【The story of coordinator】Heavy ion radiotherapy after surgery/chemotherapy for osteosarcoma of the spine　Treatment was carried out in close collaboration with doctors in home country of the patient

Although the patient was told that radiotherapy was impossible in his home country

Hearing about proton beam/heavy ion beam therapy from relatives in Japan

This young patient was diagnosed with osteosarcoma of the spine and underwent surgery to remove the tumor. After that, the patient just started chemotherapy and was told that he would be undergoing 6 sessions of chemotherapy over the next 4 months. In this South American country, where patient was living on the other side of the earth from Japan, there is little information about osteosarcoma, so he relied on his relatives who hold important positions in Japan to find out the possibility of treatment in Japan. Local doctors did not suggest radiotherapy as an option because it would cause damage to nearby tissues such as necrosis and paralysis, but based on information from relatives in Japan, proton or heavy ion beams could be used for treatment. He said he learned that it might be possible. EAJ immediately contacted proton beam facilities and a heavy ion beam therapy facility at a local national university hospital.

Heavy ion beam can be applied but difficult cases

Immediately from the heavy ion beam facility, EAJ learned that osteosarcoma is a good candidate for heavy ion beam therapy, and if it is osteosarcoma of the 1st and 2nd thoracic vertebrae, it may be difficult to treat it radically with anything other than heavy ion beam therapy. The patient’s request was narrowed down to heavy ion beam therapy. However, since this is expected to be a highly difficult case, the patient decided to consider various viewpoints. Even if the patient was to be treated with heavy ion radiotherapy, it would be better to use heavy ion radiotherapy in combination with chemotherapy, so the patient focused on how long he would go through the treatment in his home country and when he would come to Japan. He also decided to discuss the postoperative results in detail with local doctors in the home country.

Collaboration with local doctors in his home country until coming to Japan

Coordinating the timing of arrival in Japan with local stakeholders

In the beginning, regarding chemotherapy, the first option was to receive 6 sessions of chemotherapy using the method currently being used in the home country, as planned, and then come to Japan. However, the Japanese doctor opined that it would be better to immediately switch to heavy ion radiotherapy if progressive disease (PD) developed after 2 to 3 sessions, and EAJ requested the local doctors in the home country to share this course of therapy. There is a possibility that the patient might develop blood toxicity due to chemotherapy when he comes to Japan, so it was decided that this matter also would be to be coordinated between doctors from both countries.

Strengths of general hospitals that can handle difficult cases

The patient also said that even if he is to undergo heavy ion therapy, it might be more convenient for him to go to a heavy ion therapy facility closer to Tokyo, where his relatives are living. In this regard, if chemotherapy provided in the home country does not work and as its result the patient has to switch to continuing chemotherapy in Japan, or even if he has finished chemotherapy in his home country, chemotherapy for osteosarcoma has strong side effects, so it may be difficult for him to fully recover his physical strength. Because there is a possibility that complications may occur if he comes to Japan for treatment at an inopportune time, it should be better for him to be treated at a facility that is a little far from Tokyo but could be better prepared for unexpected situations as a part of general hospital, rather than to be treated at a facility near Tokyo that only provides heavy ion radiotherapy. Our staff explained this option and the patient was convinced.

Discussion between doctors from both countries regarding residual tumor

Images were also used to confirm with local doctors whether there was any residual tumor after surgery. EAJ requested the patient to take a CT scan about a month after the surgery to check for residual cancer, and to send it to Japan as well. In the local doctor’s opinion, no evidence of residual tumor was found. However, the resection margin of tumor resection was not clear, and contamination (movement or spread of tumor cells to surrounding normal tissue or other parts) was observed at the upper end, but it was difficult to remove any more during surgery. Since it was not possible to do so, the doctor in the home country opined there is no doubt that heavy ion radiotherapy is essential. Coordination was made through communication between Japanese doctors and local doctors, including marking areas on the image where they thought there might be contamination in order to determine the irradiation range.

Post-operative metal fixation devices become a new issue

This CT image revealed a new problem. The metal fixation was performed after the surgery. If it remains unchanged, there is a risk that the images taken to make a treatment plan will be distorted, making it impossible to produce an accurate plan. Therefore, after confirming the material of the metal, it was necessary to consider whether to remove the metal, perform heavy ion radiotherapy, and then return it after treatment, or continue with heavy ion radiotherapy without removing it. According to a local doctor in the home country, the metal used was titanium. The local doctor inquired if there is any problem as he heard that there were cases in which proton beam therapy was performed with the metal fixed in place. Removing the fixation device would cause instability and affect the position for irradiation, so a spine specialist decided to consider this. On the other hand, there is also the disadvantage that if the fixation device is left in place, the uncertainty of being occupied by the metal cannot be avoided, and if severe spinal cord damage occurs in this area, the patient will become paralyzed from the waist down. It was decided that matter would be discussed at an in-hospital conference to make a careful decision. The patient also informed us that the metal used in the fixture is titanium, and that only some of the screws are made of alloy. As a result of comprehensive evaluation, it was determined that a treatment plan would be produced without removing the fixture. A PET scan was also sent after completing 3 sessions of chemotherapy, and since there was no evidence of anomalies, the date of arrival in Japan after completing 6 sessions was decided as planned, and specific preparations for coming to Japan began.

Smooth treatment progress

It was decided that irradiation would be performed 16 times on an outpatient basis. The local doctor in the home country also prescribed medicine to prevent blood toxicity after chemotherapy. Before coming to Japan, the doctors confirmed the tests, medical information, and pathological specimens that should be completed in the home country. EAJ suggested the patient a preparation for serviced apartment, but since Japan has good transportation links and the patient can often go to Tokyo by Shinkansen, etc., he preferred to staying at a hotel and undergoing treatment for over a month, including tests. The hospital carefully checked whether the patient needed a wheelchair or not. After arriving in Japan, the treatment progressed smoothly even though the patient traveled back and forth between Tokyo and the hospital. There was no problem with spinal cord injury, which everyone was worried about. After the treatment was successfully completed, the patient felt well enough to travel to Thailand a month later. A Japanese doctor prepared a medical report and letter of referral for the doctor in the  home country after the treatment, and the doctor in the home country also reported the results of comparing images several months after the treatment.