Sarcoma Frequently Asked Questions
Q: What are the differences between Sarcomas and Carcinomas?
Sarcomas and carcinomas are types of malignant tumors that can affect bones, but they derive from different types of cells. Sarcomas arise from mesodermal (mesenchymal cells) and carcinomas are stem from epithelial types of cells. Sarcomas and carcinomas also grow and spread differently. Sarcomas grow into "ball-like" masses and can push adjacent structures, such as arteries, nerves, veins away. They compress adjacent muscles into a pseudocapsule that contains microscopic projections of the tumor referred to as satellite nodules. The local ball-like growth of sarcomas enables resection in most instances. Sarcomas tend to arise primarily from bone, as opposed to spreading to bone from another site. They spread most commonly to the lungs, but can also spread to other bones and to the liver. Sarcomas rarely spread to lymph nodes.
Carcinomas grow in an infiltrative manner and can invade adjacent structures, such as adjacent nerves, blood vessels and muscles. They do not form a pseudocapsular layer, so it is difficult to determine its exact anatomic extent during surgery and can pose removal difficulties. Carcinomas spread to lymph nodes, lungs, bones and many other organs, depending on the type of carcinoma. They involve bone secondarily, that is by spreading from another site such as the breast to the bone. A patient can have the primary site removed and treated (i.e. the breast cancer removed) and years later develop a bone tumor/metastasis from the old breast cancer.
Q: Is there a difference between "bone cancer" and a "bone tumor"?
These two terms are very general terms. A bone tumor refers to any abnormal growth from the bone or in the bone, benign or malignant. Bone cancer refers to a malignant bone tumor. It can be a primary malignant tumor like an osteosarcoma, Ewing's sarcoma, or chondrosarcoma. It can also be a metastatic carcinoma, such as a breast cancer, lung cancer, prostate cancer, kidney cancer and thyroid cancer. It is important to differentiate between the various types of cancers that affect the bone, because each has its own type of treatment and prognosis.
Q: Why is a biopsy needed for my diagnosis?
A biopsy is the act of obtaining a piece of tissue from a tumor. It is then studied under a microscope by a pathologist (a physician who specializes in this area) to identify the type of tumor and whether it is benign or malignant (cancerous). This enables the doctors to determine the course of treatment. It is essential to have a biopsy before any surgery or treatment is administered. Biopsies can be performed in several ways. James C. Wittig, MD, believes the safest and best way is a core-needle biopsy, as it is minimally invasive, meaning it avoids cutting the skin and making an incision.
A core-needle biopsy uses a needle to gather tissue samples. It should be performed by the surgeon (orthopedic oncologist) who will treat the tumor or by a radiologist who is experienced with bone and muscle tumors and performing biopsies of them. The orthopedic oncologist and radiologist will discuss the tumor and approach prior to the biopsy and are in constant communication. The patient is given an injection of numbing medicine (usually lidocaine and marcaine) into the area of the tumor that will be biopsied and is administered medicines intravenously (into the vein) to relax the patient and prevent pain. The physician makes a single stab hole in the anesthetized area of the skin and aims the needle in multiple directions to sample different parts of the tumor. In most instances, the procedure is performed under a CT (pronounced CAT) scan so the tumor can be seen and biopsied accurately. Ultrasound or other imaging modality may also be utilized. Once the specimen is obtained it takes about four days for the specimen to be processed and interpreted by the pathologist. Minimally Invasive Biopsies are also performed in the operating room by the surgeon often under fluoroscopic guidance.
An Open Biopsy requires that the patient be brought to the operating room and the skin is cut (incision is made) over the tumor. A piece of tumor is cut out and sent to the pathologist to be studied under the microscope. An open biopsy requires the skin to heal postoperatively before starting any treatment. This is different from a core needle biopsy in which there is no healing time. There are also more complications such as infection, hematoma and fracture associated with an open biopsy. The risk of a local recurrence (the tumor coming back after it is surgically removed) is also higher following an open biopsy than with a core needle-biopsy.
The diagnostic accuracy rate of a core needle biopsy is the same or better than an open biopsy when performed at a center experienced with the treatment of these tumors (experienced orthopedic oncologist, musculoskeletal radiologist and surgical pathologist). About 90% of tumors are diagnosed accurately with this method – and core needle biopsies are associated with fewer complications than open biopsies.
FNA refers to fine needle aspiration and should not be confused with a core needle biopsy. An FNA uses a very fine needle and does not obtain sufficient material for the diagnosis of bone and soft tissue tumors, bone sarcomas/soft tissue sarcomas. It is not used to biopsy tumors of the musculoskeletal system.
Q: What does “staging” mean?
Staging is a way of assessing specific characteristics about a sarcoma and correlating it with a prognosis. Generally, staging systems assess tumor size, grade, superficial or deep location, intracompartmental or extracompartmental involvement, and whether it has spread to any other area of the body. Most high-grade sarcomas of bone or soft tissue present as stage 2 tumors. Stage 4 tumors refer to those tumors of any size that have spread to - or metastasized to - other body parts at the time the tumor is discovered. Stage 1 tumors (early stage tumors) have the best prognosis.
Q: What is a percutaneous radiofrequency ablation (RFA)?
The latest, "state-of-the-art treatment" for osteoid osteoma is percutaneous radiofrequency ablation (RFA). This minimally invasive, outpatient procedure is performed under a CT scan, usually by a highly specialized musculoskeletal radiologist. During RFA, a needle or probe is inserted into the lesion and the lesion is heated and destroyed. The CT scan is utilized to localize the Osteoid Osteoma so the needle can be guided directly into the tumor. The procedure does require that the patient be put to sleep with general anesthesia, because insertion of the needle into the osteoid osteoma is painful. The patient must also lie motionless during the procedure. The procedure is greater than 90% effective. This is the same success rate as with actual surgical removal. The pain from the osteoid osteoma is usually relieved within one day. Often in the recovery room after the procedure, the patient will say that the pain from the tumor is gone. There is full use of the leg or arm and return to normal activities the following day. There is virtually no blood loss and very little risk (less than 1%) of developing an infection after the procedure. Less than 10% of the time the procedure needs to be repeated or the patient requires a surgical procedure to remove the tumor.
Q: How do I schedule surgery?
Surgeries are scheduled by the office's administrative staff, and you are asked to discuss your scheduling preferences with the Surgery Coordinator. Changes are made to the surgery calendar daily, and the administrative staff will do their best to accommodate your needs accordingly.
Dr. Wittig is affiliated with Mt. Sinai Medical Center in NYC as well as Hackensack University Medical Center in Hackensack, NJ. On rare occasions, surgery for his patients may be performed at either Valley Hospital in Ridgewood, NJ or St. Joseph's Regional Medical Center in Paterson, NJ.
Our sarcoma team attempts to accommodate all patients’ requests to have surgery performed at any one of these hospitals. Urgent surgery and operating room availability will determine whether or not a preferred hospital can be accommodated. On rare occasions, an emergency will arise that necessitates the rescheduling of a patient's non-urgent (elective) surgery to a later date in order to accommodate an urgent or emergent surgery. Be advised that if this situation should arise, we will do whatever is necessary to reschedule your surgery as quickly as possible.
For follow-up appointments:
Mount Sinai Orthopaedic Oncology/Sarcoma
Faculty Practice Studies
5 East 98th Street
New York, NY 10029