Dr. Orthochick: Curing cancer (not)

Mom: What's on your agenda for the week?
Me: Curing cancer.

Hey, it's not a total lie.

We did a big sarcoma case today, which I was looking forward to because I've never seen one. Soft tissue sarcomas are pretty rare, which is a good thing because they're aggressive as hell. It's deceptive, you figure if you have a tumor on your arm you can cut it out and you'll be fine, but they tend to invade your nerves and blood vessels, which means if you cut it out, you probably also have to cut off your arm since it won't be viable anymore. Also, they metastasize to the lungs. So they have a pretty crappy 5-year survival rate, and since they're so rare, not much research goes into these things so we don't have great ways of treating them. Usually you hit them with radiation, which in and of itself carries a risk of causing sarcoma.

So like I said, the surgery involves totally gutting the extremity. If you're lucky, you wind up with a functional extremity. If not, you get an amputation. This guy had a giant soft tissue tumor sitting right in his arm. It was about the size of a grapefruit and had been steadily growing for the past few months, but since he didn't have insurance and it didn't hurt, he didn't do anything about it. So by the time he was able to get an MRI of it, it had invaded his radial artery and a couple of nerves. It was also sitting right in the muscle that helps you extend your wrist. It hadn't spread to his lungs, which is good, but it also hadn't shrunk much with the 30 doses of radiation it had been attacked with, which is bad.

We made a long incision over the mass and the radial artery was pulsating through it. Which meant the radial artery had to go. Most people are actually ulnar artery-dominant (even though the radial pulse is the one you feel) so you can still have a functional arm without a radial artery, but it's not a great sign if that's the first thing you see in a surgery. So we tied off the artery, which is probably one of three times in ortho that I hand-tie my surgical knots. (I'm not including arthroscopic knots in this. The other two times that I can think of off the top of my head are when you use pop-off sutures at the end of a spine surgery and when you're with Dr. Smile and he makes you sew wound towels into your sterile field) The only reason I mention this is because this was stressed as very important on my general surgery rotation and my OB-GYN rotation and seriously, it's instrument tie or bust over here. I mean, I know how to hand tie, but I promise, you can be a surgeon without really being good at it.

The rest of the surgery was pretty much more of the same. Since he had received radiation preoperatively, his tissues were really friable, so they bled any time you touched them. Which meant the surgical field was a big bloody mess. Also, we had to sacrifice most of his wrist extensors since they had tumor strewn throughout them. We lost a couple of nerves to the tumor. After about three hours of this, we closed him up and called it a day. Except the thing is, we hadn't removed the whole tumor. It was so extensive that there wasn't going to be a way to get the whole thing out and still give him a viable arm. The tumor had crawled over almost the entire forearm and slimed down to the bones. So normally you resect the whole tumor and 5cm margins in all directions, but in this case we didn't bother since it wouldn't be possible to get margins without an amputation.

Dr. Tumor: We are so intralesional, it's not even funny.

So yeah, surgery was a big bloody mess and the dude is still going to need an amputation. I guess we're not really curing cancer over here.