Cory from Ohio - Dx July 2012 - RIP Sep 06 2013

Those who lost their battle with ASPS :(
Cory from OHIO
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Cory from Ohio - Dx July 2012

Post by Cory from OHIO »

Hi everybody,

I first want to thank everyone for all the valuable information that's being shared on this forum. My 26yr old husband of 2 years, (and high school sweatheart :) ) was diagnosed with ASPS about 7 months ago when he went to the doctor for having a "swollen" knee. We had thought it was just simply from overuse or something since he was working at 3 different jobs at the time (one full time job, and 2 part-time police officer jobs, where he was so close to getting hired on full time finally after 4 years of schooling and 2 academy classes). Anyhow, we first tried the chiropractor a year ago who gave him an X-ray and told him it was probably brucitis. Then our family dr. gave him anti-inflammatory meds until finally we requested an MRI, which led us to diagnosis at The James cancer hospital at The Ohio State University on July 19, 2012. Like everyone else it took a few weeks for the results to be finalized and in the meantime we got a second and third opinion--at CTCA Philadelphia as well as at The Universiy of Michigan. In this one month period, it was discovered that Cory had numerous lesions in his lungs, at least 2 in his brain and the primary tumor in his left thigh had begun eating away at his femur bone. He has been on crutches and on disability at work ever since, to avoid fracturing the bone where the tumor was involved.

One open biopsy on the knee/femur bone and one brain surgery later we decided to return to The James where his Onc. drew up a treatment plan involving 10 days of whole brain radiation (bc the radiologist thought there might be meningeal involvement) followed by plans to get involved in the Cedirinib trial at NIH. We visited NIH at the end of September to meet the doctors and pre-screen him for the trial. Everything looked good but we had to wait four weeks post radiation before he could actually start. Well in that four week period, weather started getting cold here in Ohio and his knee started causing him severe pain. 2 hospitalizations later, NIH called with the seemingly devastating news that he no longer fit the requirements for the Cediranib trial. The blessing was that he didnt qualify because there wasn't evidence that his disease had progressed 20%. We had the choice to wait until it DID, or choose another plan of action and it seemed obvious to choose the latter.

Our Onc. at The James then prescribed Cory with Sutent. He has been on this drug four 4 months now with manageable side effects.... Mostly complains about metal taste, and burnt tongue feeling. Initially the pain in his knee subsided quite a bit too which was a huge plus! Got to enjoy the holiday season almost free of pain. He is using a transdermal pain patch plus extra meds for breakthrough pain. I'd say the first 2 months he didn't use the extra meds at all. This past month, however he seems to be in a bit more pain, especially in this cold weather and at night. The sutent is starting to cause nausea and vomiting also, accompanied with weight-loss. So far his scans seem to show stability on average, but his knee does not seem to be getting smaller. After reading some of the posts on here I am considering getting more opinions about the possibility of resecting the primary tumor. It is pretty big! The surgical oncologist here at The James didn't want to talk about resection until the tumor shrunk. And our main oncologist doesn't seem to have much hope that it ever will. Every time we see him he seems pleased with the results of the scans but continues to talk about "the next plan" meaning traditional chemotherapy. I decided to reach out on here and ask for some advice on
A) surgical doctors with experience in this aggressive type of removal
B) ideas on alternative plans if our Onc. tries to push traditional chemo
And anything else that might be helpful to our particular battle.

Thank you in advance and again thanks for sharing on this forum, for it truly has been helpful these past few months in giving us hope and a lot of information on this disease we know so little about.

Thank you,

Angie
Olga
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Re: Cory from Ohio (dx July 2012)

Post by Olga »

Hi Angie and welcome to the club no one would like to be in. I'll later move this topic to a personal updates area to keep up with the new developments in your husband's case. He is lucky to have you by his side.
Did Cory have both brain mets removed? How big is a bone involvement?
The bone involvement is a very big deal here and it might be a source of a very big toxicity and pain and you really need to get not 1 or 2 but few opinions of what can be done here. Some ideas of what can be tried about the primary:

1. Dr.Malawer at http://sarcoma.org/Sarcoma/
2. MDACC and MSK cancer clinics usually see more sarcoma patients than other places and they have some of the best surgeons there, contact both of them.
3. Neutron radiation therapy at Fermi National Accelerator Laboratory (Fermilab - which is located close to Chicago) has listed ASPS between the histologies Neutron therapy is appropriate - probably they had a success using it. This is the link to the list:
http://www-bd.fnal.gov/ntf/what_is/softtissue.html
I asked them at some point if it can be used on the lungs and they said no it is more for the big unresectable or bad located primaries.
4. Contact Dr.Littrup in Detroit he is a cryotherapy doctor and ask if they had treated bone involvement in this location as a part of the staged multimodality treatment in conjunction with the surgery.
I do not know what to say about the chemotherapy. Usually our people did not have any luck with it but in single cases there was a regression at least temporary. It is not known if the TKI given before of that will improve the response or otherwise (sutent is one of the TKI drugs as are cediranib and pazopanib). We also had a single case of regression cased by the gemcitabine. Most of these cases had their primary resected though.
Olga
Cory from OHIO
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Re: Cory from Ohio (dx July 2012)

Post by Cory from OHIO »

Thanks for your quick response Olga.

I'm not sure how to answer your question about how big the bone involvement is.....? The initial scans showed that the distal end of his femur was involved just around the knee cap area. Couldn't tell you what the actual size was tho, sorry. That's absolutely proving to be very painful, but what do you mean by toxicity? If you mean more mets I am more than serious about finding a new Onc. We actually just saw ours today after posting my message and I confronted him with some of the stuff i've been reading on this site (particularly the importance of primary site removal) and he literally looked me in the eye and said it was pointless. He said if the disease had not reached the brain he would agree to resection, but since he does have 2 TINY spots there is no point, it's already made it to the brain. Then WHY are we doing anything at all? I asked for him to clarify his plan then... if the Sutent helps to shrink his primary THEN are we gonna talk resection? STILL his answer was "there's no point". He so graciously (yeah right) offered to let me speak with the surgical Onc. again but assured me that the tumor board at The James didn't think it was appropriate to do any surgeries. He also tried making me feel like questioning him before (when we went for 2nd and 3rd opinions) didn't help so questioning him now isn't going to be any different...

So that answers your other question, they found 3 tiny spots on his brain. None have caused any symptoms whatsoever. One, the largest, was only I think 4 mm and was located in a position where the surgeon at Temple Unversity was easily able to resect. The other 2 spots were treated with WBR bc they worried there may be more spots. His brain MRI today was said to look pretty stable, maybe a VERY TINY bit bigger the radiologist said, but not enough to change the plan of action at this point... So anyhow at this point I am feeling pretty discouraged with doctors. I know Britany has been 10+ years with brain mets but have there been others?
Bonni Hess
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Re: Cory from Ohio (dx July 2012)

Post by Bonni Hess »

Dear Angie,
I am so deeply sorry for your husband Cory's ASPS diagnosis and for all that he and you have been going through for the past seven months, but I am grateful that you found your way to this site and that you have reached out for information and advice from the ASPS Community members on this Board. I am also grateful that Cory has such a loving and devoted wife and advocate, and that you are being so pro-active in your research and communication with Cory's oncologist. Olga has provided you with some excellent information and references, and I encourage you to actively explore and pursue them. I am not a doctor, but based on my eleven and a half years of ASPS experience, relentless research, observation, and networking with other ASPS patients during our daughter Brittany's challenging battle with this insidious disease, I strongly disagree with Cory's oncologist regarding his highly questionable opinion that "there's no point" to resect Cory's primary based on Cory's brain metastasis. Since there are unfortunately currently no permanent cures available for ASPS, the most up to date studies continue to document the importance of managing the disease through resection of all resectable tumors. It is critically important that the primary be removed, if surgically possible, and if not, that it be shrunk/destroyed with ablation or radiosurgery to help reduce the body's tumor burden and strengthen the immune system to better fight the disease. Tyrosine Kinase Inhibitors (TKI's) such as Sutent, Cedianib, Pazopanib have unfortunately not proven very successful in causing significant shrinkage to large primary tumors, and the presence of the large primary tumors seems to interfere with the effectiveness of the TKI drugs in stabilizing progression of the disease and shrinking/destroying smaller mets. I also feel that Cory's two brain mets need to either be surgically removed or shrunk and destroyed with Gamma Knife BEFORE they become any larger and symptomatic. YOU DO NOT WANT TO WAIT UNTIL THEY BECOME LARGE ENOUGH TO CAUSE SYMPTOMS BECAUSE THEN IT MAY BE TOO LATE TO SUCCESSFULLY RESECT OR GAMMA KNIFE THEM!! Unfortunately, WBR has typically been unsuccessful in treating ASPS brain mets because ASPS is notoriously radiation resistant and requires more focussed and high dose radiation than is possible with WBR. Once Cory's primary tumor has been successfully resected or treated with ablation or radiosurgery and his brain mets have been resected or Gamma Knifed, then he should probably begin some type of systemic treatment with a drug that can cross the blood brain barriar to try to prevent any further brain mets. Unlike the traditional chemo being advocated by Cory's oncologist, Cediranib, and I believe some other TKI's, are among the very few currently available systemic drugs that can cross the blood brain barriar which is critical in Cory's case since he has now had metastasis to the brain. Prior to beginning her Cediranib treatment 46 months ago, Brittany was devastatingly experiencing increasing development of brain mets. Thankfully, since starting Cediranib in April 2009, her brain MRI's have been clear with no sign of any new brain mets, and complete disappearance of her previously Gamma Knifed brain mets.
Is Cory's current oncologist a sarcoma specialist? If not, I strongly encourage you to find a sarcoma specialist. Even if Cory's current oncologist is a sarcoma specialist (which I doubt given some of his questionable treatment recommendations and opinions) , I think that you need to seek a second opinion from another sarcoma oncologist who is more positive, more pro-active, and more knowledgeable in his approach to treating Cory. Dr. Fritz Eiber at UCLA in California is a highly respected and very experienced sarcoma surgeon who may be able to provide you with an expert opinion and advice regarding resection of Cory's primary. It would definitely be worth contacting him to explore the possibility of scheduling a second opinion with him. The Sarcoma Foundation of America (SFA) has a program to provide funding for sarcoma patients to travel to obtain a second opinion if you are interested.
Please know that I am here to try to help you in any way with shared information, and feel free to write me on this Board, at my e-mail address which is BonniHess@aol.com, or call me at 425-829-3210 if you have any questions that I may be able to try to answer for you.
Take care Angie, stay strong, know that you and Cory are not alone in this battle, hold tight to Hope, and keep in touch as you are able.
With special caring thoughts, healing wishes for Cory, and continued Hope,
Bonni Hess, mother of 30 year old Brittany diagnosed eleven and a half years ago in July 2001
Olga
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Re: Cory from Ohio (dx July 2012)

Post by Olga »

Angie, some comments and answers as I can:

1. What I meant by toxicity. When the met confined to a bone it s one thing, but when it reaches the bone marrow, it causes its inflammation and interacts with the bone marrow to progress further.
http://www.ncbi.nlm.nih.gov/pubmed/21620753
Bulky tumors produce an immunosupressive effect on the body. Your husband may also demand for the primary tumor to be treated (resected) as it is very painful and affects his quality of life in a situation when all the mets are stable. I think that the instruction is to treat the painful/symptomatic tumors or metastases regardless of the overall prognosis.
2. There is a clinical guide for the stage 4 sarcomas that advise to treat them palliative and on a clinical trial as the survival is usually short and the emphasis is on the preserving of the quality of remaining life not on the increasing survival, this is what this doctor meant. ASPS stands alone because of its slow growth that allows by the eliminating the most immediately dangerous mets prolong the survival. It is reflected in the articles - read out library on the main page. It is sometimes hard to get past the general guides for sarcoma stage 4 but we had people that managed to do that with the good result, they are still here few years after.
3. We have multiple examples of the excellent survival and quality of life people with the ASPS brain mets treated by the radiosurgery (Gamma Knife, Cyber Knife). Smaller mets could be treated completely with the full resolution. Read Tom from Pennsylvania - Dx 2002 story to find the radiosurgery docs there, you can his wife if more info is needed or if your onco0logist wants to get conformation from his oncologist that the patient benefited from the primary surgery, lung surgery and brain radiosurgery and leads a very productive life, working and leading the mostly normal life years after.
http://www.cureasps.org/forum/viewtopic.php?f=4&t=270

The biggest problem as of now is the primary being unresectable. Get some opinions on it.
Olga
Cory from OHIO
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Re: Cory from Ohio - Dx July 2012

Post by Cory from OHIO »

Thank you Bonni and Olga for your quick response. Sorry it's taken a while to respond but with all that info we have been extremely busy getting all Cory's records together, researching and contacting each of the suggestions you both made. We finally decided and got an appointment set up at MD Anderson on April 9th with hopes of finding a specialist with a more pro-active approach. We are also working on getting all the records sent over to Dr. Malawer in DC as well as fermilab. Trying to keep as many options open as possible...

When Cory's Dr. heard we are looking for another opinion again he started researching and called us with a clinical trial call Cixutumumab. Said it is being tried with different soft tissue sarcomas and solid tumors... I haven't seen anything about this on the forum but has anyone heard of it?

Thanks in advance

Angie Michael
Olga
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Re: Cory from Ohio - Dx July 2012

Post by Olga »

Proactive approach is the only way to find an optimal treatment/management for ASPS - versus waiting for the disease to become symptomatic and taking some drastic steps fighting for the life in an suboptimal way.
Re. Cixutumumab. It is an IGF-1R antibody (a targeted therapy drug) that is expected to block the corresponding receptor and interfere with the growth/survival of the tumor if it feeds on that stuff. I checked the Pubmed.gov to see what is the current status of the drug - what results are avail. for now. There are numerous articles with the last one from MSK in NY:
Cixutumumab and temsirolimus for patients with bone and soft-tissue sarcoma: a multicentre, open-label, phase 2 trial.
Schwartz GK, Tap WD, Qin LX, Livingston MB, Undevia SD, Chmielowski B, Agulnik M, Schuetze SM, Reed DR, Okuno SH, Ludwig JA, Keedy V, Rietschel P, Kraft AS, Adkins D, Van Tine BA, Brockstein B, Yim V, Bitas C, Abdullah A, Antonescu CR, Condy M, Dickson MA, Vasudeva SD, Ho AL, Doyle LA, Chen HX, Maki RG.
Source
Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA. Electronic address: schwartg@mskcc.org.
http://www.ncbi.nlm.nih.gov/pubmed/23477833
ask that local oncologist that recommends the drug to check in a full text article whether they had any ASPS patients on that trial. Is he talking about the trial for Cixutumumab only or it's a combination trial with addition to something else?
Olga
Cory from OHIO
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Re: Cory from Ohio - Dx July 2012

Post by Cory from OHIO »

Yeah Olga it was in combination with Temsirolimus I believe. We meet with the Oncologist again on Tuesday so I will be sure to ask if ASPS has been tested in particular. Thanks for your research!
Trixi
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Re: Cory from Ohio - Dx July 2012

Post by Trixi »

MD Anderson is a good place. I sent you a private message.
Trixi
Cory from OHIO
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Re: Cory from Ohio - Dx July 2012

Post by Cory from OHIO »

Just a quick update for everyone since so much is changing.....yesterday Cory woke up with a great amount of redness and new swelling on his knee--right below the incision scar from his biopsy. We have been watching it the last few months cause every now and then it would look like it was expanding or filling with puss. Yesterday however he had a low grade fever and we thought, I'll go to work and if it gets any worse we will go to the ER in the morning. By the time I got home it was getting almost purple and the lump was protruding more. His fever reached 100.7 so we headed to the ER at the Ohio State University hospital since we felt our local ER wouldn't know what to do with this one. Luckily they admitted us right away and got his blood drawn and x-rays and ultrasounds taken. We talked to several oncologists/doctors/surgeons and they decided an infection had started in the area where the tumor was biopsied 7 months ago. Said it could be because of the biopsy; could have been because of dying tumor cells collecting and getting infected; coulda been from a million different things, but the doctors were all certain that no amount of antibiotics would keep this infection from recurring. The orthopedic surgeons agreed limb sparing surgery was out of the question given the size of the tumor, involvement of the bone and dangerous nature of this nasty infection getting into his blood stream. They suggested amputation. We were somewhat expecting this and seem to have come to terms with it. We are just happy to have someone LOOK AT the primary. It seems so fast but they decided (as long as the MRI tonight doesn't show anything unexpected) that tomorrow they will prep him for amputation by 4 pm. I am proud of him for accepting and agreeing to this tough decision I feel needed to be made.

Our trip to MD Anderson is therefore being cancelled as of now since we found the answer we were looking for here in Ohio. At least we are hoping this is the answer!...
Olga
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Re: Cory from Ohio - Dx July 2012

Post by Olga »

Angie - it is a right decision given the circumstances. I know some other sarcoma amputee that are regretting that they have not done it earlier allowing the primary tumor to be in place and keep seeding and also being a pain and inflammation source, they felt that their quality of life has improved after the amputation. I am sure that Cory will be better without it. I also know an ASPS patient - he is not registered here - we've met at the other web-site - who had lost his leg removing the primary tumor, 5 years later he had a lung surgery, few years later he had another lung surgery and 10 years later he was having some other problems and discussing his options. Tell Cory that we are rooting for him.
Olga
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Re: Cory from Ohio - Dx July 2012

Post by Guest »

So sorry to hear... and yet it sounds like the best option... Praying for a good outcome !
Amanda
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Re: Cory from Ohio - Dx July 2012

Post by Amanda »

Hello Angie,
I am sorry that you are both going thru so much with this cancer!
Have him read the survivors postings it helps and yes they are some that have gone thru alot and are still here :)
I have read what Olga an Bonnie posted and they are very good at helping paitents they helped me also :)
The best thing done was to reach out and get others experiences in reference to this diagnosis because it is so rare an no onc can be expected to really understand every aspect of this sadly.
Here they do :)

Best wishes to you both :)
“Many times it is much more important to know what kind of patient has the disease, than what kind of disease the patient has”.
"The microbe is nothing, the soil is everything)""
Claude Bernard~

Amanda
Cory from OHIO
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Re: Cory from Ohio - Dx July 2012

Post by Cory from OHIO »

So April 1st was the official date of amputation. Everything went well overall. He had trouble urinating after the epidural was removed, which we were told is somewhat common after surgery. Cory spent 2 weeks in the hospital, and 1 week in a rehab facility... They continued to catheterize him the entire time. They finally got him to go on his own the last couple days and agreed to release him if and only if I was taught to do a catheter "in case". Good thing I did because one month later we still seem to have issues. We were holding off on seeing a urologist, Because we couldn't get in until June, but It got worse this week. This is the reason we are at the ER again tonight....The dr. wants an MRI to check if something is compressing his spine, cause he also has noticed a little numbness/weakness in his good leg.. They have some neurologists looking into this all too so we'll see...

To back up a bit, because of the surgery, Cory was off Sutent for 4 weeks. He started back up on it and quickly felt the side effect reappear... Tuesday 5/9 he had scans done on his brain and chest as well as a PET... All showed growth. The lungs had a large amount of spots, 2 were rather large but necrotic and less bright on the PET compared to the scans done in February. The dr. explained that during the time off the drug, there was progression and he didn't think the sutent was working any longer. The brain showed also a lot of spots and most were a very little bit bigger. Other than that, no new spots were noted. Concerned that the sutent has stopped working, the dr. switched him over to pazopanib.... he is looking into other options (trials) in the meantime.

Also of importance, Cory has started to feel the effects of the lung nodules....difficulty breathing deep, yawning/hiccuping seems to hurt etc. I have tried to read up on other people's experience with this but it's so overwhelming to read through year and years of posts when I don't know for sure what I am looking for.... What should our next step be? Can something be done for large unresectable lung nodules? I think i remember reading that the one is around 4-5 cm and right near the windpipe. I saw something about radiosurgery on Tom's board but I forget if that was for the spine or lungs... Also the brain mets.. We were kind of thrown off guard when the neurologist said "a lot" of them were bigger... ? ... We were under the impression there were only a few, like 2 or 3... So how do we deal with that? I am scared because apparently the WB radiation didn't do anything as seems to be he case with ASPS.

I'll let you all know what happens with this spine MRI...but in the meantime I wanted to get this update out there.

Thanks in advance,

Angie
Olga
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Re: Cory from Ohio - Dx July 2012

Post by Olga »

Angie, thank for for an update. I am so sorry to hear what you both are going trough.
There are 2 options for the bigger unresectable tumors to improve breathing - cryoablation (I know of Dr.Littrup from Detroit has done few by the windpipe - his contact information is in the cryoablation topic but I copy it for you here:
The best person to use for the pre-evaluation moves and for the scheduling is Dr.Littrup's assistant
Barbara A. Adam RN, MSN, NP-C
she can also be reached by the e-mail adamba@karmanos.org
Karmanos Cancer Center
Interventional Oncology -Image Guided Therapy
313-576-8042
DMC pager 313-745-0203 #95883

The mailing address is:

Dr. Peter Littrup
Karmanos Cancer Center
4100 John R
Detroit, MI 48201
Mailcode HPO2RR

) and a radiosurgery (Tom had it and other people too). You would need to see what is avail. locally. Brain mets could be treated by the radiosurgery - like GammaKnife etc. The guideline for the multiple brain now is to treat when symptomatic so if Cory feel something like blurried vision, depression, headache - it might be a good argument.
When was he switched to pazopanib? It may still shrink the tumors if it starts working.
Olga
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