Surgery for Bone Cancer

Surgery is an important part of treatment for most types of bone cancer. It typically includes:

• The biopsy to diagnose the cancer
• The surgical removal of the tumor(s)

Whenever possible, it’s very important that the biopsy and the surgery to remove the tumor be planned together, and that an experienced orthopedic surgeon does both the biopsy and the surgery. The biopsy needs to be done in a certain way to give the best chance that less extensive surgery will be needed later on.

The information here focuses on primary bone cancers (cancers that start in bones) that most often are seen in adults. Information on Osteosarcoma, Ewing Tumors (Ewing sarcomas), and Bone Metastasis is covered separately.

What is the goal of surgery for bone cancer?

The main goal of surgery is to remove all of the cancer. If even a small amount of cancer is left behind, it might grow and make a new tumor, and might even spread to other parts of the body. To lower the risk of this happening, surgeons remove the tumor plus some of the normal tissue around it. This is known as a wide excision.

After surgery, a doctor called a pathologist will look at the removed tissue to see if the margins (outer edges) have cancer cells.

• If cancer cells are seen at the edges of the tissue, the margins are called positive. Positive margins can mean that some cancer was left behind.
• When no cancer cells are seen at the edges of the tissue, the margins are said to be negative, clean, or clear. A wide-excision with clean margins helps limit the risk that the cancer will come back in the place where it started.

The type of surgery done depends mainly on the location and size of the tumor. Although all operations to remove bone cancers are complex, tumors in the limbs (arms or legs) are generally not as hard to remove as those in the jaw bone, at the base of the skull, in the spine, or in the pelvic (hip) bone.

Surgery for bone tumors in the arms or legs

Tumors in the arms or legs might be treated with either:

• Limb-salvage (limb-sparing) surgery: removing the cancer and some surrounding normal tissue but leaving the limb basically intact
• Amputation: removing the cancer and all or part of an arm or leg

When discussing your options with the treatment team, it's important to consider the pros and cons of either type of surgery. For example, most people prefer limb-salvage over amputation, but it's a more complex operation and can have more complications. If a limb is amputated, the patient will need to learn to live with and use a prosthetic limb.

Both types of operations have the same overall survival rates when done by expert surgeons. Studies looking at quality of life have shown little difference in how people react to the final result of the different procedures. And when researchers have looked at the results of the different surgeries in terms of a person’s quality of life afterward, there has been little difference between them.  Still, emotional issues can be very important, and support and encouragement are needed for all patients.

No matter which type of surgery is done, physical rehabilitation will be needed afterward (see below).

Limb-salvage surgery

Most people with arm or leg tumors can have limb-sparing surgery, but this depends on where the tumor is, how big it is, and if it has grown into nearby structures.

The goal of limb-salvage surgery is to remove all of the cancer and still leave a working leg or arm. This type of surgery is very complex and needs to be done by surgeons with special skills and experience. The challenge for the surgeon is to remove the entire tumor while still saving the nearby tendons, nerves, and blood vessels to keep as much of the limb’s function and appearance as possible. If the cancer has grown into these structures, they will need to be removed along with the tumor. (In such cases, amputation might sometimes be the best option.)

The section of bone that is removed along with the tumor is replaced with a bone graft (a piece of bone from another part of the body or from another person) or with an endoprosthesis (internal prosthesis), which is a device made of metal and other materials that replaces part or all of a bone. Some newer devices combine a graft and a prosthesis.

Complications of limb-salvage surgery can include infections and grafts or rods that become loose or broken. Those who have limb-salvage surgery might need more surgery in the following years, and some might still eventually need an amputation.

Amputation

For some patients, amputation of part or all of a limb is the best option. For example, if the tumor is very large or if it has grown into important nerves and/or blood vessels, it might not be possible to remove all of it and still leave behind a functional limb.

The surgeon determines how much of the arm or leg needs to be amputated based on the results of MRI scans and examination of removed tissue by the pathologist at the time of surgery.

Surgery is usually planned so that muscles and the skin will form a cuff around the amputated bone. This cuff fits into the end of an artificial limb (external prosthesis). Another option might be to implant a prosthesis into the remaining bone, the end of which remains outside the skin. This can then be attached to an external prosthesis.

Reconstructive surgery can help some patients who lose a limb to function as well as possible. For instance, if the leg must be amputated mid-thigh (including the knee joint), the lower leg and foot can be rotated and attached to the thigh bone, so that the ankle joint functions as a new knee joint. This surgery is called rotationplasty. A prosthetic limb would still be needed to replace the lower part of the leg.

If the bone tumor is in the shoulder or upper arm and amputation is needed, in some cases the area with the tumor can be removed and the lower arm reattached so that the patient has a functional, but much shorter, arm.

Rehabilitation after surgery on an arm or leg

This may be the hardest part of treatment, and it cannot be described here completely. If possible, there should be a meeting with a rehab specialist before surgery so you will understand what this might entail.

Rehab after amputation typically takes less time than after limb-sparing surgery. For a tumor on a leg bone, people are often walking again 3 to 6 months after leg amputation, whereas it takes about a year, on average, for patients to learn to walk again after limb-salvage surgery. Physical rehab is also much more intense after limb-salvage surgery than it is after amputation, but it’s still extremely important. If the patient doesn’t actively take part in the rehabilitation program, the salvaged arm or leg might become useless, and might require amputation.

Surgery for bone tumors in other parts of the body

Tumors in the pelvic (hip) bones can often be hard to remove completely with surgery. Some types of tumors can be treated with chemotherapy first to help shrink the cancer and make the operation easier. Pelvic bones can sometimes be reconstructed after surgery, but in some cases pelvic bones and the leg they are attached to might need to be removed.

For tumors in the lower jaw bone, the entire lower half of the jaw may be removed and later replaced with bone from other parts of the body. If the surgeon can’t remove all of the tumor, radiation therapy may be used as well.

For tumors in areas like the spine or the skull, it might not be possible to remove all of the tumor safely. Cancers in these bones could require a combination of treatments such as curettage (removal by scraping - see below), cryosurgery, and radiation.

Joint fusion (arthrodesis): Sometimes, after the removal of a tumor that involves a joint (an area where two bones come together), it might not be possible to reconstruct the joint. In this case, surgery might be done to fuse the two bones together. This is most often used for tumors in the spine, but it might also be used in other parts of the body, such as a shoulder or hip. While it can help stabilize the joint, it results in loss of motion, which the person will have to learn to adjust to.

Curettage (intralesional excision)

For some types of bone tumors that are less likely to spread or to come back after treatment, the surgeon might scrape out the tumor without removing a section of the bone. This is done with a sharp instrument called a curette, and it leaves a hole in the bone. After as much of the tumor is removed as possible, the surgeon might treat the nearby bone tissue with other techniques such as chemicals or extreme cold (cryosurgery) to try to kill any remaining tumor cells.

Bone cement

The bone cement PMMA (polymethylmethacrylate) starts out as a liquid and hardens over time. It can be put into the hole in the bone in liquid form after curettage. As it hardens, it gives off a lot of heat, which might help kill any remaining tumor cells.

Surgical treatment of bone tumor metastasis

If bone cancer has spread (metastasized) to other parts of the body, these tumors need to be removed to have a chance at curing the cancer.

When bone cancer spreads, it most often goes to the lungs. If surgery can be done to remove these metastases, it must be planned very carefully. Before the operation, the surgeon will consider the number of tumors, where they are (in one or both lungs), their size, and the person’s overall health.

Imaging tests such as a chest CT scan might not show all of the tumors, so the surgeon will have a treatment plan ready in case more tumors are found during the operation.

Some bone cancers might spread to other bones or to organs like the kidneys, liver, or brain. Whether these tumors can be removed with surgery depends on their size, location, and other factors.

Unfortunately, not all cancers that have spread can be removed with surgery. Some metastases might be too big or too close to important structures (such as large blood vessels) to be removed safely. People whose overall health isn’t good (for example, because of heart, liver, or kidney problems) might not be able to withstand the stress of anesthesia and surgery to remove the metastases. If this is the case, other treatments might be offered to try to control these tumors for as long as possible.

Side effects of surgery

Short-term risks and side effects: Surgery to remove bone cancer can often be a long and complex operation. Serious short-term side effects are not common, but they can include reactions to anesthesia, excess bleeding, blood clots, and infections. Pain is common after the operation, and it might require strong pain medicines for a while after surgery as the site heals.

Long-term side effects: The long-term side effects of surgery depend mainly on where the tumor is and what type of operation is done. Many bone cancers occur in bones of the arms or legs, and some of the long-term issues from surgery on these tumors are described above.

Complications of limb-sparing surgery can include loose or broken bone grafts or prostheses. Infections are also a concern in people who have had amputations, especially of part of a leg, because the pressure placed on the skin at the site of the amputation can cause the skin to break down over time. It’s also possible that the surgery could damage nerves in the limb, which might affect the function of the limb or cause pain (known as neuropathic pain).

As mentioned above, physical therapy and rehabilitation are very important after surgery for bone cancer. Following the recommended rehab program offers the best chance for good long-term limb function. Even with proper rehab, people might still have to adjust to long-term issues such as changes in how they walk or do other tasks, and changes in appearance. Physical, occupational, and other therapies can often help people adjust and cope with these challenges.