Pediatric Orthopedic Oncology – PediaCast 551
- Dr Thomas Scharschmidt visits the studio as we consider pediatric orthopedic oncology. Bone cancers, such as osteosarcoma and Ewing sarcoma, are more common in children than adults. We explore the symptoms, diagnosis, treatment and long-term outlook for those impacted by these conditions. We hope you can join us!
- Pediatric Orthopedic Oncology
- Ewing Sarcoma
- Pediatric Orthopedic Oncology at Nationwide Children’s
- What's New in Pediatric Orthopaedic Tumor Surgery
- Sarcoma in Children – Solving Kids’ Cancer
- What is Sarcoma? – St Baldrick’s Foundation
- Osteosarcoma in Children
- Ewing Sarcoma in Children
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello, everyone, and welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio.
It's Episode 551. We're calling this one "Pediatric Orthopedic Oncology." Want to welcome all of you to the program.
So, there were some big medical words and little jargon in the title there today. Just to break it down, orthopedic refers to bones and oncology refers to cancer. And so, we are going to talk about bone cancer in children and teenagers today.
Before we get to that, I just want to point out that for many of you, including myself, you can have some post-holiday blues. And I just wanted to check in and see how all of you are doing now that the holidays are over.
There's always a big buildup for the holidays. And whether you are a person who starts decorating and getting the Christmas tree up and listening to holiday music right after Halloween, there are many of us who like to do that and yes, I am one of them. And then, there's others that are like, "Hey, we don't even say the word Christmas. We don't think about the December, early January holidays until Thanksgiving is over." And sometimes there's a difference of opinion within the same household, which I'm sure is true for many of you.
And so, the holidays are an exciting time, whether you start them early or you start them late. Great time to get together with family and friends. And then, all of a sudden, boom, they're over.
And you're taking down the decorations and the lights. And often, especially if you live in the Midwest and other parts of the United States, the weather's not so great in January. And so, it's cold and gray, and you may not see the sun for a few days. And so that adds into the whole not getting enough sunlight and having a seasonal affective disorder.
And you can understand how those things all kind of come crashing together to really cause a drop and to have depression, not feeling so great about things. And so, I just want to encourage you that you're not alone in that. And especially if it's impacting your life, your quality of life, your ability to be a good parent and to go to work, and it's really affecting you, please do get help.
And there are all sorts of help you can get. If you don't know where to go, a great place to start is your primary care provider. If you don't have one, please get yourself one. And they can certainly point you in the right direction.
On the other hand, if you are thinking about hurting yourself or ending your life, it's really gotten to that point and it's important to talk about these things, then definitely get help right away. And all communities have a psychiatric crisis department. If you don't know where to go, go to your local emergency department and they'll be able to point you in the right direction.
Some helpful hints on combating the post-holiday blues. Stay active and it doesn't have to be expensive, especially after the holidays. You can have a dance party, get some indoor gym time, maybe at the YMCA. Get your aerobic exercise and strength training in. And you can certainly find fun activities you can enjoy.
Here in central Ohio, we have a great science museum in COSI. Just down the road over in Dayton, we have the Air and Space Museum, which is really fun, the Rock and Roll Hall of Fame up in Cleveland. And of course, there are many, many other fun things to do around that are indoors.
And so, plan a trip, even if it's just in a couple of weeks, at least you have something to look forward to.
Light boxes can also be helpful, especially when they're used in the morning. So when you get up, as you're having your breakfast, the light box there can be helpful. But the most important thing is to get professional help, really, if this is impacting your life, because it's common. And I just want to acknowledge that.
All right, so again, we are talking about bone cancers in children and teenagers. Now, fortunately, today's topic is a rare one. Less than a thousand cases of bone cancer are diagnosed in the United States each year.
It's really rare in adults. When it does happen, it's usually in a child or a teenager. And the reason really is that bones are still growing in kids. And tumors, remember, represent sort of out-of-control cell growth. And bone cancers are often diagnosed late because the symptoms can be non-specific.
So, we're going to talk about that more today. We'll discuss who is at risk, what are the symptoms, how are bone cancers diagnosed, what does treatment look like? What about the long-term outcomes and survival rates? And then, what are the hot topics in research related to pediatric orthopedic oncology? And where can young patients and families impacted by bone cancers find support?
So, we'll talk about all of these things. We have a terrific guest with us today, Dr. Thomas Scharschmidt. He is a pediatric orthopedic oncologist at Nationwide Children's Hospital and also director of the Pediatric Orthopedic Oncology Program at Nationwide Children's. So much more coming up with him.
Real quick, before we get to that interview, let me remind you that you can find PediaCast really wherever podcasts are found. We always appreciate when you leave a review of the program.
And we love connecting with you on social media. We're on Facebook, Instagram, Threads, LinkedIn and Twitter or X. Simply search for PediaCast.
We also have a Contact link over a pediacast.org if you would like to suggest a future topic for the program.
Also, I want to remind you the information presented in PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, be sure to call your healthcare provider.
So, let's take a quick break. We'll get Dr. Thomas Scharschmidt settled into the studio, and then we will be back to talk about pediatric orthopedic oncology. It's coming up right after this.
Dr. Mike Patrick: Dr. Thomas Scharschmidt is an orthopedic surgeon and director of the Pediatric Orthopedic Oncology Program at Nationwide Children's Hospital. He's also a professor of Orthopedics at the Ohio State University College of Medicine. He's here to talk about bone cancers in children and teenagers.
But first, let's give a warm PediaCast welcome to our guest, Dr. Thomas Scharschmidt. Thank you so much for stopping by and visiting with us today.
Dr. Thomas Scharschmidt: Sure. Thanks for having me, Mike. I appreciate it.
Dr. Mike Patrick: Yeah, really appreciate you taking time out of your busy schedule to join us. Let's just start with the basics. What exactly is pediatric orthopedic oncology and what makes this field of medicine unique?
Dr. Thomas Scharschmidt: Sure. So, it's a fairly niche field in orthopedics. Most people who go into orthopedics tend to gravitate towards things like sports medicine or joint replacement or fracture fixations, or the nuts and bolts, if you will, of orthopedics. Where we in musculoskeletal oncology deal with primary bone sarcomas, primary soft tissue sarcomas, which are cancerous tumors that start in the tissues that hold you together. So, start in the connective tissues, like bone or muscle or fat.
And we also deal, when we see metastatic lesions that spread to the bone or skeletal structures, a fair bit of my practice also does benign bone and soft tissue things. So, there are a lot of benign conditions we see that affect the bone as well that we'll handle that's in the realm of orthopedic oncology.
Dr. Mike Patrick: And as we think about bone cancers, my understanding is that they're actually more common in the pediatric population than in the adult population. Is that true?
Dr. Thomas Scharschmidt: That's true. I mean, primary bone cancers, what we call the cancers that actually start in the bone itself, as a population, luckily, are fairly rare. There are probably maybe 700 to 800 cases a year in the whole United States of all bone cancers. That includes the adult and pediatric population. But the majority of those do occur in the pediatric population when we see them. It's fairly rare to see a primary bone tumor in an adult.
Dr. Mike Patrick: And then, what are the most common orthopedic cancers that you see in kids?
Dr. Thomas Scharschmidt: There's really only two. There are, obviously, all these variations on the theme of those. But the two primary bone tumors we see are osteosarcomas and Ewing sarcomas.
Dr. Mike Patrick: Again, the overall prevalence of these is pretty low in the general population. Of course, if your family is impacted by this, if it's your child, then it means the world. And so, it's really those low numbers don't mean a lot when you're looking at individual families who are impacted by these diseases.
Dr. Thomas Scharschmidt: Yeah, absolutely. I mean, for the osteosarcoma and Ewing sarcoma, again, there are probably a couple of hundred cases in the entire year that happen the entire country. But if it happens to you, your family, obviously, we want to make sure you're getting the best care possible.
And for these rare tumors, I think it just highlights the importance of really having specialized centers that take care of these on a routine basis, even though they're relatively rare tumors.
Dr. Mike Patrick: Yeah, absolutely. So how do bone cancers usually present in children? So, are there specific symptoms that parents should watch for?
Dr. Thomas Scharschmidt: Yeah. And that's what makes it difficult, is the symptoms are relatively vague. I mean, obviously, if you see or feel a mass that's growing, that's relatively straightforward. But more commonly, these kids will present with pain.
And when you're talking about kids that are obviously playing sports and running around and always injuring themselves, there's routinely a delay in diagnosis, mainly because of the vague presentation. But to answer your question, pain and a growing mass are sort of the two hallmark signs of a bone cancer.
Dr. Mike Patrick: Yeah, this is our podcast for parents, but we also have a lot of pediatricians and other pediatric providers who listen. We all see kids who the parent brings them in because of leg pain, for example. It's often when we hear it, it's at the end of the day, the child's going to bed and they're complaining that their leg hurts.
And we call these growing pains. Sometimes, I don't know that growth really hurts, but more likely, most of these kids are going to have a strain or a sprain, or they've overused their muscles. And now that things have quieted down, they're paying attention to where they hurt and are more likely to say something.
And we see that a lot. So how do you differentiate that sort of presentation? What would be different that would make us worry about there being a bone cancer? Because we don't necessarily want to get x-rays and blood work in all of these kids. Otherwise, you'd overdo it then.
Dr. Thomas Scharschmidt: Right. Yeah, I know. I mean, you're hitting on the sort of crux of what the struggle of diagnosis can sometimes be.
And we know from a couple of large studies, the average time, looking back from when a child starts to have pain to the time they actually get imaging or we start to worry about it being a bone cancer is somewhere around three or four months, which feels like a long time.
And parents oftentimes will sort of beat themselves up a little bit and say, "Gosh, it's been three months. We've thought this was John's little leg was having growing pains, or he had a soccer injury, and, gosh, we really missed it." And we deal a lot with just the reassurance to the parents and the team that that's just the way that these things present. There's always a delay.
Because most of the time it is going to be some sort of muscle strain, growing pain, soccer injury, football injury, whatever that may be. So, I think what we sort of counsel is, if it's a pain that sticks around longer than it feels like it should, or if it really is consistently waking the child up from sleep, that's something that we should probably see and evaluate with at least an x-ray as an initial step, to make sure we're not missing an early stage of one of these bone cancers.
Dr. Mike Patrick: Yeah, and I think that's an important distinction because most of these kids that we see don't wake up in the middle of the night with the pain. Oftentimes, they're still playing and active during the day. It's more in the evening when they start to complain.
So, I guess from the provider's standpoint, if you have a kid who the parent tells you they're waking up in the middle of the night, or the pain is there all day or it's lasting, we don't necessarily want it to go three to four months. If you have a pain in a particular place that's lasted more than a couple of weeks, probably ought to at least see someone. And as providers, we ought to put this in the back of our head as a possibility, even though it's a rare one.
Dr. Thomas Scharschmidt: Yeah, I agree. It's pretty safe and inexpensive to get a plain x-ray radiograph done. So, if there's any question, oftentimes it's better to just get that image to make sure, again we're not missing something.
Dr. Mike Patrick: Yeah, absolutely. What recent advances have been made in diagnosing these conditions? Is there anything new, or is it really still just an x-ray? And then, are you able to tell what it is just by how it looks on the x-ray? Or do you have to get more advanced imaging? Or is there blood work that you can do to nail down the diagnosis?
Dr. Thomas Scharschmidt: Sure. So, the plain x-rays usually give us a pretty good guess, I will, or at least start to raise a little red flag that that's what we're worried about. And if the x-ray is at all concerning, we usually do follow that up with some advanced imaging, typically an MRI scan, which will give us a lot more information about sort of the internal characteristics and the soft tissues surrounding the area of question.
Unfortunately, for these types of cancers, there's no blood work detection that's available. So blood work is typically normal. A lot of times, we'll do a little blood work because infection can sometimes masquerade as a tumor and vice versa. So, we'll oftentimes get blood work more from an infection evaluation than anything else. But from a tumor biology standpoint, there's no blood work that will help us.
So, once we get that x-ray and MRI scan, if there's still worry, then typically a biopsy is going to be the next step in the treatment algorithm.
Dr. Mike Patrick: And the biopsy, is that done in the operating room?
Dr. Thomas Scharschmidt: It can be done in two ways, either done in the operating room where we do what's called an open biopsy, where we make a little incision and actually take a small sample of the area of concern. Or it can be done with our interventional radiology colleagues as well, where it's done with just a needle biopsy. So, depending on the characteristics of the imaging and the location of where this is, it could be done in either one of those two ways.
Dr. Mike Patrick: And then, the biopsy is taken to the lab, a pathologist looks at it under the microscope and maybe does some various testing that I'm not well versed on, and then lets you know whether it is a cancerous or a benign bone lesion that you're seeing there.
Dr. Thomas Scharschmidt: Correct, yeah.
Dr. Mike Patrick: And then, once you have the diagnosis of an osteosarcoma or Ewing sarcoma, what treatment options are available? And I would imagine that you probably collaborate with some other pediatric subspecialists in that case as well.
Dr. Thomas Scharschmidt: Absolutely. I mean, we have a really robust team here of sarcoma specialists. And we really feel and treat this like it's a team sport. So, once we make the diagnosis, we very early on and even probably even prior to diagnosis, get our medical oncology team on board and meeting with the family to sort of talk through just potential directions it may go.
Obviously, we work very closely with our pathology team and our radiology team. But once we get into establishing the diagnosis, the treatment protocols for either one of those common cancers, the osteosarcoma or Ewing sarcoma, is fairly protocol-driven across the country. So essentially, you get the same treatment here as you would at MD Anderson or Sloan Kettering or any other center, children's hospital or cancer center in the United States.
And they're really driven by children's oncology group protocols, where it's a combination typically of chemotherapy and what we call local control, which is usually an operation to actually remove that cancerous tumor.
Dr. Mike Patrick: I know in other areas of cancer medicine, a lot of times you can look at the person's genes to figure out what the best therapy might be because they have in the past looked at the outcomes with various therapies and then start to make connections between particular genes and what might work better or not. Is that also true with orthopedic oncology? Or are we not really there yet in terms of being able to personalize the treatment plan?
Dr. Thomas Scharschmidt: It's a great question. And I think it's an emerging area that we're exploring actively with these bone cancers. We typically get genetic testing done on virtually all of these patients. In addition, the tumors typically undergo a very robust pathologic analysis where we get genomic evaluation of the actual tumor itself.
Unfortunately, we haven't really found how that's going to translate into treatment regimens or therapeutic regimens at this point in time. But it's certainly something that's, again, on the emerging front, and we're actively exploring.
Dr. Mike Patrick: When you have a disease that has such a low incidence in the general population, it's definitely more difficult to study, which is a good thing. It's not good for the folks who are impacted by this, for sure, but I guess low incidence is good for those who aren't, and there would be more otherwise. So, I guess it must be kind of frustrating. Not that you wish more cancers, for sure, but it does make it more difficult to move forward and evolve in treatment when there's few opportunities to treat these diseases.
Dr. Thomas Scharschmidt: Yeah, it's definitely one of the struggles in sarcoma care is, unfortunately, research resources and grant funding and all those things is a finite pie. And when you look at overall effects on population, sometimes as a rare disease, it's difficult to get the same right resources that, say, people with breast cancer or colon cancer.
The more common cancers where there's literally millions of cases a year, oftentimes sort of, probably rightfully so, but oftentimes get a majority of those resources. So sometimes getting meaningful stuff done on a rare cancer is certainly a challenge.
Dr. Mike Patrick: From the parents' lens, as they get this diagnosis that their child has a bone cancer, probably one of the first things that comes in their mind is are they going to lose an arm or a leg? Is that something that happens frequently or with today's treatments, is that even more rare?
Dr. Thomas Scharschmidt: Yeah, that's an interesting question and a great point, because I think probably 90- plus percent of the time, we can perform what's called a limb salvage surgery, meaning we don't have to consider an amputation.
But that being said, we've also made some just massive advances in our amputee patients when they do, unfortunately, have to undergo an amputation, where we can do things to improve their function and improve their sort of daily living, even with an amputation. And sometimes their function may be better than a complex limb salvage surgery.
So, although we are usually able to salvage most limbs, we certainly have this discussion where we go through all the options and take the family and the child wishes and expectations into account, to really try to personalize that decision for each of those families.
Dr. Mike Patrick: I imagine that if a child is impacted by one of these cancers and they play sports, that can be devastating for these kids. Is there a role in physical therapy and rehabilitation for all of these kids? But in particular, if they are playing a sport, is it reasonable to think that they may be able to return to their sport?
Dr. Thomas Scharschmidt: Yeah, I mean, that's also, obviously, going to be a very individualized discussion as far as where the cancer is located, what the surgery will take to remove the cancer, what the sport is that they're playing, as well as what our reconstructed options are. So, we try to, again, have a lot of discussions preoperatively as we're making those decisions to try to personalize that approach for patients.
But oftentimes, we are able to get these kids back doing the things that they want to do. Granted, there may be some adaptations and things we have to take into consideration. But for a lot of kids, we're able to get them back doing things they want to do.
Dr. Mike Patrick: And as you mentioned, the team, the sarcoma team, I would imagine that mental health professionals, psychologists, psychiatrists, counselors would also be a part of this, because there is certainly a mental health toll that takes place whenever there's a cancer diagnosis.
Dr. Thomas Scharschmidt: Oh, 100%. Again, we have a very robust team here, and that includes our support services like you mentioned. Obviously, dealing with a child with cancer, not only is it tough on the kid, but it's extraordinarily tough on the family and support staff and brothers, sisters, those sorts of things that are also going through this.
So, we have a lot of resources in place and available both locally here within Children's, as well as connecting the families with the different patient advocacy groups and different families that have been down that road to try to connect and make sure we're giving the best support we can.
Dr. Mike Patrick: Yeah, absolutely. And in the show notes, we're going to have some links to particular resources that folks may find helpful. So, I'd encourage families to check out the website pediacast.org and look in the show notes for this episode 551, and you'll be able to find those resources there.
Just some examples, the St. Baldricks Foundation has a nice site with lots of support information, and Solving Kids' Cancer is another one. And I'm sure that if there are others, you will let us know. And we'll include those in the show notes, too, because those resources are really so important for families.
What about the prognosis for these cancers? Sort of the long term, when we hear about cancers, we think about survival rates. Is that something that we talk to families about with the bone cancers?
Dr. Thomas Scharschmidt: Oh, absolutely. I mean, I think it's important to, even though they're tough conversations, those are important, transparent conversations that need to happen early on just to, again, set expectations. And more importantly, make sure we're supporting the family the best that we can.
So, one of the big challenges we've had with both osteosarcomas and Ewing sarcoma is we really haven't seen a meaningful bump in our survival rates over about the last 20 to 25 years. And a lot of it is really limited to the things we've already highlighted. It's a very rare cancer. Resources can be limited in terms of studying things.
So, we've had some challenges in improving our survival rates overall. So, the things that we talk about is, once we make the diagnosis of this cancer, the next step is we want to make sure it hasn't spread anywhere else.
By definition of it being a cancer means it can metastasize or spread to other areas. And for these cancers, the lungs is the primary area we worry about. So, we get some scans done on the lungs to make sure everything looks clear there.
When we talk about overall survival rate, as long as it presents in what we call localized disease, meaning it hasn't spread and it is surgically resectable, meaning we can remove the cancer at the appropriate time, our survival rates are somewhere between 65 and 85% at five years. So, they're not great, but we were doing everything we can to try to optimize and improve upon those on really a daily basis.
Dr. Mike Patrick: And I think for listeners out there, this is an area where, if you're thinking about philanthropy and helping support research efforts, this is going to be a good one, because it is, again, a rare disease. Oftentimes, funding is lacking. And so, in terms of supporting other families who may be impacted by this, this is definitely an opportunity to help your neighbor.
Dr. Thomas Scharschmidt: Absolutely. I appreciate that, Mike. Yeah, we could definitely use help if available. And one of the luxuries we have here at Nationwide is that we really have one of the leading sarcoma centers in the country, which is probably a little-known fact to the community here.
But when we look at all the different clinical trials and the different things we're doing surgically, we're really one of the nation's leaders in taking care of kids with this what could be devastating diagnosis. So certainly, welcome any help we can get.
Dr. Mike Patrick: When we look at the whole program, you had mentioned just how strong of a team that we have here at Nationwide Children's. And especially when you have a disease that does not impact that many people, you really do want to go to a center that has experience treating these kinds of things.
And so, as you mentioned, it's a little-known fact that we have such a great sarcoma program that's really nationally recognized. But the folks who don't live in central Ohio, it is important to know that we do have a great one. And we do see folks who travel to Columbus in order to be treated for their sarcoma, correct?
Dr. Thomas Scharschmidt: Oh, absolutely, yeah. We've seen and continuing to see referrals and just even second opinions from really all over the US and internationally. We get referrals from really all over the world.
And obviously, the more that we do here, the better that our team also gets at it and the more we learn about this. So, we really welcome as many patients as we can, even if it's just for a second opinion, so we can learn something from them as well.
Dr. Mike Patrick: And I would imagine that we have support for folks who travel in terms of helping them find a place to stay because you're away from home and this all becomes more difficult and complicated. And so, sort of having a team going on this journey with you can be very helpful.
And so, we will, of course, put a link in the show notes to the Pediatric Orthopedic Oncology Program at Nationwide Children's. And so, folks, hopefully will be able to get connected with you very easily.
Let's talk about the future. What are some of the hopes and goals that you have in this field?
Dr. Thomas Scharschmidt: Well, obviously, we want to improve our survival rates and good functional outcomes for these kids. So, we have a lot of research going on, both in the overall treatment of the disease in terms of clinical trials and a few of the things we hit on earlier, looking at the genetic profiling and looking for better targets that we can do to hopefully keep these cancers from spreading and improve the survivability of the cancer.
And then in my world, particularly in the surgical world, we want to give these kids the best function that we can. So, we are doing a lot of local research here on things like 3D printing, virtual surgical planning, doing things to make our surgeries for these kids both safer and more predictable and better functional outcomes.
So, on the global scale, we want to obviously improve our survivability. But while patients and families are going through this, we want to make it as comfortable and as easy a journey as we can for them. So, we're trying to improve in all those aspects of care.
Dr. Mike Patrick: What advice do you have for parents who get this diagnosis and they're navigating this journey? What are some of the challenges and barriers that they may face and how can they overcome those?
Dr. Thomas Scharschmidt: Yeah, I think it's important to connect with other families that have walked that journey already for them. So, again, connecting with some of the other patient advocacy groups, or we help connect with families here locally that have been down a similar path. I think in a rare disease, just feeling like you're not alone in fighting, it is really important.
So, I think we try to connect families very early on. And then, I think I would encourage families to don't be afraid to ask for or get second opinions or third opinions or as many opinions as you need to, to feel comfortable with where your child's being treated, that they're getting the best care they can from practitioners that are the leaders of the field.
So oftentimes, I think families can feel bad about that for some reason. But we try to encourage parents and help arrange for those second and third opinions, if need be, just to, again, give them the comfort that they're getting the best care they can for their child.
Dr. Mike Patrick: And I'm sure that that could become frustrating from your point of view. It'd be easy for that to become frustrating. But I think the fact you have that empathy of the parent really does want to make sure that they've got the right diagnosis, the right treatment plan, the right treatment team that's managing that plan, because our kids are the most precious things to us.
And so, I love that you said, "Hey, it's okay. We encourage a second or third opinion if that's going to make you feel more comfortable, because it's not that you are criticizing our care, it's that you really want the best care for your child. And really, that's all that all of us want."
Dr. Thomas Scharschmidt: Absolutely, yep. Well said, Mike.
Dr. Mike Patrick: All right. Well, we really appreciate you again stopping by today and talking to us about bone cancers in kids, osteosarcomas and Ewing sarcomas.
And we'll point out one more time that we'll have a link in the show notes to the Pediatric Orthopedic Oncology Program at Nationwide Children's. And that's something that parents can go to that site. And if they want to get in touch with you, they don't necessarily have to have a referral, right? They can just use the Contact Us resource at your website.
Dr. Thomas Scharschmidt: That's correct, yeah. Happy to connect via email or phone call or anything really informally, even prior to an actual visit with us, if that's helpful for the families.
Dr. Mike Patrick: All right, well, once again, Dr. Thomas Scharschmidt with Pediatric Orthopedic Oncology at Nationwide Children's Hospital. Thank you so much for spending some time with us today.
Dr. Thomas Scharschmidt: Thanks for having me, Mike. I appreciate it.
Dr. Mike Patrick: We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it. Really do appreciate that.
Also, thanks to our guest this week, Dr. Thomas Scharschmidt, with pediatric orthopedic oncology at Nationwide Children's Hospital.
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