What's Next?

Now that surgery is done, we need to decide what treatments to pursue next. As all of the detectable cancer has been removed, further chemotherapy is termed "adjuvant" therapy (i.e., treatment intended to reduce the risk of relapse). This decision is heavily influence by the pathology results from my surgery.

The first issue for the pathologists was to determine the adequacy of the resection. They examined the tumor and found that the radial skin margins were very good (i.e., the tumor was no where close to the cut skin edges). The deep margin was closer, but still good. Importantly, the tumor did not appear to involve the fascia covering the gluteous muscle, which is thought to act as a strong anatomic boundary against the local spread of cancer cells.

The next issue was to determine how well the chemotherapy worked at killing tumor cells. This was a bit less clear. When comparing my pre-chemotherapy MRI to my pre-surgery MRI, the tumor volume had reduced by at least 50% (i.e., it was half as big as it used to be). This would suggest that the chemotherapy did a pretty good job of killing the cancer cells. However, when the pathologists looked at the tumor under the microscope, they saw very few dead cells mixed in with the living tumor cells. This suggests that the chemotherapy was not working very well. There was not a clear consensus among my oncologists as to how these two facts should be reconciled.

So, where do we go from here? Should I get more chemotherapy in case any cells were left behind (locally or elsewhere)? Could I just be done with treatment now? There are three options:

• Continue with the same chemotherapy for another 9 months. The fact that my tumor got smaller suggests that the chemotherapy was working, so we could continue with the same drugs. But, there is concern given that very few dead cells were seen under the microscope.
• Continue with chemotherapy, but use different agents. If we don't think that my current chemotherapy is very effective at killing this tumor, we could always use different agents (there are other chemotherapy combinations that, in general, are known to work well with this kind of tumor). However, as my tumor is now gone, we won't be able to tell if the new chemotherapy is effective or not.
  
• Don't do any more chemotherapy. There are case series which suggest that patients with Ewing's family sarcomas of the skin do very well and have a low chance of cancer recurrence. Therefore, it's possible that I don't need any more chemotherapy. However, as this kind of cancer is rarely seen in the skin, these reports involve only a small numbers of patients (around five to fifteen). So, it's hard to know if this information is reliable and generalizable to me.
  

My cancer doctors met last week and, while there was some inclination to recommend the second option (more chemotherapy, but with different agents), there was indecision. Therefore, the group recommended that I get another, independent evaluation. As some of the sarcoma doctors at MD Anderson in Houston already know about my case, we decided that it would be best to see the sarcoma group at the Dana Farber Cancer Institute in Boston. We have an appointment to be seen on July 16th.

There's no great rush to start more chemotherapy immediately; it will be good to step back and have a fresh look at where we are. As always, we are so grateful for everyone's continuing prayers and support.