Dr. Hornicek says. “These tumors might also have a higher incidence of local recurrence, so we may want to include radiation therapy to decrease local recurrence.” Patients whose disease has already metastasized — most commonly to the lungs in patients with sarcoma — are likely to be offered chemotherapy initially. This pattern of metastases is different than in the more common carcinomas. The treatment approach for soft-tissue sarcomas is very different from the approach to bone sarcomas, Dr. Bukata adds. “Soft-tissue sarcomas can develop in the muscles, fat and nerves, and sometimes in the joints, but they don’t specifically involve the bone,” she explains. These patients often are treated with radiation, and in some cases chemotherapy, prior to surgery. Bone sarcomas are almost always treated with chemotherapy, and in some cases with radiation, both before and after surgery. For bone sarcomas, the surgery typically involves taking out the cancerous area of bone and performing reconstruction. “Oncologists are trained to kill the cancer, but orthopaedics is a quality-of-life field,” says Nicholas Bernthal, MD, chief of UCLA’s Musculoskeletal Oncology Service. “For those of us who are orthopaedic oncologists, we have really pushed the field in the last several years to pay greater attention to how content patients are after the reconstruction. If a patient wants to be able to play soccer after we’ve removed the tumor in his or her leg, we might use a different reconstruction option than if that patient says he or she just wants to be able to take a five-minute walk down the beach.” On the scientific end, the sarcoma team is moving closer to personalized approaches to treating patients — for example, taking part of the material from the biopsy and studying the effect of potential therapies in the laboratory so that if patients have a recurrence or other adverse outcome, the team will have insights into what drug will be best for them. “It used to be that we really had only one shot against sarcomas,” Dr. Bernthal says. “Now, with targeted and immunotherapies, we are able to gain access to the newest drugs for second- and third-line therapies, and we have seen some very promising results.” Properly Treating Sarcoma Requires Experience and a Comprehensive Approach UCLA has one of the three largest sarcoma centers in the country, performing approximately 600 surgeries a year. The high volume allows UCLA to offer a large number of clinical trials; typically, more than a dozen are active at any given time. But it is not just the volume that’s important. “In sarcoma care, each specialty is critical to getting the patient from diagnosis to cure,” says Noah C. Federman, MD, director of the UCLA Pediatric Bone and Soft Tissue Sarcoma Program. “Having all of the specialists working together as equals in the care of these patients not only is ideal, but necessary to provide true comprehensive care for patients.” Diagnosing sarcomas is challenging for several reasons, notes Scott D. Nelson, MD, chief of musculoskeletal pathology. With so many subtypes, “you can’t just look at the slides and make the correct diagnosis. Communicating regularly with the team of surgeons, oncologists, radiologists and radiation therapists is the best way to make sure you are factoring in all of the imaging studies and clinical history you need to ensure accuracy and give the treating physicians the confidence to go forward with the therapy,” he says. Navigating all of the specialties needed to diagnose and treat a sarcoma can be challenging in any medical environment, and ensuring that the team is in constant contact is often difficult. At UCLA, “we pride ourselves in making the care of these sarcoma patients seamless,” Dr. Federman says. Patients who are referred to the group are almost always seen within 24-to-48 hours, and each week, approximately 30 physicians meet to review every active case. Together, the team — including representatives from pediatric oncology, medical oncology, radiation oncology, surgical oncology, orthopaedic oncology, musculoskeletal radiology, interventional radiology and musculoskeletal pathology — reaches a consensus on the diagnostic and therapeutic plan, which is ultimately presented to the patient. Photo: Courtesy of Dr. Susan V. Bukata The contact among team members is not confined to the weekly meetings. “We are constantly texting, calling and going into each other’s office to discuss cases,” Dr. Nelson says. “My office is next door to an orthopaedic oncologist and a pediatric oncologist. That’s very unusual.” This seamless multidisciplinary approach leads to improved patient satisfaction, the UCLA sarcoma team members say, both because the diagnostic and treatment process is expedited and because patients see that decisions about their care are being made in a rigorous and coordinated manner. “I would hesitate to operate on a patient whose case hasn’t been presented at our multidisciplinary conference, because of how often I get feedback from other members of the team that leads to a revised strategy,” says Fritz C. Eilber, MD, director of UCLA’s Jonsson Comprehensive Cancer Center Sarcoma Program. “I tell my patients that I can take their tumor out, but what they are really benefiting from is the power of this large group of sarcoma-specific physician-scientists. It’s irreplaceable.” 7 UCLA Physicians Update