muscles and soft parts of your body can develop cancers?

Well, they can, and as a group, they're called sarcomas.

Stay with us.

As we talk with surgical oncologist Doctor Michael Egger about the ins and outs of sarcomas.

[MUSIC] Next on Kentucky Health.

>> Kentucky Health is funded in part by a grant from the Foundation for a Healthy Kentucky.

[MUSIC] >> If I asked you to name some areas of the body that develop cancers, I suspect that most would say either the lungs, breast, prostate, colon, or blood system.

However, because of both rarity and unfamiliarity, many of us are unaware that cancers may develop within any organ system of the body, including our blood vessels, bones, fat, tissues, connective tissues, and muscles.

Cancers originating in these structures are called sarcomas.

Sarcomas arising in the bones of our extremities may be diagnosed early in their course and easier to treat.

However, sarcomas originating from soft tissues deep in the abdominal cavity may not be recognized until they are advanced and therefore more difficult to treat.

Though there are almost 100 subtypes of sarcomas, as a group, they are rare and account for 1% of all adult cancers.

Unfortunately, they are more frequent in children and account for 15 to 20% of all types of cancers diagnosed in young people.

There are several risk factors for developing sarcomas, and they include inherited genetic defects, radiation exposure, and exposure to environmental pollutants.

The treatment may be complex and often requires the combined efforts of multiple medical specialties to give us a better understanding of the presentation, treatment, and complexities of sarcomas.

We have as our guest today, Doctor Michael Egger.

Doctor Egger is a graduate of the Emory University School of Medicine in Atlanta.

He completed his surgical residency at the University of Louisville and then a fellowship in surgical oncology at the MD Anderson Cancer Center in Houston, Texas.

Upon his return to Louisville, he earned his master's in public Health in biostatistics at the University of Louisville School of Public Health and Information Sciences.

He is now the Deputy Director for Quality and Outcomes at the University of Louisville Health Brown Cancer Center, a practicing surgical oncologist and an associate professor in the Department of Surgery, Division of Surgical Oncology at the University of Louisville Hospital.

Doctor Egger Michael, thank you very much for being with us today.

>> Thanks for having me.

>> How did you get into surgery?

Well.

>> I always wanted to do medicine, I think, when I was a young kid.

My first interest in surgery was orthopedics.

That's kind of when you're.

When you're young, you know, you're an athlete or something like that.

That's your first interface with doctors, right?

So I thought I wanted to do sports medicine.

I was actually like an athletic trainer when I was in high school.

And then ultimately in college, I did a sort of an internship with a plastic surgeon in Louisville and fell in love with the operating room.

Confirmed.

That's what I wanted to do.

And then I sort of my path went into general surgery and then cancer surgery after that.

>> What was it about cancers that attracted your attention?

I mean, obviously you're a very bright guy doing a whole lot of stuff.

So how did you get there?

>> Certainly the patients.

Right.

You know, my family had an experience with cancer when I was a young kid, and that was very impactful.

But but, you know, cancer patients, I really enjoy working with them.

You know, you really sort of lead them through a very difficult point in their life.

What I like about surgical oncology is you sort of develop this longitudinal relationship.

I'm part of their care really, throughout their disease.

I have a long term follow up with them.

I find the research interesting, challenging at times, certainly.

And the operations can be simple.

Sometimes it can be rather complex.

>> If you had to do it over again, would you tell the young kid to do it?

Of course.

There you go.

Nothing like being a surgeon.

So as a surgical oncologist, obviously you're dealing with cancers.

So we call something sarcoma.

But then we say cancer.

Are they one and the same thing.

>> So all sarcomas are cancers right.

But not all cancers are sarcomas right.

You alluded to it at the top.

So sarcomas it's very broad categorization of what a type of tumor right.

I always I always tell patients, you know saying you have sarcoma is like saying you have an automobile, right.

It could be a car.

It could be a truck.

It could be a fast car, big car, semi truck, trailer tractor.

Right.

It can be all these different things.

And it's because it's just what you alluded to.

So sarcomas come from all the stuff, bits and parts of our body that put us together something like colon cancer, something like lung cancers typically mostly 3 or 4, maybe different subtypes.

Right.

But like you said, somewhere 50 to 100 different subtypes of sarcomas depending on the cells from which they arise.

>> So how do you classify it then.

>> So one two broad categories sarcomas from the bone and then sarcomas from the soft tissue.

But even within those categories there's there's multiple classifications.

And it's the pathologist who do it right.

They have these categorizations.

They have the way that they're described either microscopically genomically etc.

So that's I mean, it gets more and more, they keep kind of coming up with more and more as we sort of learn more about these different subtypes.

>> So a lot of it is based on the tissue from which it originates.

And then you add on a whole bunch of adjectives after that.

>> Absolutely.

Right, right.

>> Wow.

That's pretty good.

Who gets these things?

>> Anybody can get them.

Really.

So there's you know, most of them are sporadic.

So you alluded to some of the risk factors that we know about.

But you know when most patients ask me why they got them I say it's really bad luck.

They are some of the more common cancers you can get in children.

In adults, they're less common.

And there are different types.

The type that pediatric patients get are a little bit different than the ones that adults get.

But really, really anybody there's certain subtypes that are associated with exposures or certain risk factors.

But mostly it's bad luck.

>> Why do we see it more often in kids?

>> There are different types.

So those are the types that are in.

Kids are very different types, different kind of cell lines.

And it just happens to be that that those develop in children.

So if you think about adult cancers, many adult cancers are related to long term exposure to bad things.

Right.

Lung cancer with cigarette smoking, melanoma with sun exposure, etc.

You know, pediatric cancers are different, right?

They don't necessarily arise from sort of long term exposures or long term DNA damage.

They get switched on a little bit differently and they act a little bit differently.

>> Are there things that we can do to mitigate the risk of developing a sarcoma overall?

>> General health recommendations, right.

You know, live live right.

Eat well, exercise things like that will reduce your risk of developing any types of cancers.

There are certain types of sarcomas that are associated with very specific risk factors.

You mentioned this at the beginning.

So we do know that some sarcomas are related to radiation exposure.

Some of that is radiation treatment for previous cancer.

>> Oh really?

>> Okay.

That's the most common one that we would see with something like that would be breast cancer.

So women who get radiation treatment for their breast cancer ten, 15 years down the line can develop a certain type of sarcoma in that area.

Now that's an example of that.

But I don't want that to make somebody think, oh, they shouldn't get radiation therapy because they are worried about getting sarcoma down the road.

They need to treat the cancer that's in front of them.

And radiation is typically a very strong part of that.

Other environmental exposures.

And you in the audience may be interested in this.

So you mentioned exposure to chemicals.

So Voluntour polyvinyl chloride.

Vinyl chloride is related to a specific sarcoma of the liver.

And that was actually first described here in Louisville in Rubbertown.

>> So that's interesting.

Have we seen a change in the frequency of sarcomas.

>> Now there's a rising incidence like there are for most cancers.

Yes.

>> Any difference in sex.

Male female.

>> Slight predominance in male which is typical of a lot of cancers actually.

>> Why is that?

>> I don't know if men live live worse or there's some thoughts of estrogen exposure maybe being somewhat tumor suppressive in general, but perhaps some of the risk factors that are associated with developing cancers may be higher in men.

>> So much for live moss, I guess.

What are the more common sites where we're seeing sarcomas?

>> Most most common area is in the extremities.

About 60% are in the arms or legs.

About 30% would be sort of in the chest or abdomen, and 10% are in the head or neck.

>> Does that mean the bone is more likely to be the source of sarcoma?

Or is it just because just finding it.

>> So that's probably part of it.

Right.

So the long bones are areas where you can get sarcomas right in the extremity, but then the extremities have a lot of the other soft tissues that make us up.

Right.

So you talked about muscles, tendons, cartilage, joints, things like that.

Sarcomas can arise there as well.

>> It seems like though when you're talking about the bones and I guess I'm thinking about kids too.

These are areas where you're having a rapid turnover of cells or a lot of mitotic activity, which suggests to me that there's a chance an error could take place.

Am I wrong in thinking that when you're seeing this stuff in the bones and in the kids?

>> So I think that's true, and that's true in any type of cancer, really.

So most cancers arise from some error in replication.

Right now our body is designed to deal with that.

You and I probably have cancer cells that just formed in our body while we're talking through some error of replication.

But our body, maybe with an intact immune system or other sort of error detection response, identifies and eliminates those cells.

What happens in cancer?

Somehow those cancer cells that get turned on can evade that response and grow and spread.

>> Gotcha.

Is there a typical presentation or does it vary by site of origin?

>> It varies by site of origin, something on the extremity.

A lot of times patients will come in and say, you know, they had a trauma, they hit their hip or something like that, and then they noticed maybe a bruise on their thigh or a hematoma, and it hasn't gotten better.

What usually what we think happens in those situations where they probably had a very slow growing tumor.

And, you know, this this trauma was sort of incidental.

It was not caused by that trauma, but it just sort of brought attention to it.

So that's in the extremity, what you can sometimes notice a little bit sooner than others, certain types of sarcomas, like retroperitoneal sarcomas, which are in the abdomen, are sort of way back in your belly.

And they can grow very slowly over time.

So by the time you see them, it's this sort of vague constellation of symptoms that have gradually worsened over time.

But they can be quite large once you finally figure out what's going on.

>> So there's nothing like when a person who has a lung cancer may have a cough or coughing up blood or colon cancer, abdominal distension, change in stools, urinary.

I mean, you don't get anything that's kind of specific to that area.

>> Not necessarily.

But remember what we talked about.

Right.

Like there's so many different types of sarcomas.

Right.

They can arise from so many different areas.

Some grow fast, some grow slowly.

And so the presentations can be quite varied.

>> So I would imagine then this lack of specificity with symptoms.

And given all the myriad of locations, this can be obstacles to making a diagnosis.

Or are there other things that lead to delays in diagnosis?

>> So it's it can be difficult to figure out what's going on.

Right.

And and I think one thing, every lump or bump that you have is not a sarcoma.

Right.

>> It will be after the show.

Right.

>> So sometimes you know, the most common benign tumor that somebody might have a regular surgical excision for lipoma or something like that.

Right.

And every once in a while you get fooled.

And when you remove that tumor, you realize, oh, actually, this is this is a more malignant sarcoma.

So we sometimes diagnose them that way when, when they're removed for what was thought to be a benign tumor and it turns out to be malignant, but other times they just sort of grow slowly over time, but eventually they cause enough pain or symptoms that it prompts a biopsy.

>> Does the lag between the diagnosis or recognition of the problem from the time it starts?

Does that affect the outcome for the patient?

>> So larger tumors would potentially have a higher chance of spreading.

Right.

And so sometimes more advanced tumors by the time they're diagnosed they may have metastases.

They may have already spread.

Now that being said, very small sarcomas can still be very aggressive and spread even even when detected early.

>> How do you go about making the diagnosis?

>> Biopsy is the typical way.

So we need a tissue diagnosis.

The most common way now that we do that would just be with a needle biopsy a core needle biopsy.

So you take a sampling of the tumor through a needle.

Take a couple cores.

The pathologist looks at it, does their tests and determine what kind of what kind of tumor it is.

Every once in a while we talked about where it's incidentally excised.

So maybe the whole tumor was removed because we think it was a benign tumor.

And then the diagnosis is made that way.

>> But if you're seeing a person who complained nonspecific abdominal pain or has a little something on the arm or any x rays or role for that sort of thing that start the cascade.

>> So not every lump or bump needs an MRI and biopsies, etc.

Well now.

Yeah.

So again, the vast majority of time somebody's got a little something on their elbow or shoulder or something.

It's it's a benign lipoma.

It can be excised.

It should be checked, you know, under pathology.

But they don't necessarily need any workup.

You know, the sort of, let's say maybe risk factors or alarm symptoms, if you will, that may prompt you to consider biopsying or additional imaging would be large tumors, tumors that seem to grow quickly, tumors that seem deep.

So for instance, lipomas are usually superficial right underneath the skin.

Liposarcomas the sort of cancer variant of those are oftentimes deeper within the muscle and are growing more quickly than the lipomas.

>> It seems like I used to recall that depending upon how long something has been present, may help determine if something is going to be benign, non-cancerous versus cancer.

What do you use for that?

>> And that's the growth, right?

If they've had a lump on their back, they've had it forever.

And it hasn't changed in 30 years.

Yeah.

It most likely is not going to be a sarcoma.

Right.

But if they say, boy there was nothing there.

And six months later it feels like I got an orange sticking up out of the thigh or back or something like that.

Those are those alarm symptoms, right?

But if it's been there for a long time and hasn't changed in size, it is most likely to be benign.

>> How does the person get to you?

Is it that they're the patient comes to see you directly, or they tend to go to their primary physicians?

>> Primary physician general surgeons will oftentimes see these patients first.

And and the astute physicians will sort of pick up on these alarm symptoms.

They may say, look, this thing is growing a little bit more quickly.

It's causing a little bit more pain.

It's firm.

And that is that is a reason for which they may be referred to myself or one of my partners for further evaluation.

>> What are the treatment options when you're trying to handle somebody with a sarcoma?

>> We always like surgery, right?

This is what we do.

But surgical treatment, if it's if it's localized, if it hasn't spread, the most effective treatment for the vast majority of sarcomas would be surgical excision, excising the tumor, typically with what we call margin, a rim of normal tissue around it, so that we are reasonably sure that we have removed the entire tumor.

And then we consider radiation therapy a lot of times for sarcomas.

And we do that to reduce the risk of it coming back in that area.

Excuse me.

And that's that's actually kind of been a game changer.

So we said how sarcomas are most common in the extremities passed in the, you know, the past history of treatment of sarcomas was very aggressive surgery, limb amputation.

Yes.

It's common.

And that's and that's patients are terrified they're going to lose their arm, lose their leg from something like that.

With the advent of radiation therapy, better techniques, better surgical techniques, understanding these limb sparing techniques, it's actually very rare now to have to need an amputation for surgical resection of your sarcoma.

>> So if something is deep in the abdominal cavity and you're being called in, are you just again, are you just resecting out the tumor or do you have to take the a lot of surrounding tissue out too?

>> So it goes back to depending on what kind of tumor it is?

Right.

Some of these sarcomas are more aggressive.

Some of them some of them are sort of well-encapsulated.

Right.

It's a nice it's a nice well-defined tumor.

They're not very sticky.

They're not very infiltrative into things.

And so they can kind of come right out.

Other sarcomas are sort of notorious for being invasive into surrounding tissues.

When we are faced with those types of sarcomas, we may recommend a more radical operation that is taking more of the surrounding tissue to try to get better margins.

>> Is there a role for chemotherapy in these patients?

>> There likely is.

And there's a role potentially either before surgery, perhaps after surgery to reduce the risk of it coming back, particularly in the more aggressive kinds.

Now, some sarcomas are fairly slow growing, slow growing tumors actually don't really respond very well to chemotherapy.

And so again, in certain types of subtypes of sarcomas, there could be a role for chemotherapy, but not for all of them.

>> Immunotherapy.

I mean we hear about that being used for so many types of cancers nowadays.

>> There are there's probably a role for certain types of advanced sarcomas.

This would be metastatic sarcoma sarcomas that cannot be resected.

Everybody's trying immunotherapy.

And every type of cancer sarcoma is certainly one of them.

And there have been some some pretty exciting advances actually where immune checkpoint blockades, which is the most common type of immunotherapy, and even what we call adoptive cell therapy, sort of engineered or altered T cells, immune immune cells to fight sarcomas, really.

>> Is it directed at a specific type, or is this in general.

>> It can be very specific subtypes of sarcoma with very specific types of T cell responses.

This has been tried.

>> When are the times that you can't do surgery on somebody?

>> Typically if the sarcoma is already spread.

So if there's metastases for instance, for sarcomas the most common area of metastasis is to the lungs.

So if you have a tumor in your arm but you have spread of the cancer to your lungs, an operation to remove that tumor from your arm doesn't necessarily help you.

That doesn't treat the tumors in your lungs.

So you need sort of whole body chemotherapy.

And that's the that's for a role for chemotherapy.

Sometimes these tumors are what we call locally advanced.

They're stuck to things that we can't take out or can't take out safely.

We try to do everything we can as far as reconstructing nerves, arteries, you know, blood vessels, things like that, if we need to.

Bones.

But sometimes if there's just if it's sort of stuck or invasive and too many to vital organs, we can't remove them.

>> Tell me a little bit about functional outcomes.

You mentioned, and you just briefly alluded to it when something's like in a bone.

But, you know, obviously, as you also said, that there are people who are concerned if something on the arm, I don't want to lose my arm or if you've got to go something in the belly, how?

And tell me about how you weigh this functional outcome.

Curing of the disease, quality of life for your patient.

>> So we try to do all of those.

Right.

So we sort of we've learned that we don't have to do as radical or an aggressive as surgery as we thought we used to.

And then again, that's that limb sparing technique.

Right.

But sarcomas the functional deficits from sarcoma surgery can be greater than some of the other things we talk about.

Right.

So a lung cancer operation a colon cancer operation, there may be some changes in your in your breathing or maybe some of your bowel functions.

But you can usually get along.

Think about sarcomas there in the muscle.

They're sort of by definition in these large parts of your body that when you remove them, you may very well have some long term functional deficits.

Now, we certainly have great cancer rehabilitation specialists, physical therapists, occupational therapists, physical medicine and rehabilitation specialists who particularly really like to work with sarcoma patients.

Right.

Because these are their needs, right?

They very much have strength, range of motion, functional needs.

But we wouldn't let those outcomes deter us from trying to cure somebody from cancer.

So when we're aggressive and we need to be with an aggressive surgical resection and sort of that shared decision making with the patient, trying to help them to understand what their outcomes would be, what their deficits may be from both the temporary and long term status.

We come to what's right for them.

>> You alluded to the therapist after the fact.

Tell me about what you're doing for the patient prior to surgery.

And then, of course, who is this whole team that's taking care of these patients over there to Brown Cancer Center?

>> So that's one of the fun parts about being a cancer surgeon, right?

I get to work in a team.

I get to work with a great team of specialists who are really great at what they do.

A lot of times what we'll do for for sarcomas is treat them with radiation therapy actually before surgery.

So sometimes I'll see the patient, we'll make the diagnosis and we'll put our heads together in a team and say, hey, this patient might be better treated with radiation before surgery.

So now we have 2 to 3 months where we have that patient in our system.

We can work with physical medicine and rehabilitation.

We can work with the cancer rehab specialists, sort of get them strong.

That prehab concept of getting them ready for what's going to be a big operation.

So we're getting them through that radiation treatment, we're getting them stronger, we're getting them fit for surgery, and then afterwards we're helping them recover, whether that's with inpatient rehabilitation, outpatient rehabilitation or other modalities.

>> Do you get social workers and things involved too?

>> Absolutely.

It's a whole team, right.

So there's going to be sometimes there's a need for durable medical equipment with major abdominal surgery.

Sometimes there's need for, you know, supplemental feedings and things like that.

So it really takes a lot of people to do this.

>> What do you got going on over the Brown Cancer Center that's special, that we need to know about?

As far as Sarcomas.

>> We certainly have some clinical trials related to sarcoma, really one of the one of the trials that we have that we work with our medical oncologists, Doctor Kumar right now is trying to figure out, does it make sense to give chemotherapy before surgery in some of these sarcomas.

And so we're currently enrolling patients in cooperative group trials where we where we try to evaluate that question.

And certainly we have clinical trials for more advanced sarcomas metastatic sarcomas that may need treatments, like you said, immunotherapy or other more advanced treatments.

>> If a primary health care provider or someone else out there wants to get in touch with you or get over there to Brown Cancer Center, how do they go about doing that?

>> So the Brown Cancer Center, you can contact the Brown Cancer Center with the Hope line, which is the number that you can find on the internet that will get you right to where the specialists that you need, and so they can direct you to either the surgeons or the medical oncologist, whatever specialist you may need.

We can get going on getting biopsies, imaging workup, etc.

and try to help you along.

>> The way.

And you don't know the phone number to the whole plan.

I don't isn't that I knew.

>> You didn't ask me that before.

>> They're going to be mad about it.

>> They're going to be really mad.

I'm sorry to mess with you on that one, doctor Egger, but.

Yeah, but but if people does someone have to have a referral though, from their physician?

Or can they themselves say, hey, I've been told I have this.

I want to get another opinion.

>> Give us a call.

We're happy to see you anytime.

Referrals.

It may it may matter on their insurance but we'll we'll figure it out.

>> Give me three things you think we need to make sure we keep in the back of our minds when we're thinking about sarcomas, if we think we have one, or if we do have some.

>> So sarcomas are very treatable.

The workup is very important.

And so if there's a if there is any suspicion that it may be a sarcoma more aggressive than getting to a specialist to help you from the workup phase on through the diagnosis and treatment phase is very important.

It does not mean you're going to lose your arm or leg.

We definitely have treatments available.

And even for advanced sarcomas, we have treatments available that can try to cure sarcoma.

>> Really, anything on the horizon that we're seeing to think that we may prevent developing of sarcomas or even some other cancers, that you may come about that you're excited about.

>> Well, we're always I think screening is important.

There's not necessarily screening procedures laid out globally for sarcomas.

However, patients who are at increased risk from some family or genetic predisposition, we know that we need to do screening for them.

As far as chemoprevention or preventive medicines, nothing necessarily sarcoma specific, other than all of the sort of, you know, healthy diet and exercise interventions that we're working on from a population health level.

You know, I always say that the longest people live from cancers when they never get it.

And so the best thing we can do is prevent cancer rather than treat it.

>> Prevent it rather than and if we can't prevent it, make an early diagnosis.

>> And we'll treat it.

>> Then we'll treat it.

But also want to get an early diagnosis I would imagine.

Yeah.

What's the best way?

She said, just say, hey, I've got something.

I'm gonna go see somebody about it.

>> Yeah, we can do that.

And then, like I said, now what?

A lot of times what we may do is we'll say, look, this is very much, very, very likely to be a benign thing.

It just needs to be excised.

We don't need to do biopsies.

We don't need to do a bunch of workup, but just ask.

That's what that's what your healthcare providers are here for.

>> Nothing like it's nothing to worry about.

Michael, thank you very much for being with us.

It's always a pleasure to talk with you and thank you for being with us today.

Sarcomas, while rare, are not uncommon, especially in children, though they can be difficult to diagnose and treat.

Cures and good functional outcomes following treatment are achievable through timely recognition, diagnosis and coordinated efforts between multiple healthcare specialties.

[MUSIC] If you wish to watch this show again or watch an archived version of past shows, please go to ket.org Health.

If you have a question or comment about this or other shows, we can be reached at KY Health at ket.org.

I'll look forward to seeing you on the next Kentucky Health.

And remember, if you have a question or concern, talk to your primary healthcare provider or give the good folks at the Brown Cancer Center, University of Louisville, a call in.

Specifically call Doctor Egger.

Thank you very much for being with us today.

See you next week.

>> Kentucky Health is funded in part by a grant from the Foundation for a Healthy Kentucky.

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