Orthopaedic Surgery news

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1 Orthopaedic Surgery news UNIVERSITY OF CALIFORNIA, SAN FRANCISCO f a l l V O L U M E 8 N U M B E R 2 Compression implants deliver lasting hope to young cancer patients In 2004, an active 14-year-old teen arrived in the office of Richard J. O Donnell, MD, chief of Orthopaedic Oncology at UCSF Medical Center. The young man had a lesion in his proximal femur that tests revealed to be a Ewing s sarcoma. Removal would require a massive hip replacement. O Donnell and his team were confident there were multiple treatment options that would preserve the young man s life, and worked with him and his family to sort through those options. The family wanted to salvage the limb, but there was concern that the bone loss from stress shielding and wear that commonly causes cemented and press-fit devices to fail would dictate multiple surgeries throughout the young man s life. C O N T E N T S : Message from the Chair 2 Adult Soft Tissue Sarcomas 4 Case Study 5 Radiologic Diagnoses 6 Spine Tumors 7 Grand Rounds 8 CME 8 O Donnell had an alternative. A pioneer in compressive osseointegration a technique in which a spring-loaded implant applies hundreds continued on page 3

2 Message from the chair T The specialty of musculoskeletal oncology deals with a complex and often rare array of conditions. There is no specialty where strong leadership and an integrated team are more important. This issue of Orthopaedic Surgery News highlights how we bring these qualities to our patients through the Helen Diller Family Comprehensive Cancer Center in San Francisco and our satellite clinics in Contra Costa and Marin counties. Thomas Parker Vail, MD Led by Richard J. O Donnell, MD, our musculoskeletal oncology program includes collaboration among specialists from areas within our department, such as the Spine Center, and from throughout UCSF Medical Center. The team approach includes surgeons, specialized nurses, medical oncologists, radiation oncologists, radiologists and pathologists. These experts draw on an unusually rich clinical experience; many are pioneers who have performed numerous procedures rarely seen in other hospitals. In fact, in 2008, U.S. News & World Report has ranked UCSF s cancer program as No. 8 in the United States and the best in California. Our ability to bring state-of-the-art treatment to our patients also depends upon our research programs, as well as our participation in organizations such as the homegrown sarcoma treatment group, the international Spine Oncology Study Group and the National Comprehensive Cancer Network. Finally, the stories in this newsletter illustrate that we have access to the latest and most advanced diagnostic and treatment equipment. Patient access to these services is of paramount importance. To facilitate access for those outside San Francisco, Dr. O Donnell has established a weekly clinic in Pleasanton (Contra Costa County), and Dr. Shane Burch conducts a weekly clinic in Greenbrae (Marin County). All of these factors offer powerful advantages for diagnosing and treating sarcoma and musculoskeletal tumors of all kinds. We hope you agree and will view the Department of Orthopaedic Surgery at UCSF as your partner and resource in helping your patients confront these rare, often life-threatening conditions. osn Thomas Parker Vail, MD, Professor and Chair Department of Orthopaedic Surgery

3 Compression implants deliver lasting hope to young cancer patients continued from front cover of pounds of pressure to hold an anchor plug in the remaining bone O Donnell believed the technique promised a better quality of life than traditional limb salvage surgery, without increasing the risk of complication. In the hands of an experienced surgeon, the success rate with this procedure is exceedingly high, says O Donnell, who has done more of these procedures than any other practicing surgeon in the world more than 150 and who, together with Professor Emeritus James O. Johnston, MD, oversaw the multicenter clinical trial that led in 2003 to FDA clearance of the device used in the procedure. In addition, the compression force actually encourages bone to grow around and into the titanium implant, thereby providing long-term stability. Four years later, the cancer-free young man sends O Donnell pictures of the hikes he takes in areas around California. Coordinating treatment Of course, long-term prognoses always depend on the full spectrum of cancer care and a closely coordinated team. Pediatric medical oncologist Steven G. DuBois, MD, notes, You can t cure bone sarcoma patients with surgery or chemo alone; it requires both. Treatment choices need to be made at a place that understands what s possible, says pediatric medical oncologist Robert E. Goldsby, MD. At UCSF Medical Center, these options and the latest research are discussed at two tumor boards run by the pediatric multidisciplinary program and the sarcoma program. While each case is different, treatment usually begins with 12 weeks of chemotherapy, at which time the team gathers to evaluate the response. After repeat staging studies, the next step is local control, says DuBois. Even if the Compressive osseointegration encourages bone regrowth and long-term stability. patient s tumor is progressing, we almost always need to resect the tumor. After surgery, patients typically undergo another six to eight cycles of chemotherapy. Beyond biomedical support The sarcoma program also conducts long-term followup in collaboration with patients community providers. Goldsby, who directs the Survivors of Childhood Cancer Program at UCSF Children s Hospital, says that all patients receive a wallet-sized card to remind them of recommended follow-up care. The pediatric team sends a more detailed version of those recommendations to patients community physicians. Compressive osseointegration patients typically return to UCSF for regular imaging studies every three to six months. Some patients from the East Bay, South Bay, Central Valley and Sacramento areas come to a recently opened satellite office at ValleyCare Medical Center in Pleasanton. We believe that for patients with lower extremity tumors, compressive osseointegration is an excellent alternative that results in successful, long-term limb preservation more than 90 percent of the time, says O Donnell. osn To contact Dr. Richard O Donnell, call (415) Richard O Donnell, MD When amputation is the treatment choice Sometimes, for reasons both clinical and personal, osteosarcoma patients opt for amputation. For these patients and for post-traumatic patients, immediate postsurgical prosthesis fitting can offer many clinical benefits. After an amputation and once the wound is closed in the operating room, the prosthetists place the residual limb in a soft tissue container [cast] to compress the tissue, and attach a plate to the cast, says Walter Racette, director of the Orthotic and Prosthetic Service at UCSF Medical Center. The next day, we can attach the remainder of the prosthesis for early weight bearing. This procedure is repeated once the cast gets loose, and is continued until wound healing is complete, at which time a preparatory prosthesis is provided. The even pressure of the cast helps to reduce edema and provide a favorable healing environment. It also prevents contracture, protects the wound and allows the patient to get up right away, says Racette. 3

4 Advancing the treatment of Thierry Jahan, MD Watching fluids, side effects and the loss of electrolytes can all be tricky for clinical teams that don t regularly use chemo in these cases. adult soft tissue sarcomas S Intraoperative radiation therapy (IORT) requires a mobile linear accelerator with adequate clearance beneath the table for the base and the shield. Soft tissue sarcomas are extraordinarily heterogeneous, so experience is particularly important when deciding among treatment options, says medical oncologist Thierry M. Jahan, MD. Jahan notes that because earlier sarcoma research was limited by the relative scarcity of cases, initial studies tended to treat sarcomas as a homogeneous group. Consequently, treatment was often limited to a combination of surgery and radiation. Yet, as sarcoma programs have accumulated experience, they have found that for certain sarcomas, using chemotherapy in conjunction with surgery and radiation can actually be quite effective. Chemo, radiation or both? At UCSF Medical Center, referring physicians typically send orthopaedic surgeon Richard J. O Donnell, MD, and general surgeon Eric K. Nakakura, MD, PhD, patients with painful, growing soft tissue masses. If their initial examination convinces them that there is a sarcoma concern, they move on to a staging workup that includes various imaging modalities and, eventually, either a needle or incisional biopsy. Once a tumor has been subtyped by Andrew E. Horvai, MD, PhD, the team discusses the case at the sarcoma program tumor board that meets twice a month at UCSF Medical Center and, of course, with the patient. In some cases, the team recommends chemotherapy in addition to surgery and radiation. For tumors that are high-grade, deep and larger than five centimeters (which have a high likelihood of relapse), we believe that the evidence over the last 10 or 15 years indicates that chemo can have a positive effect, says O Donnell. Jahan often oversees two to three chemotherapy cycles prior to surgery. O Donnell and Nakakura then remove the primary tumor. If necessary, thoracic surgeon Michael J. Mann, MD, resects lung lesions, often with a minimally invasive procedure called videoassisted thoracoscopic surgery. IORT When appropriate, the team also offers patients the option of intraoperative radiation therapy (IORT). The potential benefits of IORT include its ability to reduce or prevent complications associated with preand postoperative radiation, to ensure a clear field with optimized margins, and to reduce the field for postoperative dosing. We also use IORT when Dr. O Donnell believes there will be microscopic disease remaining after resection due to the close proximity of the tumor to nerves or vessels, says radiation oncologist Alexander R. Gottschalk, MD, PhD. The procedure, which requires that a hospital have a mobile linear accelerator available for the operating room, is associated with very little toxicity. Postoperative collaboration After surgery, most patients require another five to six weeks of radiation or several cycles of chemotherapy or both. For technical reasons, some remain at UCSF for these treatments. But, says O Donnell, We always leave the decision to the patient and their physician.

5 Case study: Coordinated care for adult soft tissue sarcoma In April 2006, while on a family vacation in Arizona, DE, an active 47-yearold man, called his California cardiologist because he felt unusually tired. He also had noticed a small mass in his upper calf. DE had recently undergone mitral valve repair, and his cardiologist was concerned enough about deep vein thrombosis to suggest that DE go to the local emergency room. Scans and X-rays were negative, but the team there suggested DE get what they believed was a hematoma looked at upon his return to the Bay Area. That process led to his being referred to Richard J. O Donnell, MD, chief of Orthopaedic Oncology at UCSF Medical Center. Evaluation and surgical intervention After an initial examination, O Donnell ordered an imaging workup. A combination of CT and PET scans revealed a mass in the popliteal fossa, says O Donnell. The subsequent pathology report from an incisional biopsy in May 2006 identified a grade 2 myxoid round cell liposarcoma. When patients do opt for postoperative treatment in their home community, the team works closely with referring physicians to convey treatment recommendations. For radiation, some postoperative treatment is very straightforward. But in other cases, it can be difficult to replicate Gottschalk s direct observation of the surgery, his experience with sarcomas and his access to equipment that enables such procedures as image-guided radiation therapy. But we do our best to convey all of the necessary information, he says. For chemo, Jahan typically faxes a sample order to the referring physicians to ensure that they and their nurses are comfortable with the procedures. The devil is in the details, says Jahan. Watching fluids, side effects and the loss of electrolytes can all be tricky for clinical teams that don t regularly use chemo in these cases. In the future, he hopes to open a chemo infusion unit at Mount Zion that would facilitate an aggressive research program. osn To contact Dr. Richard O Donnell, call (415) O Donnell resected the tumor in early June. During the procedure, radiation oncologist Alexander R. Gottschalk, MD, PhD, administered intraoperative radiation therapy to reduce the dose needed for postoperative care. Unfortunately, when the pathologist s report came back the next time, the tumor had progressed to grade 3. Postoperative care: Chemo and radiation Concerned about microscopic residual disease, O Donnell and his team, including medical oncologist Thierry M. Jahan, MD, believed that a combination of radiation and chemotherapy would be the best option for minimizing the likelihood of recurrence. DE underwent radiation therapy with Gottschalk through January As for chemotherapy, though, since one of the drugs was associated with cardiac toxicity, the team was concerned its administration might complicate DE s heart condition. After consultation with DE s cardiologist and with the heart surgeon who had completed the mitral valve repair, the team arrived at a plan to go ahead with the chemo, along with an echocardiogram before each of the six cycles to monitor the drug s effect on DE s heart. Throughout the treatment, all the echocardiograms showed the left ventricular ejection fraction consistently above 60 percent, says Jahan. A team approach DE did, however, incur other common complications during his 18 months of postoperative treatment. Those complications and return trips to the hospital kept him in close contact with many of the staff at the Helen Diller Family Comprehensive Cancer Center. Dr. Jahan has kept in close touch with my [community] internist, whom he recommended, says DE, who still undergoes CT and PET scans every three months. As of July 2008, DE remains disease-free. osn

6 More precise diagnoses can improve sarcoma outcomes TThe rarity of bone and soft tissue sarcomas heightens the value of having an expert radiologist on the sarcoma team. Many benign masses can mimic sarcomas, and vice versa, so establishing the correct diagnosis is incredibly important, says Lynne Steinbach, MD, professor of radiology at UCSF. When initial imaging studies fail to make clear whether musculoskeletal lesions are malignant or benign or what type of tumors they might be radiologists access to and expertise with a full range of modern imaging modalities, their experience with image-guided biopsies, and their close collaboration with other specialists can improve diagnoses and, in turn, patient outcomes. Perhaps most important, Knowing the proper approach is essential to avoid contamination of the surrounding structures, which can make the subsequent surgery more difficult and cause more complications, says Link. Consequently, collaboration with the orthopaedic surgeon at the center where the procedure will be done is essential. At UCSF Medical Center, radiologists participate in regular meetings of multidisciplinary sarcoma and tumor boards that include orthopaedic and general surgeons as well as pathologists, radiation oncologists and hematologists/oncologists. osn To contact Dr. Thomas Link, call (415) Experience, options and collaboration matter Depending on the individual situation, after an MRI or CT scan radiologists might move to a PET-CT scan, which has a number of advantages for diagnosing tumors. Radiotracer uptake can often indicate malignancy, says Steinbach. In addition, PET-CT scans can reveal other tumor sites, be they primary or metastatic. If the tumor is not necrotic, fluid or mucinous, image-guided biopsy is another option, says Thomas Link, MD, professor of radiology and chief of musculoskeletal imaging at UCSF, who has done approximately 150 of these procedures over the last four years. An image-guided biopsy is appropriate after all imaging studies have been reviewed, and you need a definite diagnosis for therapeutic management of an aggressive, potentially malignant tumor, says Link. Link s experience in doing core biopsies using larger-gauge needles has improved their accuracy over fine-needle aspirations and decreased the risks. At UCSF Medical Center, the presence during the procedure of a pathologist or cytologist who can quickly assess whether the radiologist has harvested a large enough core helps avoid repeated procedures. In this axial CT image of the right hip joint, a biopsy needle aims at a sclerotic lesion within the femoral head. The lesion turned out to be a benign mesenchymal tumor. Thermal ablation of tumors and osteoid osteomas UCSF Medical Center is among the most active sites in California for an interventional radiologic technique known as CT-guided, percutaneous, radiofrequency thermal ablation. The technique can remove chondroblastomas, metastases and chordomas, but to date is used mostly to ablate painful osteoid osteomas. For osteoid osteomas, our follow-up shows the pain is gone for 90 percent of our patients, says Thomas Link, MD, who performs about one of these procedures each month. Radiofrequency thermal ablation is a minimally invasive procedure with no drilling and resultant scars that are typically less than five millimeters. After careful planning based on imaging studies, Link chooses either a 10mm or 7mm probe, based on the size of the nidus. Then, with patients under general anesthesia, Link ablates the area as well as the margins. Because diagnosis and choosing the proper approach are essential, it s important to do these procedures in centers where the interventional radiologist has a lot of experience, says Link. For more information about this technique, visit

7 Following anterior and posterior spine tumor removal, a metal cage, rod and screws are installed for stabilization. Fighting spine tumors with experience and research P E T - C T s a t U C S F M e d i c a l C e n t e r When traditional imaging modalities do not reveal enough information, radiologists have begun turning to PET-CT scans. Because positron emission tomography (PET) detects the metabolic signal of actively growing cancer cells in the body and computerized tomography (CT) provides a detailed picture of the location, size and shape of abnormal, cancerous growths, the combined image provides the most complete information possible on cancer location and metabolism. In most cases at the UCSF Imaging Center at China Basin, a radiologist can interpret a scan and return results to the referring physician within 24 to 48 hours. To contact the UCSF Imaging Center at China Basin, call (415) Whether it is the rare primary chordoma or the relatively common metastasis from another site, a tumor of the spine poses significant clinical challenges for spine surgeons. Optimal treatment requires ongoing experience with the latest treatments and technology, and a team approach that helps ensure patients have a clear understanding of their full range of treatment options. Fortify and resect For example, tumors and their treatments can cause osteolysis and vertebral body fractures that lead to pain, progressive deformity and functional limitations. Once disease is metastatic, our goal is to prevent paralysis and improve pain, says Serena S. Hu, MD. As part of the Spine Center at UCSF Medical Center which includes Sigurd Berven, MD, Shane Burch, MD, Vedat Deviren, MD, and Bobby Tay, MD Hu has conducted research that helps clinicians better understand how certain patterns of spinal involvement by a tumor indicate a greater risk of fractures and paralysis and, therefore, justify more invasive treatment. She notes that experience in vertebroplasty and kyphoplasty can help surgeons shore up the spine, relieve pain and prevent bony collapse. Moreover, the availability of equipment such as an operating room CT scanner enables experienced surgeons to immediately redress any intraoperative complications. Experience also matters when performing en bloc resections, procedures where the surgeon completely removes solitary metastases and primary tumors in single pieces to prevent the spread of tumor cells in the spinal area. Research has shown that leaving no margin of residual tumor improves survival; with an intralesional resection, recurrences are more likely, says Berven, who has taught courses on the technique. The UCSF Spine Center is one of the only centers in California that perform these types of resections. Collaboration Another key success factor is collaboration. At regular interdisciplinary spine tumor conferences, UCSF spine surgeons, neurosurgeons, oncologists, radiation oncologists, radiologists and pathologists discuss a full array of treatment options, including adjunct chemotherapy and radiation therapy for complex cases. The group draws upon information that members bring back from their participation in the Spine Oncology Study Group, an international, biannual meeting that sets treatment guidelines based on current, outcomes-based research. So many studies [of spine tumors] are necessarily smaller studies it can take years to get enough data together, says Burch. The Spine Oncology Study Group is a way to combine thinking and expand impact for these rare diseases and to bring treatments to our patients faster. The next generation of treatment An active research program, like the one at the UCSF Spine Center, can also benefit patients. Recently, for example, Burch encountered a patient with tumors that had spread through his sacrum and pelvis. Essentially, he had been told to go home and die, says Burch. Drawing on research in this area, Burch used MRI and CT scans to model the bones that needed to be surgically removed, and created titanium replacement parts in an attempt to reconstruct the patient so he could walk again. continued on page 8

8 Referral Liaison Service Tel: (800) Fax: (415) Our Referral Liaison Service provides you with improved access to our physicians and medical services. Liaisons can expedite the referral process, assist in obtaining follow-up information and are available to help resolve difficulties. continued from page 7 Another example from Burch s work is his demonstration that light-based technology can activate a chemotherapeutic agent to precisely target and kill bone lesions without harming the bone. (Traditional radiation therapy can damage the spine and its surrounding structures.) He notes that with nearly 100,000 cancer cases per year in the United States metastasizing to the spine, photodynamic therapy proven for other cancer treatments has enormous promise. osn To contact Dr. Sigurd Berven, Dr. Shane Burch, Dr. Vedat Deviren, Dr. Serena Hu and Dr. Bobby Tay, call (866) 81-SPINE [(866) ]. Shane Burch, MD Transfer Center Tel: (415) Fax: (415) The UCSF Transfer Center is staffed 24/7 by a specialized team to evaluate the clinical needs of your patient to ensure the most appropriate medical care is provided and to coordinate transfer and transport from hospitals throughout the region. This centralized service provides quick access to our physicians and team members, including nurses, financial counselors, case managers and social workers. At discharge, the Transfer Center can facilitate the return transfer. Citywide Grand Rounds Dec. 6, 2008 CME Courses For more information, visit orthosurg.ucsf.edu/grandrounds Stanley Prusiner, MD, UCSF Discovering a New Life Form: The Process For more information, visit 3rd Annual Primary Care Sports Medicine: ABCs of Musculoskeletal Care Nov , 2008 San Francisco, CA 8th Annual UCSF Clinical Cancer Update Jan , 2009 Lake Tahoe, CA 4th Annual San Francisco Orthopaedic Trauma Course April 30-May 2, 2009 San Francisco, CA 2nd International Conference: Advances in Orthopaedic Osseointegration May 1-2, 2009 San Francisco, CA 54th Annual LeRoy C. Abbott Society Scientific Program and 30th Annual Verne T. Inman Lectureship May 7-8, 2009 San Francisco, CA 4th Annual UCSF Spine Symposium June 5-6, 2009 San Francisco, CA Written and designed by UCSF Public Affairs Photos: Majed, p. 2 This publication is printed on New Leaf paper made with 100 percent recycled fibers, 50 percent postconsumer waste and processed chlorine-free The Regents of the University of California PR764 UCSF Medical Center San Francisco, CA Orthopaedic Surgery news Nonprofit Org. US Postage P a i d San Francisco, CA Permit No Return Service Requested