treat children, adults, men, and women; we treat all areas of the human body. Perhaps the biggest ‘draw’ for those of us who enter this profession is that if someone has cancer and you can save both a limb and a life, then you are having a major impact.”

Treating tumors also means that your career ends up with a sort of cross fertilization. “Orthopedic oncology is a multidisciplinary pursuit that requires a large, dedicated team of orthopedic oncologists, pathologists, medical oncologists, radiation oncologists, diagnostic radiologists, interventional radiologists, reconstructive plastic surgeons, vascular surgeons, and general surgeons who specialize in oncology. This is a reflection of the fact that the best care for tumor patients is usually done at a major teaching hospital...it is difficult to find all of these resources in a small hospital.”

The Musculoskeletal Tumor Society works hard to get everyone on the same page. Dr. Lackman says, “We have numerous activities, all of which are focused on our goal of continuing the dissemination of knowledge and the evolution of treatment. We do this via society meetings, research studies, publications, specific tumor sessions at AAOS, etc. An example of one of these sessions is, ‘Are our attempts to improve surveillance in high grade soft tissue sarcomas working and are they safe?’ The issue is that we want to optimize treatment without harming our patients…but these are rare tumors and no one institution has a tremendous volume of data. We are working towards doing more multi institutional studies in an effort to get a larger study population.”

“Fellowship training began in the late ‘70s and has grown to 12 programs (almost too much). We struggled with reimbursement issues for years, and until recently had the worst reimbursement rate in orthopedics. It was only a year ago that spine was reimbursed at one dollar per unit (based on the Intraoperative Work per Unit Time measure), while tumor surgery was reimbursed at 34 cents. Things have improved somewhat and this may further motivate people to consider orthopedic oncology.”

These vital specialists are needed by patients, and they are needed by their colleagues. The fact is that an orthopedist or a general surgeon may have a tumor patient in front of them and not know how to proceed. Enter the MSTS. “We teach surgeons how to ‘keep out of trouble’ when it comes to tumors as there are lots of pitfalls where it is easy to do the wrong thing. Our annual courses attract hundreds of non tumor surgeons and teach them about the issues involved in, for example, how to approach a patient with no cancer history who reports a painful lytic bone lesion. Another example that we cover deals with soft tissue tumors, making surgeons aware that if a patient has a deep mass, you should not biopsy the mass before obtaining an MRI scan and you should not excise it until you know that it is benign.”

“We serve as regional resources and get calls from local doctors asking help for particular situations. They may just say, ‘Can I email you a picture and can you tell me if it’s something to worry about?’ I’m really pleased that more and more orthopedic surgeons have been sensitized to the fact that improper treatment can harm the patient. That means they more frequently tend to seek out advice.”

From the 1940s to the 2010s, the practice of treating the oncology patient has been transformed—and at the center of that remarkable history is the dynamic and ever forward looking Musculoskeletal Tumor Society.