Understanding Sarcomas of the Digestive System

Podcast Transcript

Dr. Scott Steele: Butts and Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end.

Dr. Scott Steele: Hi again, everyone, and welcome to another episode of Butts and Guts. I'm your host, Scott Steele, the Chair of Colorectal Surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. And today, we're very pleased to have Dr. Daniel Joyce, a Surgical Oncologist in the Department of General Surgery in Cleveland Clinic's Digestive Disease and Surgery Institute. We're going to talk a little bit about understanding sarcomas of the digestive system. Dan, welcome to Butts and Guts.

Dr. Daniel Joyce: Thanks for having me.

Dr. Scott Steele: So, we always like to start out with a little bit of background. Obviously, I've known you for a long time, but where are you from? Where'd you train? And how did it come to the point that you're now here on staff at the Cleveland Clinic?

Dr. Daniel Joyce: All by chance. In summary, I came to Cleveland in December of 2010 to escape a windy, rainy Irish winter to find snow. I interviewed for a general surgery residency position. I was in my early 20s at the time. And I got the position. It was really a flight of fancy at the time. And here, well over 10 years later, I'm on staff at The Clinic and it's been a wonderful adventure. I grew up in Ireland, went to medical school there, and then completed the rest of my postgraduate training in the U.S. And I'll hopefully never leave.

Dr. Scott Steele: Fantastic. And we're lucky to have you here. So today, as I mentioned, we're going to talk a little about cancers of the digestive system. So, to start, can you touch a little bit on what sarcomas are and where they can form in the digestive system?

Dr. Daniel Joyce: So, sarcomas can actually form anywhere in the body. They are some of the rarer tumors. I often tell patients that they're tumors of the glue that holds us together. So, bone, muscle, nerves, connective tissue. So, in the GI tract, they're relatively rare, but we certainly see a lot of them here. The most common sarcoma of the gastrointestinal tract would be something called a GIST, or gastrointestinal stromal tumor. Give or take, maybe there'd be 5,000 cases a year in the United States. And then they tend to come to more specialized centers like us since, due to their rarity, people may not be so familiar with them in more day-to-day practices.

Dr. Scott Steele: So, what causes a sarcoma to form, especially in relation to the digestive system?

Dr. Daniel Joyce: So, in most cases, we actually don't know why, and that applies to many different cancers. Due to the rarity of these tumors, we don't have a great understanding of whether environmental factors play a big role. But then there are a small number of patients who have genetic conditions that predispose them to these tumors. The majority of patients that we see with sarcomas involving the GI tract are older patients and cancer is a disease of aging. But certainly, when we see younger patients with these conditions, we sometimes have to delve a little deeper to see whether there's a genetic cause for their sarcoma.

Dr. Scott Steele: So, I'm a patient out there listening and I'm like, "Wow. Sarcoma. I haven't heard of that one.Or maybe I remembered some family member or friend that had it. But what are the warning symptoms that maybe you have a sarcoma? And how would sarcoma affect the digestive tract in particular?

Dr. Daniel Joyce: So, it's quite interesting actually. So, the majority of patients that we see don't know anything is going on. Maybe they're in a car accident and they get a scan, and their doctor tells them, "You know what? You have no injuries, but we found a mass somewhere in your gastrointestinal tract." However, there are a certain number of patients who will have symptoms. So, they can be bleeding from the GI tract, and some patients may vomit blood, other patients may notice that they have a change in their bowel movements. Occasionally, like any mass involving the gut, it can cause a blockage, whether that be a blockage of the stomach that leads to nausea and vomiting or a blockage of something lower down like the colon where a patient may have a difficulty passing gas and bowel movements and actually may present with an obstruction. But to summarize, the vast majority of these are picked up during a workup for other reasons. And nowadays, we get so many CAT scans, we're finding an awful lot more of these tumors in comparison to the past.

Dr. Scott Steele: So, we had talked a little bit earlier that these are a little rarer tumor. But amongst sarcomas, one of the ones that's maybe a little bit more common is the gastrointestinal stromal tumors, or what we say, the GISTs. So, can you share a little bit of a 10,000-foot view, a little overview if you will, of GIST for our listeners?

Dr. Daniel Joyce: Yeah. So, these are certainly one of the more common types of sarcomas that we see. The commonest location would be in the stomach, but they can involve any part of the gastrointestinal tract all the way from the esophagus or food pipe all the way down to the rectum. I tend to see a lot of them in my stomach. And the majority of those are treated by surgery. Some may not need to be treated at all. And like we say, many of them are asymptomatic. And sometimes it can take a little bit of time to make the diagnosis because one can need special endoscopic techniques to diagnose them.

Dr. Scott Steele: So, truth or myth: GISTs are very rare in people under 40 years old.

Dr. Daniel Joyce: I would say that's a true statement. The vast majority of patients would be in an older age group. But there are some rarer genetic conditions where we can see these tumors in children, adolescents, and younger adults. I would say overall, that's a true statement.

Dr. Scott Steele: So, Dan, I know that you said earlier that you have maybe bleeding or maybe an incidental finding on a CAT scan for another reason. But at the end of the day, somehow, you got to make a diagnosis of a GIST. So how is that diagnosis made?

Dr. Daniel Joyce: So, there's a number of ways. Sometimes we have such a characteristic suspicion on a CAT scan, for example, this would apply to the small intestine that we say that's almost certainly a GIST and we will go ahead and treat it, and that's an operation to remove it. In some cases, we don't like biopsying these from the outside, meaning through the skin, because it can lead to some tumor seeding or spillage and cause more problems. However, when it comes to the esophagus or stomach or the lower intestines, we frequently diagnose these with endoscopies. And certainly, it takes a little bit of skill for the endoscopist to get a good biopsy of these.

These tumors tend to lie a little bit under the lining of the intestines. More common cancers like stomach cancer or colon cancer, they're easy to biopsy or sample. But the endoscopists or GI docs that do these tend to use ultrasound to guide their biopsies so that we can get the tissue and samples that we need to make a correct diagnosis.

Dr. Scott Steele: So, I got to ask this question about a different tumor today, but I think it's fair in this setting, as well. So, I don't want sarcoma. So, is there something I can do to prevent just from forming in our digestive system?

Dr. Daniel Joyce: Nothing in particular. Don't go hang out in a nuclear power plant or something like that. We often associate radiation with sarcomas. It's difficult to pinpoint something to prevent a GIST. But what I often say to patients is, well, stay healthy. Eat a healthy balanced diet, so that if you do develop something like this, your body in tiptop shape to undergo very effective and safe treatment as the vast majority of these tumors are quite easily treatable.

Dr. Scott Steele: So, speaking of that, let's delve into that a little bit more. And obviously, you're a surgical oncologist, so you operate. But what are treatment options that are available for GISTs? One of the things you mentioned is that maybe they don't need to be treated at all, or maybe even other sarcomas as they're found in the digestive tract. So how do you figure that all out?

Dr. Daniel Joyce: So, the first thing is to be clear about the diagnosis, and that often involves a biopsy. And that's actually really critical. Patients may not realize it, but there's a whole team of doctors behind the scenes that help us correctly diagnose these patients. They're called pathologists. The pathologists look at the biopsy specimens under the microscope. And to an inexperienced eye, everything that's a soft tissue tumor in the GI tract can be called a GIST. But sometimes we see patients on the outside where they've been told they have a GIST and it's a different type of tumor, which radically changes their treatment plan. So, it all starts with that correct diagnosis and making sure that we're confident what the diagnosis is so that we can create a treatment plan. The vast majority of GISTs are treated with surgery, but more advanced ones are ones that have spread and may need medical treatments. And we actually have very powerful and effective medical options to treat GIST nowadays, which prior to the 2000s, we did not.

Dr. Scott Steele: So, does everyone need some of these medications in the pre-op setting or the post-op setting? Or does it go by size? Or what is that all about?

Dr. Daniel Joyce: So, after a patient has an operation for a GIST, which is usually the most common pathway, we do what's called a risk assessment. So based on the size, some of the features under the microscope, and location, meaning is it in the stomach, the small bowel, the rectum, we develop a sense or a prediction of what we think the chances are that this tumor could come back or that it could spread. And in those patients where there's a higher chance of it coming back or spreading, we often treat it with medical therapies. Probably the most common one is something called Imatinib or Gleevec. This was a revolutionary drug. And our understanding has only continued to grow of that because nowadays, we do special genetic testing so that we can better determine whether the patients will respond to this drug and at what does that we should treat with. So, it's really a good example of precision medicine. And it really takes a whole team and a tumor board to come up with a correct decision so that we can get the best outcomes.

Dr. Scott Steele: So, you mentioned some of these advancements in some of the antibodies that you just spoke about. Are there any other advancements on the horizon for treating and/or diagnosing these within the digestive system?

Dr. Daniel Joyce: Well, I think probably the first one, as we've grown to understand these more, is we've figured out that some of these may not need to come out. So, for example, GIST in the stomach is very common and many of them are small. And when they're under two centimeters, we've learned that we can maybe see a lot of these tumors. So, I think that's a big win for patients. We always want to make sure that interventions are warranted and that any risks are necessary.

And then I think from a surgical technique standpoint, some of these GISTs can occur in tricky locations. One example might be near the gastroesophageal junction, that's where the esophagus or food pipe meets the stomach. And a technique that we've pioneered here is where we do minimally invasive or laparoscopic surgery, but we actually put our instruments directly into the inside of the stomach so that we can remove these in very, very tight and tricky locations in order to preserve the organ. Because one of the interesting things about GIST is all you really need to do is to carve it out. In more common cancers, you have to remove lymph nodes and blood vessels, so that you can remove a whole field of lymph nodes. That's really not the case in GIST. You just need to be able to carve the stinker out and have negative margins, meaning that it's all removed. So, I think robotics and minimally invasive surgery have helped us a lot in that regard, as well.

Dr. Scott Steele: That's fantastic. And so now it's time for our quick hitters where we get to know you a little bit better. So, what was your favorite car?

Dr. Daniel Joyce: Oh, my favorite car. It's interesting. I'm a child of Ireland in the '80s. So. when I grew up, we didn't have a lot of money or anything like that. But my dad bought a new Toyota Corolla when I was young. So, I think those shiny new Toyota Corollas are fun memories, but never much of a car person as a result of that.

Dr. Scott Steele: That's fantastic. And so, what's your favorite trip that you've ever been on?

Dr. Daniel Joyce: I love traveling in Europe. It was always something that I'd done during the summers in Ireland. I think the South of France is just somewhere that's very near and dear to my heart. I went there as a young 15-year-old. Somehow, I managed to get my parents to agree to send me off to learn language, and I spent a month in Montpellier and really fell in love with the French culture. So, I think that France is the one place that I always return to, and it's always familiar but always new.

Dr. Scott Steele: You have a choice, salt or sweet. Which one do you choose?

Dr. Daniel Joyce: Sweet, I think.

Dr. Scott Steele: then if you could go back and give yourself a little bit of a piece of advice, maybe when you came over here from Ireland, what would you tell yourself on that first day?

Dr. Daniel Joyce: Buy property when I come here. I might have saved a lot of money.

Dr. Scott Steele: Touché. So, what's the final take home message to our listeners, especially with regards to the sarcomas of the digestive system?

Dr. Daniel Joyce: I think, overall, these are largely treatable conditions. And I think if patients have more advanced cases of these tumors, science is really accelerating. Even in the past four or five years, we've developed multiple lines of new drugs that can help control these diseases so that even if they're not curable, patients can really live a long time with a chronic disease. So, I think it's an interesting and rewarding disease to treat because we can make a big difference.

Dr. Scott Steele: That's great advice. And to learn more about treatment for gastrointestinal stromal tumors and other digestive sarcomas at Cleveland Clinic, please call our Cancer Answer Line at 866-223-8100. That's 866-223-8100. Dan, thanks for joining us on Butts and Guts.

Dr. Daniel Joyce: Thank you.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.