Sarcoma, challenging to diagnose, encompasses a variety of cancers

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

Cancers that arise in bones, muscles, tendons and other connective tissues are called sarcomas.

Today, I am speaking with Dr. Jade Homsi, who specializes in the care of patients with sarcomas. He's the chief of the division of hematology and oncology at Upstate.

Welcome to "The Informed Patient," Dr. Homsi.

Jade Homsi, MD: Thank you. Thank you for having me.

Host Amber Smith: Are sarcomas new cancers, or have they spread from cancers that originated elsewhere in the body?

Jade Homsi, MD: Sarcomas are actually new cancers, so they could start in different areas in the body, and they do have the potential themselves to spread to other areas in the body, and not to be confused with other cancers that can also spread to other areas in the body.

Host Amber Smith: So where are most sarcomas found?

Jade Homsi, MD: So sarcomas are, probably easier to think about it, they're divided into two major categories. The first one is the soft-tissue sarcoma, and the second one is the bone sarcoma. So just based on the name itself, you can tell where it starts.

So the soft tissue sarcoma starts in the soft tissue, and that's usually muscle, blood vessels, fatty tissues. And the bone sarcomas start usually in the bones and the cartilage around the bones as well.

Host Amber Smith: Who is most at risk for this? Adults, children, men, women?

Jade Homsi, MD: Anybody, everybody is at risk to have a sarcoma.

There's no specific patient population that tends to have more likelihood to get sarcomas. Indeed, with the exception of some very rare genetic syndromes, where we can see some patients having more sarcomas than others.

Going back to the two categories, as far as bone sarcomas, that's the one that is more common in children. As far as the soft-tissue sarcomas, and when we say soft-tissue sarcomas, we mean things like liposarcoma, leiomyosarcoma, pleomorphic sarcoma. These are all terms that can be used to describe one thing, which is sarcoma. And these tend to be more common in older patients.

In general, males may have higher likelihood to get a sarcoma, compared to females, but again, every disease -- I probably didn't mention, but sarcomas tend to be, or tend to describe, multiple diseases, so each one of these diseases could have a higher likelihood in men or women and different age population.

Host Amber Smith: Well, other than genetic risks, are there other factors that would increase someone's risk for developing sarcoma?

Jade Homsi, MD: There are, and the one that we know the most about is radiation. Receiving radiation therapy in the past could be a factor in developing sarcoma in the future. And that's a very interesting thing we face, or we deal with, where a cancer patient could receive radiation therapy to treat that cancer, and, many years later, they could present with sarcoma in the area where they received the radiation.

Other things, such as different chemicals, have been associated with some type of sarcomas, (also) viruses, most specifically herpesvirus, and that's specifically to one type of sarcoma, called Kaposi sarcoma, associated with a specific herpesvirus. The last thing that tends to, or may, be a little more controversial is the idea of a trauma or chronic inflammation in the area. That has been an area of studies and also research looking for the possibility of a chronic inflammation in one area of the body, or trauma in that area of the body, leading to the development of sarcoma.

These are the most studied, or reported, factors to be associated with sarcoma.

Host Amber Smith: How are sarcomas typically discovered?

Jade Homsi, MD: There isn't just one sign or symptom to suggest that someone has a sarcoma, and that makes it more challenging to diagnose.

Many times we have patients, or we see patients, where they've had a delayed diagnosis of their sarcoma due to the vague signs and symptoms of the disease. And so the most common ones, if we were to try to be aware of some of these signs and symptoms, is usually a lump or a mass that is growing in one area of the body, or a lump that was not there, and now, we can feel a lump.

Also, pain is another type of symptoms that we see sometime with sarcoma, as well as sometimes abdominal swelling. Some sarcomas start in the abdomen, and deep in the abdomen. And sometimes patients come to the office and say, "My waist size has increased significantly," and that could be also an indication of something going on.

Host Amber Smith: So how quickly do the sarcomas grow?

Jade Homsi, MD: So again, going back to what we started with, that sarcoma is multiple diseases, it's different diseases, it's not just one. And so based on what specific disease we're talking about or what specific type of sarcoma we are referring to, how rapid the growth of sarcoma could be determined.

So we do have some types of sarcomas, and I would mention some types of liposarcoma, and that's the sarcoma of the fatty tissue, could grow very slowly. And many times we could just observe patients with that condition over time and only intervene if we see significant growth.

However, some other types of sarcomas, like the more aggressive types that we see with, what we call sometimes pleomorphic sarcoma, some types of  leiomyosarcomas, these are the types where we can see a rapid growth of the sarcoma. And that sometimes can carry higher risk of a spread of the disease. These tend to be a more aggressive type of sarcomas.

Host Amber Smith: You're listening to Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with the chief of hematology and oncology at Upstate, Dr. Jade Homsi. So what tests might be done to diagnose sarcoma?

Jade Homsi, MD: So there's not really one test to diagnose sarcoma.

As I mentioned before, some people with genetic syndromes, very rare syndromes like Li-Fraumeni syndrome or Gardner syndrome, could have a higher potential to have sarcomas. And these could be monitored closely by their primary care physician and other types of health care providers.

However, once we are suspicious that there is a sarcoma, or we think a sarcoma is what someone has, then we tend to diagnose that initially with imaging testing. And these include CT scans, and these are the scans that look inside the body, in the organs. An MRI is another one that we also use. A PET scan sometimes can be used to further evaluate the spread of the sarcoma.

Eventually, we do need to be able to diagnose a sarcoma. We will need to have what we call a tissue diagnosis, meaning we need some kind of a tissue from that mass or from that suspicious lesion to be examined under the microscope. And usually, that type of testing requires very specialized equipment and personnel to be able to read the results of that tissue biopsy.

Host Amber Smith: Let's talk about treatment options. How do you decide which is the best course for a particular patient?

Jade Homsi, MD: I feel like this is maybe a little more related to also the type of the sarcoma and also how rapidly a sarcoma is growing.

Most of the time we tend to make these decisions in what we call a multidisciplinary team approach. And that's where different specialists are involved in making the treatment decisions. So once we make that diagnosis, usually it's a team approach that involves surgeons, radiation oncologists, as well as medical oncologists.

The treatment is most of the time focused, as I said, on the type of sarcoma, the stage of sarcoma, the type of symptom, and how rapidly the growth of the sarcoma has been or is. Also what determines the type of treatment we choose sometimes could be dependent on the patient. The patient's physical condition and other medical problems could play a role in determining that the best approach or the best treatment we recommend to treat the sarcoma.

Host Amber Smith: So it could include surgery and/or radiation and/or chemotherapy?

Jade Homsi, MD: Correct, correct. Many sarcoma treatments involve the combination of these three modalities, and that's why having a team approach and having very good communication between the team members addressing and treating cancer is really what we recommend for these kinds of very complicated cancer to treat.

Host Amber Smith: What about things like immunotherapy or targeted therapies? Are those used with sarcomas very often?

Jade Homsi, MD: Immunotherapy is a newer treatment that has become available in the past few years and is something that we now use in many types of cancers.

However, in sarcoma, the data, or the studies, that were done looking at immunotherapy in sarcoma have not been always successful. So sometimes we've seen some good results with immunotherapy, but these results have not been always consistent. So choosing immunotherapy for sarcoma, the decision has always been made based on the testing that we do on the tissue to tell us if a sarcoma could be responsive to immunotherapy or not.

And also the type of the sarcoma that we're dealing with. Some types of sarcoma tend to be more responsive to immunotherapy than others, and that's where we would use that kind of modality.

As far as targeted therapy, it's something that's been used in some types of sarcomas, depending on also finding the target or identifying a target, because targeted therapy, as the term may tell you, is something that is based on inhibiting a target that is involved in the development and the spread and the growth of the sarcoma. So having that as the background to targeted therapy, it's only when we know of a target that could be involved where we just recommend doing a targeted therapy.

Host Amber Smith: How long does treatment typically take and how might a person's life be impacted during the treatment?

Jade Homsi, MD: So the treatment can take a long time. And also, there are, what I would say, maybe different intents to the treatment. So in early-stage sarcoma, or the early stages of sarcomas, the intent of the treatment is, hopefully, to achieve a cure, meaning to get rid of the cancer and, eliminating any risk of the cancer, hopefully, coming back with the additional treatment that we offer.

However, when the sarcoma is in more of an advanced stage, or what we call metastatic, meaning it has spread to other places and organs, then the intent of the treatment is usually palliative, meaning to, hopefully, stop the sarcoma from growing, maybe shrink it, but we are not able to cure it. And the treatment may be ongoing for as long as the patient can tolerate the treatment. And the decision on the duration, on the type of the treatment, could be different from one patient to another.

Host Amber Smith: How likely is it that there would be a recurrence of another sarcoma or the same sarcoma coming back?

Jade Homsi, MD: So it really depends on the sarcoma we are dealing with, and that's usually determined by the stage.

So the more advanced the stage, the higher the likelihood of the sarcoma to come back, to return. The stage is usually determined by mostly two things, which is the size -- the larger the size, the higher the chances of the sarcoma returning. Also something we call the grade. The grade is how the cells look under the microscope and how fast they're dividing. And so the higher the grade, the sarcoma is also the higher likelihood of the sarcoma returning.

Host Amber Smith: Does having a sarcoma raise a person's risk of other cancers, like in an organ or a blood cancer?

Jade Homsi, MD: Usually what raises the risk of having other cancer is really the treatment for the sarcoma.

So, as I mentioned, radiation itself, which is a treatment that is used in treating sarcoma, can cause cancer itself in the future. Some of the chemotherapy that we use to treat sarcoma also can cause cancer later on, many years after the treatment and after receiving the chemotherapy. An example of that is things like leukemia, for example, we see after the use of chemotherapy, and that usually happened years after completing chemotherapy.

Host Amber Smith: Well, Dr. Homsi, I thank you so much for making time to tell us about sarcomas. Thank you.

Jade Homsi, MD: Thank you. Appreciate it.

Host Amber Smith: My guest has been Dr. Jade Homsi, the chief of the division of hematology and oncology at Upstate.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe, with sound engineering by Bill Broeckel and graphic design by Dan Cameron.

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