Susie Ruppelt, dedicated mother, attorney and runner, didn't think anything of it when she began having nighttime pain in her thigh. After all, she was training extra-hard in preparation for a vacation and had probably strained a muscle. But then, she noticed her pants felt tight — on one side only — and she discovered a large lump on the inside of her left thigh. After a series of tests, her primary care physician suspected soft tissue cancer and referred Susie to the Froedtert & Medical College of Wisconsin Cancer Center for further testing and diagnosis.
There, she found expert care from a team of cancer specialists who dedicate their careers to helping save the lives — and limbs — of people with bone and soft tissue cancers. The team includes two of the four musculoskeletal oncologists in Wisconsin — orthopaedic surgeons with advanced fellowship training in treating bone and soft tissue cancer — as well as sub-specialist radiologists and a pathologist who is fellowship-trained in diagnosing musculoskeletal diseases.
Bone and soft tissue cancers are relatively rare, making expert treatment hard to find. "Most hospitals see one or two cases a year, while at Froedtert & Medical College of Wisconsin, we see 15 times that," says Susie's physician, David M. King, MD, Medical College of Wisconsin musculoskeletal oncologist. Patients from all over Wisconsin, Michigan's Upper Peninsula and northern Illinois travel to Milwaukee for precise diagnosis, advanced therapy, access to the newest drugs, participation in national research studies and limb-saving surgery.
Specialists from radiology, pathology, medical oncology, radiation oncology and plastic and reconstructive surgery meet at a regularly scheduled conference with musculoskeletal oncologists to collaborate on each patient's care and treatment plan, each bringing to the table a wealth of knowledge and experience.
Making Amputation Obsolete
"When I first met Dr. King, I told him I feared two things: death and amputation," says Susie. "He said, 'You're not going to die and I'm not going to cut off your leg.' I left the meeting feeling incredibly relieved and 100 percent confident I would receive the best possible care."
"Fifteen to 20 years ago, amputation was the standard treatment for most types of bone and soft tissue cancer," explains Donald Hackbarth, MD, Medical College of Wisconsin musculoskeletal oncologist. He and Dr. King, however, are specialists in limb salvage, helping to make amputation a thing of the past. Surgery to remove the tumor, plus reconstruction using bone or an implant, combined with radiation therapy and/or chemotherapy, is now considered the gold standard of treatment. Studies have shown no difference in recurrence rates or rates of metastasis — the spread of cancer to another area of the body — between amputation and limb salvage. And at the Froedtert & Medical College of Wisconsin Cancer Center, advances in implant technology have created implants that remain functional for many years.
In Susie's case, Dr. King removed the inner thigh muscles and the tumor, which radiation had shrunk to less than half of its original grapefruit size. Hanh Nguyen, MD, Medical College of Wisconsin plastic and reconstructive surgeon, then created a "flap" from Ms. Ruppelt's abdominal muscles, which he flipped over to fill the space.
Achieving such positive outcomes requires an extremely precise diagnosis, since certain cancers respond to different treatments. "Without an exact diagnosis, there is no way to do proper treatment," says Vladimir Osipov, MD, Medical College of Wisconsin musculoskeletal pathologist. Dr. Osipov brings to Froedtert & Medical College of Wisconsin diagnostic skills honed by working with world-recognized experts in the field. During his fellowship at Mayo Clinic, he estimates he studied close to 4,000 orthopaedic cancer cases, more than any other pathologist in Milwaukee. Dr. Osipov says the rapid development of knowledge about cancer has created the need for sub-specialists who can more easily keep on top of recent findings and new procedures.
Among the advanced tools in his diagnostic arsenal are immunostains, in which antibodies against certain tumorspecific receptors are applied to the tumor cells. By using these tumor markers, Dr. Osipov can observe the reaction and make a definitive identification.
Genetic studies are another important tool, as many tumors have been found to have very specific chromosomal abnormalities. In a type of bone cancer known as Ewing's sarcoma, for instance, a portion of the 11th chromosome shifts to the 22nd chromosome and vice versa. This type of chromosomal abnormality and more subtle changes can be observed in the laboratory by growing tumor cells in a special medium.
Advances in radiology also make diagnosis — and treatment — more precise. The Cancer Center utilizes the most advanced imaging technology available to help determine the best course for each patient. This includes the most up-to-theminute MRI, CT and PET scanning, along with nuclear and ultrasound studies. But, says Guillermo F. Carrera, MD, Medical College of Wisconsin radiologist and a specialist in bone radiology, equally important is the skill of the radiologist, who must apply that instrumentation in very specific ways for musculoskeletal cancer.
The refinement of image-guided biopsy has greatly increased surgeons' precision as well. "The difference of a few milliliters can mean the difference between saving a limb and amputating," says Dr. Carrera. "Image-guided biopsies allow us to see the relationship between the tumor and nearby critical structures, such as blood vessels and nerves, making it much safer for the patient."
But the most important thing, he says, is the combined knowledge of a multidisciplinary group of experts: "The real key is having a team that understands musculoskeletal diseases."
Research funding for rare cancers, such as bone and soft tissue sarcomas, is harder to secure than for more common diseases, such as breast or lung cancer. But the Cancer Center's orthopaedic cancer team has joined a consortium of other academic medical centers to combine data — and allow Froedtert & Medical College of Wisconsin patients access to the latest findings.
Drs. Hackbarth and King are involved in several research studies investigating new fixation techniques for bone reconstruction, the effect of bone mineral density changes in children with bone sarcomas, and the use of MRI studies to analyze tumor vascularity.
Less than a year after her diagnosis, Susie Ruppelt is back at work, walking without crutches and grateful for the care she received at the Froedtert & Medical College of Wisconsin Cancer Center. "I don't think I could have been in better hands," she says. "The doctors and staff answered all my questions and helped me maintain a positive attitude during a frightening time. It was comforting to know that I was getting the best medical care available.
"Almost every day since my surgery, my five-year-old son, Jack, asks me when my 'bump leg' is going to be better. It's been hard for him, because I can't run or play sports with him, and he is sensitive to my physical limitations. However," she says, "thanks to Dr. King and the entire team, it won't be long before I'll be running with Jack again."