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Sarcomas and Bone Health: When a Painless Lump is More Than Just a Mass · Fit As A Fiddle

• 0:00
  SPEAKER_00: Some people will surprise you very positively where you thought that they would take a long time to recover and not get a hundred percent function back and they you recover quickly.
• 0:11
  SPEAKER_00: And then you could have another patient with a very similar situation who takes a lot longer to recover.
• 0:18
  SPEAKER_00: And you did the exact same thing.
• 0:20
  SPEAKER_00: Everything was more or less the same.
• 0:22
  SPEAKER_00: It's just a matter of patient factors, luck, and whatever else may be influencing it.
• 0:28
  SPEAKER_01: Hello, everyone.
• 0:29
  SPEAKER_01: I'm your host, Dr.
• 0:30
  SPEAKER_01: Sneha Ghazi, a physical therapist, course creator, and mom.
• 0:35
  SPEAKER_01: I own Sneha Physical Therapy, a private practice in New York City, and created the course Master Your Pelvic Floor to help you transform the way you think about and move your body.
• 0:46
  SPEAKER_01: Use discount code FIT20 for a special 20% discount exclusively from my listeners at the link in all show notes.
• 0:53
  SPEAKER_01: Each episode brings phenomenal guests in the health and wellness space who share inspiring tips and tangible advice.
• 1:01
  SPEAKER_01: All things health and wellness starts right here.
• 1:05
  SPEAKER_01: Welcome to this week's episode on Fit as a Fiddle.
• 1:08
  SPEAKER_01: Our guest today is Dr.
• 1:10
  SPEAKER_01: Ilya Ayofin.
• 1:12
  SPEAKER_01: He is the Chief of Orthopedic Oncology Service at Mount Sinai Hospital.
• 1:16
  SPEAKER_01: And we met recently, and I'm really, really, really interested to learn about his work and how he treats patients here in New York City.
• 1:25
  SPEAKER_01: He comes from a really wonderful background of education and really, really cares about his patients.
• 1:31
  SPEAKER_01: So welcome to the show today, Dr.
• 1:32
  SPEAKER_01: Ayofin.
• 1:34
  SPEAKER_00: Thank you very much.
• 1:35
  SPEAKER_00: It's a pleasure to be here.
• 1:36
  SPEAKER_01: Absolutely.
• 1:37
  SPEAKER_01: Thank you for talking to our listeners.
• 1:39
  SPEAKER_01: I know your time is very, very precious.
• 1:41
  SPEAKER_01: So first, I would love for everyone to get a chance to know you a little bit better.
• 1:46
  SPEAKER_01: So could you tell us a little bit about your background and what brought you to this field of medicine and why do you do what you do every day?
• 1:54
  SPEAKER_00: Certainly.
• 1:54
  SPEAKER_00: So I specialize in orthopedic oncology, which is the rarest subspecialty of orthopedics.
• 2:00
  SPEAKER_00: There are only about like 15 doctors who specialize in this in New York City.
• 2:06
  SPEAKER_00: While if you look at doctors who treat traumas or the joint replacements in orthopedics, there are hundreds of those, if not thousands.
• 2:14
  SPEAKER_00: And um I enjoy doing what I do because we really see the outcomes, and the patients are usually very grateful.
• 2:23
  SPEAKER_00: And some the patients I treat, some of them have benign tumors, others have, unfortunately, cancers or malignant tumors.
• 2:32
  SPEAKER_00: But it becomes, you can make a very big difference in a patient's life and they express it.
• 2:38
  SPEAKER_00: And oftentimes the things that we take for granted, like the ability to walk the patients, they once they s lose it for some time or are at risk of losing it, they're very grateful of when they're able to have this ability back.
• 2:56
  SPEAKER_00: And as far as how I chose orthopedic oncology and residency, I kind of liked everything in orthopedics.
• 3:04
  SPEAKER_00: I liked trauma, I liked joint replacements.
• 3:07
  SPEAKER_00: And I couldn't quite pick what I wanted to do, but then I found that in orthopedic oncology there's lots of variety.
• 3:15
  SPEAKER_00: So you have broken bones which break because of cancer.
• 3:19
  SPEAKER_00: You take out big fragments of bones due to cancer and replace them to like big joint replacements.
• 3:25
  SPEAKER_00: So it's almost it's almost it never happens that you do the same, two of the same surgery in one day.
• 3:33
  SPEAKER_00: I've probably like a 17 years of practice had two days like that where it's like, wow, I did the same surgery twice in one day.
• 3:41
  SPEAKER_00: Wow, if you do hip or knee replacements, it's every day that you do the same thing almost.
• 3:47
  SPEAKER_01: Wow.
• 3:47
  SPEAKER_01: And I think what that speaks to is the level of expertise that's required.
• 3:52
  SPEAKER_01: Because when you do something every single day, you kind of get into like a rhythm, right?
• 3:56
  SPEAKER_01: It's like sort of you just keep rinse and repeat, rinse and repeat.
• 4:00
  SPEAKER_01: But I feel like you always have to be on when you get new things coming in.
• 4:03
  SPEAKER_01: I mean, especially as a physical therapist, you know, I treat largely more or less similar things on a regular basis.
• 4:11
  SPEAKER_01: But when there's like, you know, a rare genetic condition or something that comes through, you have to kind of look that up and research it and make sure that you know what you're doing if it's something that you're not doing every single day.
• 4:21
  SPEAKER_01: But for you, it seems like every day is like that, which just speaks to the level of, I guess, expertise, focus, concentration, and also creativity.
• 4:29
  SPEAKER_01: I'm sure that there's a lot of thinking on the spot and critical reasoning.
• 4:33
  SPEAKER_01: And, you know, it's not just a memorization or repeating the same thing.
• 4:37
  SPEAKER_01: So um, thank you for being one of the few people who do this in New York City.
• 4:41
  SPEAKER_01: Thank you.
• 4:41
  SPEAKER_00: Thank you.
• 4:42
  SPEAKER_00: Yeah.
• 4:43
  SPEAKER_01: So um before we jump into our topic of conversation today, which is the soft tissue sarcomas, which we're gonna break down.
• 4:51
  SPEAKER_01: Can we just talk about cancer as a whole in the first place?
• 4:55
  SPEAKER_01: As somebody who just kind of dedicated his life to this.
• 4:58
  SPEAKER_01: So I personally I lost two of my grandmas to cancer.
• 5:02
  SPEAKER_01: My uh one yeah, one was uh multiple myeloma, thank you, and the other one was a non-smoking type of lung cancer that kind of got passed down.
• 5:10
  SPEAKER_01: Her mother, her cousin, her sister, a lot of people in the family had passed away from.
• 5:14
  SPEAKER_01: Um, and so I guess when people think about cancer, right?
• 5:18
  SPEAKER_01: I'm just trying to think when the word cancer comes to your mind, I feel like a few things might go off.
• 5:24
  SPEAKER_01: It's either like death, right?
• 5:26
  SPEAKER_01: People are like, oh, you got cancer, you're gonna die immediately.
• 5:29
  SPEAKER_01: Some other people might think uh cancer is just not something that belongs to, you know, organ-related disease.
• 5:37
  SPEAKER_01: Um, what we know is that it's use soft tissue, it could be bone-related, it could be blood related, it could be, it could be if cancer can present in so many different ways.
• 5:45
  SPEAKER_01: It's not just limited to just lung cancer, just cervical cancer, or just breast cancer, which is kind of like some of the top things people might think of.
• 5:54
  SPEAKER_01: So, my question to you is what is your way of explaining what cancer is and how it presents to your patients when you first try to explain this to them?
• 6:06
  SPEAKER_00: Well, usually when patients come in, they already know, they have a general idea of what the cancer entails.
• 6:11
  SPEAKER_00: But and if you think of cancer, it's not necessarily one disease, it's a kind of a grab bag of diseases.
• 6:18
  SPEAKER_00: So you can have breast cancer, you can have soft tissue sarcoma, they all behave differently.
• 6:23
  SPEAKER_00: They have different genetic mutations, they affect you differently.
• 6:27
  SPEAKER_00: You can have a skin cancer such as squamous cell carcinoma, which most of the time, if it's caught reasonably early, it can be removed and almost never spreads.
• 6:37
  SPEAKER_00: On the other hand, you take the same cancer, let it grow to where it gets large enough and then it starts invading into the deeper tissues, and then it can metastasize it, meaning it can spread, it can become deadly.
• 6:48
  SPEAKER_00: And then you take another skin cancer such as melanoma, which even at early stages can be very dangerous and can be life-threatening.
• 6:56
  SPEAKER_00: And then you take the same type of cancer.
• 6:58
  SPEAKER_00: Let's say you take somebody with breast cancer, then you look at the mutations that it may have.
• 7:03
  SPEAKER_00: Some people have some cancers, they are responsive to the female hormones, other cancer in other patients' cancers they are not, and that makes a big difference in prognosis and treatment.
• 7:16
  SPEAKER_00: And so it's a kind of a grab bag of diseases.
• 7:19
  SPEAKER_00: But when I speak to patients, I usually explain to them what their specific cancer is, and then the biggest question becomes is there a chance of cure for this cancer or not?
• 7:29
  SPEAKER_00: So usually the general rule is once the cancer has spread, in most cases, you can manage it for a long time with medications like chemotherapy or immunotherapy, which is a newer um type of uh treatment, but usually you can't cure it.
• 7:44
  SPEAKER_00: On the other hand, if you have a cancer, let's say a soft tissue sarcoma, which you can remove surgically, and then you have a reasonable chance of curing the patient where they can live for many, many years without the cancer ever showing up again.
• 8:00
  SPEAKER_00: So I usually I explain to the patient like what their situation is, and also you don't want to tell them it's not curable, you try to explain it, say, you know, we'll try to control it for as long as possible.
• 8:13
  SPEAKER_00: Uh and but without saying that, you know, it's ultimately going to regress, unfortunately.
• 8:23
  SPEAKER_00: But other cases where you say you have a reasonable chance of cure, but also you obviously don't give any guarantees because nobody can guarantee anything in life, especially not in medicine.
• 8:34
  SPEAKER_01: Yeah.
• 8:34
  SPEAKER_01: No, I think that that that brings an interesting point because I remember when both my grandmothers were going through their um cancer treatments.
• 8:41
  SPEAKER_01: That was like obviously the family's question who was how long does this person have?
• 8:46
  SPEAKER_01: Like, what's going on?
• 8:47
  SPEAKER_01: What is the prognosis?
• 8:49
  SPEAKER_01: What can we expect?
• 8:50
  SPEAKER_01: And the pervasive answer was, we don't know.
• 8:53
  SPEAKER_01: And we can't and guarantee or tell you like this is the number of weeks or months or days, or this is what it's gonna look like, or this is how she's gonna respond to the different types of treatments that we're going to try.
• 9:05
  SPEAKER_01: They usually will say something along the lines of, you know, she had great doctors and both of them.
• 9:10
  SPEAKER_01: And I think they said something to the effect of, we're gonna do everything that we can to provide whatever evidence-based treatments, you know, the immunotherapy, which was more my um one of my grandmothers just passed away less than a year ago, and she didn't get the immunotherapies, which were considered newer.
• 9:26
  SPEAKER_01: And they just told us the evidence-based data.
• 9:28
  SPEAKER_01: They're like, this is what we know, this is the statistics, this is the research, but we don't know how she is gonna respond to this, right?
• 9:35
  SPEAKER_01: Like anybody can respond to treatments differently.
• 9:38
  SPEAKER_01: And that's the same thing with PT2.
• 9:40
  SPEAKER_01: I can never tell a patient, like, in six weeks, you're gonna be la-di-da.
• 9:43
  SPEAKER_01: It's here's what we kind of predict, but we uh so much of it is how does your body react and respond to it, which is based on so, so, so many things, right?
• 9:53
  SPEAKER_01: It's not even just like a physical response, but there's an emotional and a psychological response that affects the tissues and affects your physical response as well.
• 10:01
  SPEAKER_01: So um, I think you said that beautifully.
• 10:03
  SPEAKER_01: That it it I know that people, it's so hard being on the family side because you want clarity, but so much of medicine and especially something like cancer, which is just a whole, you know, process on its own, you can't really predict what's gonna happen.
• 10:19
  SPEAKER_01: So I do, I do love how you frame that.
• 10:21
  SPEAKER_01: And it's patient specific, right?
• 10:22
  SPEAKER_01: It's cancer specific and it's also patient specific.
• 10:25
  SPEAKER_01: So depending on the type stage and I guess also the comorbidities, which are for people listening, the other factors that play into disease processes, not just the like if somebody has diabetes and high blood pressure and age is a factor and other kinds of uh conditions, if they have a heart condition, if they have other kinds of other disease processes or other issues in their um organs or other tissues or other systems, that can affect treatment.
• 10:52
  SPEAKER_01: That can affect the type of treatments that they receive and um change the prognosis.
• 10:57
  SPEAKER_01: So um let's dive into the soft tissue sarcomas, because I know you mentioned this is um your specialty specifically, and I don't know much about it.
• 11:06
  SPEAKER_01: I don't know too much about it.
• 11:08
  SPEAKER_01: So I would love for you to first break down what kind of what is a sarcoma.
• 11:13
  SPEAKER_01: Let's start there.
• 11:13
  SPEAKER_01: What is a to explain to everyone what is a sarcoma as it relates to cancer?
• 11:18
  SPEAKER_00: So sarcoma, it's a very rare type of cancer uh that arises from the connective tissues.
• 11:25
  SPEAKER_00: And generally you can break it up into bone sarcoma.
• 11:29
  SPEAKER_00: So sarcomas arising in bone and soft tissue sarcomas that arise in the soft tissues, usually muscle, it could be fat, it could be and the tendons entities like that.
• 11:40
  SPEAKER_00: They are very rare.
• 11:41
  SPEAKER_00: So soft tissue sarcomas, they're about 15,000 cases a year on average in the United States, which has a population well over 30, 300 million people.
• 11:52
  SPEAKER_00: And bone sarcomas are even more rare.
• 11:55
  SPEAKER_00: They're on the order of maybe seven, eight thousand cases a year.
• 11:58
  SPEAKER_00: So very rare diseases.
• 12:01
  SPEAKER_00: And as any cancer, they can spread and they vary in their in how aggressive they are.
• 12:09
  SPEAKER_00: Uh for bone sarcomas.
• 12:11
  SPEAKER_00: Usually the treatment, there are several types of bone sarcoma, such as osteosarcoma, ewing sarcoma, and chondrosarcoma.
• 12:18
  SPEAKER_00: Osteosarcomas produce bone, chondrosarcomas produce cartilage, just the tissue that you see, the pathologist sees under the microscope.
• 12:25
  SPEAKER_00: For most of them, the treatment is a combination of chemotherapy and surgery, except for chondrosarcoma, where it's just surgery.
• 12:32
  SPEAKER_00: But what, and then for soft tissue sarcomas, surgery is the mainstay of treatment.
• 12:37
  SPEAKER_00: Um role of chemotherapy is still somewhat controversial.
• 12:41
  SPEAKER_00: It's not clear if it helps as opposed to bone sarcoma such as osteosarcoma, where you know that without chemotherapy, the chances of cure are minuscule.
• 12:52
  SPEAKER_00: And then radiation and soft tissue sarcoma also plays a role where it lowers the risk of the cancer growing back in the same spot.
• 13:02
  SPEAKER_01: Okay.
• 13:03
  SPEAKER_01: So when you are talking about surgery, right?
• 13:07
  SPEAKER_01: Like people usually might think of that as like being a last resort or being like a big intervention that can happen.
• 13:14
  SPEAKER_01: But um, I know you explained that surgery is a mainstay for some of these types of sarcomas.
• 13:20
  SPEAKER_01: What uh what do you explain to patients and how do what do they expect going in and what what kind of level of function do they feel like they can have post-surgery?
• 13:31
  SPEAKER_00: Well, just to take a histor step back historically, up until maybe like the 1970s or so, all of the sarcomas more or less were treated with an amputation.
• 13:41
  SPEAKER_01: And so that's what I was thinking.
• 13:43
  SPEAKER_01: Yeah.
• 13:43
  SPEAKER_00: Yeah.
• 13:44
  SPEAKER_00: So people used to think of it, it's like if I have a sarcoma, you know, I'm done for.
• 13:48
  SPEAKER_00: But then now, for the most part, we do limb sparing surgery, meaning that you're able to preserve the arm or leg where the sarcoma is.
• 13:57
  SPEAKER_00: And people can have very good function.
• 14:00
  SPEAKER_00: But as we spoke about before, it there are many very variables.
• 14:04
  SPEAKER_00: You can have a very small sarcoma that you can remove and the patient can have excellent function, or you can have a very large sarcoma that after removing it, you know, you're going to maybe walk with a limp or you're going to be weaker.
• 14:20
  SPEAKER_00: The radiation can cause stiffness.
• 14:22
  SPEAKER_00: So it's very variable on the factors of every specific patient as to what the outcome is likely going to be.
• 14:31
  SPEAKER_00: And you explain to the patient that, you know, this is what we need to do.
• 14:35
  SPEAKER_00: That's how to remove it.
• 14:37
  SPEAKER_00: And that's the most likely outcome.
• 14:39
  SPEAKER_00: And again, without any guarantees, because some people will surprise you very positively where you thought that they would take a long time to recover and not get a hundred percent function back and they recover quickly.
• 14:53
  SPEAKER_00: And then you could have another patient with a very similar situation who kind of takes a lot longer to recover.
• 15:02
  SPEAKER_00: And you did the exact same thing.
• 15:04
  SPEAKER_00: Everything was more or less the same.
• 15:05
  SPEAKER_00: It's just a matter of patient factors, luck, and whatever else may be influencing it.
• 15:12
  SPEAKER_01: Okay.
• 15:13
  SPEAKER_01: So coming actually taking even more steps back, when I know you mentioned that some of these soft tissue sarcomas, especially, people are coming in because they at first it's painless.
• 15:23
  SPEAKER_01: So it's hard to identify.
• 15:24
  SPEAKER_01: So what do people come in for?
• 15:25
  SPEAKER_01: How do they first kind of um like for somebody who's listening, what are the symptoms or what would they be coming in for that this is detected?
• 15:33
  SPEAKER_01: Is it kind of like a secondary, they have something else going on, and it just through imaging that they figure this out, or or how do you guys identify?
• 15:40
  SPEAKER_00: It's usually it's patients come in, they they feel a lump.
• 15:43
  SPEAKER_00: So it might be like a mask wearing on the thigh, bodic area, arm.
• 15:48
  SPEAKER_00: And for the most part, they're painless.
• 15:51
  SPEAKER_00: And uh that's what sometimes people don't take it seriously.
• 15:56
  SPEAKER_00: They say, you know what, I have a lump growing on my thigh, it doesn't hurt, it can't be anything bad.
• 16:01
  SPEAKER_00: Unfortunately, that's not the case because post-soft tissue sarcomas are painless.
• 16:06
  SPEAKER_00: And so, and sometimes you'll even see doctors who get confused enough about it.
• 16:12
  SPEAKER_00: And I've had patients who said, Yeah, I saw my primary care doctor, and he told me if this lump doesn't hurt, it's not a big deal.
• 16:18
  SPEAKER_00: And that unfortunately can lead to delayed treatment.
• 16:22
  SPEAKER_00: But that said, each time you feel a bump, it doesn't necessarily mean that it's likely to be a sarcoma, because as I mentioned, about 15,000 cases a year in the United States, there are also benign soft tissue masses, which are far more common than sarcomas.
• 16:37
  SPEAKER_00: So, for example, a lipoma, maybe one to two percent of the population is affected by lipomas, which are benign fatty deposits, they're most commonly occur under the skin.
• 16:48
  SPEAKER_00: So if you have a little bump, more likely than not it's going to be benign, especially if it's just right under the skin, if it's very superficial, if it's small, if it's under two inches in greatest dimension, and if it's not growing.
• 17:03
  SPEAKER_00: On the other hand, if you have something that feels like it's deep within muscle, if it's more than two inches in size, and if it's growing, even if it's painless, you know, take it seriously, see a doctor.
• 17:15
  SPEAKER_01: What if it is just because I think it's really important for listeners to hear and understand the difference?
• 17:20
  SPEAKER_01: Because I have seen people who have told me when I'm, you know, assessing them and I'm like, oh, I feel I see a bump here.
• 17:26
  SPEAKER_01: Do you know that this is exists?
• 17:27
  SPEAKER_01: And oftentimes they'll more more than often they'll say, Oh, I just got this checked out.
• 17:32
  SPEAKER_01: It's a benign, it's a lipoma, it's a it's just a regular lump.
• 17:35
  SPEAKER_01: Um for both healthcare practitioners listening and for um patients who may be or anybody else who may be listening.
• 17:43
  SPEAKER_01: Um, I know you mentioned that two inches diameter or under is more likely than not a lipoma.
• 17:48
  SPEAKER_01: But when you're talking about depth, what if it is more in in a superficial area, like for example, like closer to bony prominences, like not in the knee of your hamstring muscle, for example?
• 17:59
  SPEAKER_01: But what if it's somewhere where it the the muscle itself is in a more superficial area?
• 18:04
  SPEAKER_01: Well, what are your chances of, or I know you can't say it right off the bat, but what what what would you be thinking of if it's somewhere on your shoulder, for example, or somewhere on the back of your neck, for example?
• 18:14
  SPEAKER_00: Well, it depends.
• 18:15
  SPEAKER_00: For example, on the shoulder, you just like if it feels like it's right under the skin, you can freely move it around.
• 18:20
  SPEAKER_00: And even if the muscle, so you stand stop, it's still mobile, it's more it means that it's superficial.
• 18:26
  SPEAKER_00: On the other hand, if you feel like you really need to dig deep in there and you feel the lump that's not right under the skin, but it's within the muscle itself, then it becomes far more concerning.
• 18:36
  SPEAKER_00: But that said, some sarcomas are subcutaneous, meaning they're right under the skin.
• 18:42
  SPEAKER_00: So just because something is uh right under the skin doesn't guarantee that it's going to benign to be benign.
• 18:49
  SPEAKER_00: It just makes says that it's most likely that it's going to be benign.
• 18:53
  SPEAKER_00: And also the sarcomas, again, there are many different subtypes.
• 18:58
  SPEAKER_00: For the most part, they grow and they grow relatively quickly.
• 19:01
  SPEAKER_00: So if you have a small superficial mass that's been present for 10 years, most likely it's benign.
• 19:08
  SPEAKER_00: On the other hand, on occasion you'll see patients, and it's very rare, who come in and they say they've had this mass that's been present for 15 years, 20 years, and then you get an MRI.
• 19:19
  SPEAKER_00: And that's usually what you the first step in evaluating potential soft tissue mass.
• 19:24
  SPEAKER_00: And it doesn't look like anything like a lipoma or a ganglion cyst, which is a fluid-filled cyst, which are all benign entities, and you biopsy, it turns out that it's some sort of sarcoma.
• 19:36
  SPEAKER_00: And again, those are very rare, but it just again, something that's been present for a long time most likely is benign, but unfortunately not a guarantee.
• 19:45
  SPEAKER_01: Got it.
• 19:46
  SPEAKER_01: So a couple of things that I'm hearing from you, and correct me if I didn't summarize this right, but I'm hearing that depending on the size, how long it's been present and how mobile it is, and how superficial it is, those are all factors to consider from clinical reasoning.
• 20:03
  SPEAKER_01: But of course, we you'd have to get an MRI and a biopsy to confirm it.
• 20:07
  SPEAKER_01: So for listeners, I think it's always a good idea to get it checked out.
• 20:12
  SPEAKER_01: And maybe because you're saying a lot of um primary care physicians may not be able to identify correctly.
• 20:19
  SPEAKER_01: So maybe if you're told that it's nothing, maybe you just get another opinion about it.
• 20:24
  SPEAKER_01: Um it's just important to make sure that you catch these things early because the timeline changes everything, right?
• 20:32
  SPEAKER_01: For you, if you kind of just let it sit there for a really long time versus catching it early and re- and acting early.
• 20:38
  SPEAKER_00: No, surely I've seen patients where I've seen them where they had an MRI where it was this very small soft tissue mass, and for whatever reason they did, and which turned out to be a sarcoma, they didn't have it removed where removal there would have led to excellent function.
• 20:53
  SPEAKER_00: And then you see them like a year or two later, and at that point the surgery is far more morbid and the function is much worse.
• 21:02
  SPEAKER_00: And then you mentioned also take a step back about a biopsy.
• 21:06
  SPEAKER_00: Not every soft tissue mass needs to be biopsied.
• 21:09
  SPEAKER_00: Sometimes, based on the MRI alone, you can say with a high degree of confidence that this is nothing worrisome.
• 21:16
  SPEAKER_00: And at times just observation is uh the proper answer.
• 21:21
  SPEAKER_00: But again, it's very every case is different.
• 21:25
  SPEAKER_00: With that said, also not to scare people that if you have like a pin-sized nodule that's under the skin, you know, doesn't mean you need to run and check out if it's a cancer or not.
• 21:36
  SPEAKER_00: On the other hand, if it's something that's deeper and growing, even if it's painless, you'd be more alarmed by the fact that it's growing than be reassured by the fact that it's painless.
• 21:48
  SPEAKER_01: Yeah.
• 21:49
  SPEAKER_01: So the the growth factor is really important for people to see that it's changing in structure because that's what cancer does, right?
• 21:55
  SPEAKER_00: It's supposed to be very much so.
• 21:57
  SPEAKER_00: Correct.
• 21:58
  SPEAKER_00: With those rare exceptions of these.
• 22:00
  SPEAKER_00: Rare sarcomas.
• 22:01
  SPEAKER_00: I've seen maybe two patients like that where they had a mass where they said it's been there for 10 or 20 years, it hasn't grown.
• 22:09
  SPEAKER_00: And then it turned out to be a sarcoma.
• 22:12
  SPEAKER_01: Yes.
• 22:13
  SPEAKER_01: So basically you still never know.
• 22:15
  SPEAKER_01: Now, what if somebody's listening and they're like, oh, I happen to have this lump, it's just probably a good idea to get it checked out.
• 22:21
  SPEAKER_01: My doctor told me X number of months ago or however long ago that it's nothing to be worried about it's nothing that we need to worry about.
• 22:29
  SPEAKER_01: Who should they go see, or what kind of a professional should they go see to get a proper assessment if their primary care said it was nothing?
• 22:38
  SPEAKER_00: So orthopedic oncologists, we certainly specialize.
• 22:41
  SPEAKER_00: We treat a good number of patients with soft tissue masses, both benign and malignant ones like sarcomas.
• 22:47
  SPEAKER_00: Then the general surgeons, they also have a subspecialty of surgical oncology, where they also treat uh soft tissue masses and soft tissue sarcomas.
• 22:58
  SPEAKER_00: You know, with me being an orthopedic oncologist, I'm biased towards the orthopedic side, but certainly the general surgeons do a very good job with those in most cases.
• 23:08
  SPEAKER_01: Wonderful.
• 23:09
  SPEAKER_01: Okay, so lots of great information here.
• 23:12
  SPEAKER_01: Um, if I could snag you for a little longer, could we talk about the metastatic bone diseases as well?
• 23:17
  SPEAKER_01: So the audience can learn a little bit more about what that is and how that's different from what we've already spoken about.
• 23:24
  SPEAKER_00: No, certainly.
• 23:25
  SPEAKER_00: So, you know, there are many cancers that can metastasize the bone.
• 23:29
  SPEAKER_00: Realistically, just about any cancer can metastasize the bone, but there are the five main ones that can do so.
• 23:36
  SPEAKER_00: It's going to be breast, prostate, lung, kidney, and thyroid cancer.
• 23:41
  SPEAKER_00: Uh and if they metastasize the bone, it's usually means for the most part, unfortunately, it's not going to be, you're not going to be able to cure the patient, but you can help them a lot because sometimes the tumors in the bone they can be painful.
• 23:57
  SPEAKER_00: At other times they can even weaken the bone to the point where it fractures.
• 24:02
  SPEAKER_00: Uh the important thing where it's more like a point, not for patients, but more for doctors, especially orthopedic surgeons, sometimes if you it's usually pretty obvious in an x-ray if a bone fractured through because of a tumor weakening it.
• 24:17
  SPEAKER_00: And also the history is different.
• 24:19
  SPEAKER_00: So if somebody uh has a broken femur or the thigh bone because they're hit by a truck, well, it's likely the bone was healthy, just that the truck hit them.
• 24:28
  SPEAKER_00: But if somebody was walking along the street and their femur snapped and they fell into without really any injury, their bone broke.
• 24:36
  SPEAKER_00: And the femur, it's a very strong bone.
• 24:38
  SPEAKER_00: It takes a lot of force to break because normal femur.
• 24:42
  SPEAKER_00: Or somebody was just jogging along or twisted wrong and it fractured, most likely you have to suspect there may be a tumor there.
• 24:50
  SPEAKER_00: But and usually metastatic disease of bone, it affects people who are a little bit older over age 40.
• 24:56
  SPEAKER_00: While people under age 40, it's more likely to be a bone sarcola.
• 25:00
  SPEAKER_00: And so sometimes people fall into the trap of thinking if somebody is older and they have a fracture because of a tumor, it's going to be because of metastatic disease.
• 25:10
  SPEAKER_00: There's also, you mentioned, multiple myeloma that your grandmother had.
• 25:13
  SPEAKER_00: So that's another type of bone cancer that can present like that, also usually affects older people.
• 25:20
  SPEAKER_00: But the mistake to not make is not to assume just because somebody is over age 40 and has a fracture because or because of a tumor or the bone is about to break because of a tumor that it's not a sarcoma, because rarely you can have people who are like 60, 70, 80 years old who have a sarcoma, and the surgical treatment is very different.
• 25:40
  SPEAKER_00: So if somebody uh has a bone sarcoma, you want to take it out as one piece in order to save the limb, as opposed to if somebody has a fracture because of multiple myeloma or cancer that spread, then you can just put a rod into through the tumor and to try to fix the fracture.
• 26:02
  SPEAKER_00: Interesting.
• 26:03
  SPEAKER_00: The other error some some surgeons make is they say somebody, let's say, had lung cancer that was treated a year ago and they now have a bone lesion, but the cancer had never spread.
• 26:14
  SPEAKER_00: And so the issue becomes uh is that uh they assuming that the new the bone tumor is from the cancer that they had.
• 26:26
  SPEAKER_00: Most of the time that assumption will be correct, but you never know for sure.
• 26:30
  SPEAKER_00: And rarely we'll see patients who had one cancer and they develop another cancer.
• 26:34
  SPEAKER_00: And then if you treat a bone sarcoma inappropriate, we will place survival, it end up medium reputation as opposed to being able to salvage the land.
• 26:46
  SPEAKER_01: Yeah, and so much of what we want to do is this great find balance between function and salvaging whatever somebody has, and then whatever person's perception of is getting rid of the cancer entirely.
• 26:59
  SPEAKER_01: And so, how do you navigate that?
• 27:01
  SPEAKER_01: If somebody's like, for example, if the best treatment route is to remove a limb, right?
• 27:06
  SPEAKER_01: And they're like, don't do that.
• 27:09
  SPEAKER_01: I want to keep my limb um for as long as I can because I need to be able to, it's more important that I'm able to walk for as long as I can possibly walk and die earlier than you know, live this life where I'm living longer and don't have one or more limbs.
• 27:26
  SPEAKER_01: How do you navigate that conversation?
• 27:28
  SPEAKER_00: Well, you explain the rationale behind it and you say that sometimes the surgery it'll make this their situation.
• 27:34
  SPEAKER_00: If you do the wrong surgery, it will make the situation even worse if it comes to kind of not doing an amputation when it's needed.
• 27:42
  SPEAKER_00: But you can't really force anybody to do anything.
• 27:45
  SPEAKER_00: So you present all the evidence that you have, and then you ultimately the patient makes a decision.
• 27:53
  SPEAKER_00: And you might disagree with their decision, but you know, it's their life.
• 27:56
  SPEAKER_00: And sometimes I even tell patients, I tell them that you know, you're only if you give advice, but regardless of what you do, the consequences they'll affect you much more so than me.
• 28:07
  SPEAKER_00: So, you know, you you you're the one who has to make a decision.
• 28:13
  SPEAKER_01: Yeah.
• 28:14
  SPEAKER_01: Have you had a lot of instances where you have tried to do the best, you know, evidence-based, you know, treatment plan for a patient, and that patient has denied it and gone a different route, and you had to navigate that situation?
• 28:31
  SPEAKER_00: No, I've had some patients who kind of you offer them advice and they do what they think, and sometimes you don't see them again, and sometimes they come back and say, Well, I wish I followed your advice, but it's one of those again, you can only do so much.
• 28:47
  SPEAKER_01: Yeah.
• 28:49
  SPEAKER_00: Fortunately, if you have forced people who do things against their will, but unfortunately, sometimes people make decisions that they discovered were not the best decisions, and that um they they're the ones who live with the consequences and they can't go back.
• 29:07
  SPEAKER_01: Yeah.
• 29:08
  SPEAKER_00: And then do their best choices.
• 29:11
  SPEAKER_01: It's hard.
• 29:12
  SPEAKER_01: It's really difficult, right?
• 29:13
  SPEAKER_01: Because you're coming in with this knowledge and this experience, and uh you're going in, I'm sure, with every single patient wanting the best for their life and best for their outcomes.
• 29:24
  SPEAKER_01: And um, but at the end of the day, it is absolutely the patient's um choice to, you know, decide on what kind of interventions they receive and what their plan of care is, which is of course best practice and what we should be doing.
• 29:36
  SPEAKER_01: But there's always like there's a conflicting feeling when you know that something is right for somebody and they choose otherwise.
• 29:43
  SPEAKER_01: Um, and you know, we just hope, we always hope that whatever they choose is gonna end up becoming the best for them because you know we are practitioners who want best patient outcomes.
• 29:54
  SPEAKER_01: That's how we are trained in um medical fields to to help people.
• 29:58
  SPEAKER_01: That's why we do it, right?
• 30:00
  SPEAKER_01: Um, Dr.
• 30:01
  SPEAKER_01: Iopin, this has been really wonderful.
• 30:04
  SPEAKER_01: I want to keep talking to you about this forever, but I know you have lives to save right now and limbs to save right now.
• 30:10
  SPEAKER_01: And I wanted to know if you had any other final thoughts, anything that you feel like you didn't get a chance to say or that you really want our listeners to know about.
• 30:19
  SPEAKER_00: I think that's about it.
• 30:21
  SPEAKER_00: We covered two interesting topics.
• 30:24
  SPEAKER_00: As far as lives to save, the way I see I sorry, the way I see it is you do the best you can, but ultimately it's kind of up to God what happens to your basin.
• 30:36
  SPEAKER_00: Because if I felt that I saved a life, that if things didn't go the way I wanted them, I'd feel very something I did wrong, even though I know that I did everything to the best of my ability.
• 30:50
  SPEAKER_00: So I think by the same focus, you can't blame yourself for like bad outcomes which are outside of your control.
• 30:59
  SPEAKER_00: You also shouldn't be the one to take credit for the good outcomes because a lot of things are outside of your control.
• 31:05
  SPEAKER_00: And lock or gutter whatever you may believe in was on your side or on the patient's side at that time.
• 31:11
  SPEAKER_01: Wonderful.
• 31:12
  SPEAKER_01: I have one more question for you, if that's okay.
• 31:15
  SPEAKER_00: Certainly.
• 31:16
  SPEAKER_01: Um, it is, and I'm sure somebody who's listening and thinking about this as well.
• 31:20
  SPEAKER_01: What I know this is this is like probably an entire podcast on its own, but if you have a few minutes just to give us your thoughts, what is the role that AI, artificial intelligence, and robotic therapy, what is uh the you know, the development of that in your field?
• 31:36
  SPEAKER_01: Um, how is that going to impact your work and patients?
• 31:41
  SPEAKER_01: Curious.
• 31:42
  SPEAKER_00: Well, I think I think that artificial intelligence, it can significantly improve your ability to analyze literature, where it can, you know, it the program will it kind of reads the literature and gives you a summary.
• 31:56
  SPEAKER_00: With that said, I've seen on occasion it gives you summaries which are completely wrong.
• 32:01
  SPEAKER_00: So you have to look at the sources that they recommend rather than taking the summary at base value.
• 32:08
  SPEAKER_00: As a surgeon, I think it'll be a while before we'll be able to be replaced by robotics or computers, because you know they talk about how AI is going to replace certain professions and that manual labors are going to be the most resistant to it.
• 32:24
  SPEAKER_00: And as a surgeon, you're pretty much a very well-trained manual laborer.
• 32:31
  SPEAKER_00: But but that said, you know, they have robot-assisted surgery, but it still requires the human banker.
• 32:37
  SPEAKER_00: But the AI certainly allows you to analyze inflammation a lot quicker.
• 32:41
  SPEAKER_00: But again, you have to take it with a grain of salt and double-ched the results that AI offers you.
• 32:49
  SPEAKER_01: Yeah, I I agree with that in so many ways.
• 32:52
  SPEAKER_01: I often have used AI recently just to understand literature.
• 32:56
  SPEAKER_01: That's like the number one um use that I have for it.
• 32:58
  SPEAKER_01: But I always still, to some effect, read the literature.
• 33:02
  SPEAKER_01: But I, you know, the amount of volume that sometimes uh practitioners have to read and understand, you it helps to have something to assist you, but not to replace your critical thinking, is what I usually tell people.
• 33:15
  SPEAKER_01: Um, thank you so much, Dr.
• 33:17
  SPEAKER_01: Ayophin.
• 33:17
  SPEAKER_01: This has been here again.
• 33:18
  SPEAKER_00: Thank you for hoping.
• 33:19
  SPEAKER_01: Lovely.
• 33:20
  SPEAKER_01: Absolutely.
• 33:21
  SPEAKER_01: Thank you for your time and thank you for all the work that you do.
• 33:24
  SPEAKER_01: And um, thank you for helping this world become, you know, a more a place where people feel like they can continue their life in um more meaningful ways because of the care that you provide.
• 33:37
  SPEAKER_01: Thank you for that.
• 33:38
  SPEAKER_00: Thank you.
• 33:40
  SPEAKER_01: Thank you all for tuning in and investing in yourself and your well-being.
• 33:44
  SPEAKER_01: If you listened to the show today and gained anything out of it, share it far and why.
• 33:50
  SPEAKER_01: It means a world when you rate and review the show.
• 33:53
  SPEAKER_01: Don't forget to use your exclusive 20% discount code FIT20 when you sign up for our signature course, Master Your Pelic Floor, linked in the show notes.
• 34:03
  SPEAKER_01: See you again next week with an exciting new guest and topic.