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Treating Cancers That are Bad to the Bone and Soft Tissues

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LOUISVILLE Like many medical doctors, Rodolfo Zamora, MD, is the type of person who enjoys problem solving. He liked numbers, logic and thinking about how to fix problems. Early in his medical training, one particular problem directed his ultimate career path.

“The most difficult part is seeing pediatric patients with cancer. The parents are suffering more than the child. The strong one in the family is often the child who has the cancer,” Zamora says. “After I saw a few bone and soft tissue tumors in patients, especially young patients, I decided to do orthopedic oncology early in my residency.”

Today, Zamora is an orthopedic oncologist with UofL Physicians and UofL James Graham Brown Cancer Center and is a faculty member of the UofL School of Medicine. His journey, however, began in Santiago, Chile, where he was born. The second of three boys in the family, his father is an engineer and his mother is a social worker. Both his brothers are lawyers. Zamora, who notes that the medical track is a little different in Chile, opted to attend medical school immediately after high school.

After medical school, internship and residency at the University of Chile, he took a year of training at the National Chilean Reference Center for Orthopedic Oncology. He was hired to work there two additional years, practicing lower extremity trauma and orthopedic oncology.

Zamora left Chile and did a two-year research fellowship at Mount Sinai in New York. He then did a trauma fellowship at UofL in 2014, followed by an orthopedic oncology fellowship at the University of Washington School of Medicine in Seattle. He and his wife then decided to move back to Louisville where they would be closer to her family in Illinois.

“I saw the need here. No one was doing orthopedic oncology,” Zamora says, noting that he splits his time between orthopedic trauma and orthopedic oncology. “We have five residents per year. Before I came, there was not a formal orthopedic oncology program for the residents. I created an orthopedic oncology course that is given once a year. Physicians, residents, and fellows from different specialties come. My plan is to create a regional sarcoma center that can be the referral place for patients with bone and soft tissue tumors.”

An Expanding Patient Population

Patients of all types come as well. Most of his primary tumor patients are under the age of 20. The other big population are patients who have cancer in another part of the body, resulting in bone lesions. Generally, those patients are 50 and older. His trauma patients come from all age groups.

Zamora acknowledges that bone cancer is particularly scary for patients both young and old.

“In general, bone tumors are not a tumor we want to have. They are more aggressive than most variations of breast cancer or thyroid cancer,” he says. “Most of my patients who are referred to me with a bone tumor think, ‘I’m dying.’ We need to let them know that there is always a hope. The message that we need to send is to have hope. We can save the lives of those patients if we do the diagnosis in good time.”

The diagnosis generally starts with the patient complaining of pain. If they’ve had no trauma to the painful area, that’s an indicator that an x-ray is needed. Additionally, if a part of the body that did experience trauma and pain persists longer than expected, it’s another indicator to have an x-ray.

“The overall survival is good if we are able to find the tumor at the right time,” Zamora says. “That’s why it’s so important to teach orthopedic surgeons about bone tumors. If they don’t see it, they don’t suspect what’s underneath. It’s important to teach them the cases where they need to take an x-ray and make sure there is nothing in the bone. If we do it late, it’s a very aggressive tumor.”

Zamora says that fever, chills, or lost weight are indicators that the tumor has already spread. However, if the tumor is still located only in the bone, Zamora says the five-year survival rate is 70 to 80 percent. Moreover, there is seldom a need for amputation.

“The case is very rare that we need to do an amputation to control the tumor,” Zamora says, adding that the extremity can be saved in about 95 percent of cases. “There are multiple studies that have shown that the overall survival rate does not increase by doing an amputation. If we are able to do a resection, leaving an extremity that is functional, it’s always better than doing an amputation. For us in orthopedic oncology, the main goal after resecting the tumor is to save the extremity.”

Zamora says bone tumors are frequently found around the knee. Other locations such as proximal femur and proximal humerus are less frequent. If a patient under 30 years old is complaining of pain in the knee but there is no history of trauma, Zamora recommends x-raying both the knee and the hip.

Once bone sarcomas are suspected on imaging, the protocol is a biopsy to confirm the diagnosis. “In our center, once the tumor is diagnosed, clinical cases are presented on a tumor board where, after a deep discussion of every case, the treatment plan is decided. Most of the times the treatment includes chemotherapy, surgery, and more chemotherapy, say Zamora.

Treatment of bone tumors involves an entire team of providers, including the orthopedic oncologist, medical oncologist, musculoskeletal radiologist, and musculoskeletal pathologist. Nurse practitioners and plastic surgeons are also commonly part of the team.

“The treatment of any kind of bone tumors is complex,” Zamora says. “It’s not just surgery. It’s not just chemo. The first step of treatment is chemotherapy, and this setup is mostly done by the oncologist. They will be in touch with the patient frequently. As an orthopedic oncologist, I make the diagnosis and set up the time of surgery which usually happens within three months of diagnosis and chemotherapy. After surgery, patients need postoperative chemotherapy.”

Soft tissue sarcomas are a complex disease. The treatment relies mostly on the local control of the tumor, meaning the surgical resection of the tumor. Radiotherapy plays an important role in the soft tissue sarcoma treatment and can be administered before or after surgery. “Thorough surgical resection is the cornerstone of the treatment for soft tissue sarcomas. Chemotherapy is discussed case by case and there is still not a defined standard of care of chemotherapy for soft tissue sarcomas,” says Zamora.

Precision through Technology

One significant improvement in the surgical process is the Surgical Guided Navigation, says Zamora. Much like the GPS in a car, the system directs the surgeon by synchronizing the MRI and CT scan with the real patient at the moment of the surgery. The importance of this precision is that it allows the surgeon to save more of the healthy tissue and also be accurate with the tumor resection that was planned. “The difference now is that I can be very accurate where I’m resecting the tumor, follow my pre-surgery plan, and leaving as much healthy tissue as possible,” he says.

This surgical precision is especially necessary since there is no targeted chemotherapy for bone tumors as is available for other types of cancer. “It’s essentially the same chemotherapy that we’ve been using since the 1970s with minor modifications,” Zamora says.

While most bone tumor patients are younger, most of the soft tissue sarcomas are in patients over 60 years of age. These are most frequently found around the thigh. Few soft tissue sarcomas respond to chemotherapy, so the treatment is radiation before and after surgery. In all the cancers that Zamora treats, he says early diagnosis is the biggest factor in patient outcomes.

“Bone tumors are many times confused with metastatic lesions, meaning a patient had breast cancer, for example, and the tumor spread to the bones,” Zamora says. “That kind of bone tumor does not have a good prognosis. My function as an orthopedic oncologist in that type of tumor is not to cure the disease, but to improve the quality of life.”

It’s a difficult reality for anyone, but particularly for a doctor determined to find answers and deliver hope.