Advances in Orthopedics

Wakenda K. Tyler, MD, MPH, Chief, Orthopedic Oncology Service, Columbia Orthopedics

Faculty in the integrated Sarcoma Service for Cancers of the Bone and Soft Tissues at Columbia University Irving Medical Center are confronting sarcoma together. This rare and often lethal cancer that develops in the bones and soft tissues is the focus of a joint program among physicians in orthopedic oncology, hematology/oncology, and radiation oncology. They collaborate on developing the optimal course of treatment for each patient and then execute that plan, which could involve surgery, chemotherapy, radiation, and at times a combination of all three. Their work is characterized by a personal approach in every aspect of their interactions with patients. To them it’s not only about quality of care, but also about quality of life.

• Developing individually tailored treatments based on genetics
• Improving methods to diagnose metastases
• Studying ways to stop metastasis
• Preparing patients for postoperative rehabilitation
• Easing the lives of patients when a cure is no longer viable

Applied Genetics

Sarcomas each have a specific genetic profile and to that end every sarcoma biopsy is genetically sequenced, a service not yet available in most hospitals. The results inform a personalized treatment protocol that can offer targeted therapies based on the specific genetic features of the tumor. Finding the genetic abnormality within that tumor allows the Columbia team to target it with some of the newer therapeutic agents under development. Collecting these gene analyses enables them to identify specific genes that either allow for a good response or a poor response to therapy and then select an alternative therapy with greater precision based on that analysis. While a patient may still need surgery and radiation, they can now be offered targeted therapies to home in on particular genetic features of the tumor, which can increase the survival rate.

Intra-Articular Tumors

In a study published in the December 2018 issue of The Journal of Bone & Joint Surgery, Columbia orthopedic faculty focused on the challenges of diagnosing intra-articular tumors, which are often mistaken for other non-neoplastic conditions, and the importance of recognizing when surgical or nonsurgical treatment is indicated. The authors recommend that with these tumors, physicians look for more subtle signs of a malignant or more aggressive benign process, including employing contrast magnetic resonance imaging, and if detected, refer patients to an orthopedic oncologist for evaluation and management.

Limiting Metastases

For patients with metastatic disease, the Orthopedic Oncology Service focuses on keeping the cancer at bay in other parts of the body, while also concentrating on the bone. While many therapies are available that target cancers in the lung, liver, and kidney, they don’t always work when they invade the bone. Our orthopedic faculty are currently looking at antiangiogenic and anti-vascular tumor therapies to block tumor angiogenesis in the bone, with a goal of blocking the blood supply to those tumors to inhibit the cancer from spreading. For a variety of reasons, the bone environment does not allow chemotherapy to have the same impact on the cell as it does in other parts of the body. To better understand this obstacle, Columbia researchers are also studying the bone environment’s effect on cancer cells that insulates them from chemotherapy.

Introducing Patients to Rehabilitation Early

Nearly every sarcoma patient will undergo surgery, which can radically alter mobility and function. Columbia orthopedic faculty have established a program connecting high-risk patients with rehabilitation medicine prior to their surgeries. For many patients, the pain and impeded movement caused by a tumor forces them to compensate, for example, favoring one leg over the other. As a result, many will have functional deficits or mobility impairments going into surgery, making physical and occupational therapy vital contributions to ongoing quality of life. Through this program, patients will already have a network of physicians and staff who are aware of the functional issues and ready to support them without delay postoperatively.

Palliative Care

When cure is not possible, Columbia orthopedists strive to achieve pain control and improve function to the greatest extent possible for each patient. With metastatic disease, when the therapies start to fail, patients are often in pain. To address this, our physicians integrate a variety of pain management modalities and surgical techniques to treat and control pain.