Surgery for Osteosarcoma

Surgery is an important part of treatment for almost all osteosarcomas. It includes:

• The biopsy to diagnose the cancer
• The 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 to remove the tumor. The biopsy should be done in a certain way to give the best chance that less extensive surgery will be needed later on. 

The main goal of surgery is to remove all of the cancer. If even a small amount of cancer is left behind, it might continue to 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 that surrounds it. This is known as a wide excision.

A doctor called a pathologist will look at the removed tissue under a microscope to see if there are cancer cells at the margins (outer edges).

• 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 osteosarcomas 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.

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

Limb-salvage surgery

Most patients with tumors in the arms or legs can have limb-sparing surgery, but this depends on where the tumor is, how big it is, and whether it has grown into nearby structures.

Limb-salvage surgery is a very complex operation. The surgeons who do this type of operation must have special skills and experience. The challenge 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 may sometimes be the best option.

The section of bone that is removed along with the osteosarcoma is replaced with a piece of bone from another part of the body or from another person (a bone graft) or with a man-made device made of metal and other materials that replaces part or all of a bone (an internal prosthesis). 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. Patients who have limb-salvage surgery might need more surgery in the following years, and some might still eventually need an amputation.

Using an internal prosthesis in growing children is especially challenging. In the past, it required occasional operations to replace the prosthesis with a longer one as the child grew. Newer prostheses have become very sophisticated and often can be made longer without any extra surgery. They have tiny devices in them that can lengthen the prosthesis when needed to make room for a child’s growth. But even these prostheses may need to be replaced with a stronger adult prosthesis once the child’s body stops growing.

It takes about a year, on average, for patients to learn to walk after limb-salvage surgery on a leg. Physical rehabilitation after limb-salvage surgery is more intense than after amputation, and it’s extremely important. If the patient doesn’t actively take part in the rehabilitation program, the salvaged arm or leg might become useless.

Amputation

For some patients, amputation may be the best option. For example, if the tumor is very large or if it extends into the nerves and/or the blood vessels, it might not be possible to save the limb.

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

Surgery is usually planned so that muscles and the skin will form a cuff around the remaining bone. This cuff will fit into the end of a prosthetic (artificial) limb. Another option might be to implant a prosthesis into the remaining bone, with the end of the prosthesis remaining 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 example, 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 functions as a new knee joint. This surgery is called rotationplasty. Of course, the patient would still need a prosthetic limb to replace the lower part of the leg.

With proper physical therapy, a person is often able to walk on his/her own 3 to 6 months after a leg amputation.

If the osteosarcoma 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

This may be the hardest part of treatment, and it cannot be described here completely. Patients and parents should meet with a rehabilitation specialist before surgery to learn about their options and what might be required after surgery.

If a limb is amputated, the patient will need to learn to live with and use a prosthetic limb. This can be particularly hard for growing children if the prosthetic limb needs to be changed to keep up with their growth.

When only the tumor and part of the bone is removed in a limb-sparing operation, the situation can sometimes be even more complicated, especially in growing children. More surgery might be needed in the future to replace an internal prosthesis with one more suited to their growing body size.

Both amputation and limb-sparing surgery can have pros and cons. For example, limb-sparing surgery, although often more acceptable than amputation, tends to lead to more complications because of its complexity. Growing children who have limb-sparing surgery are also more likely to need further surgery later.

When researchers have looked at the results of the different surgeries in terms of quality of life, there has been little difference between them. Perhaps the biggest problem can be for teens, who may worry about the social effects of their operation. Emotional issues can be very important, and support and encouragement are needed for all patients. (See Living as an Osteosarcoma Survivor.)

Tumors that start in other areas

Tumors in the pelvic (hip) bones can often be hard to remove completely with surgery. But if the tumor responds well to chemotherapy first, surgery (sometimes followed by radiation therapy) may get rid of all of the cancer. 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 bones 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 may not be possible to remove all of the tumor safely. Cancers in these bones may require a combination of treatments such as chemotherapy, surgery, 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, the person will have to learn to compensate for the resulting loss of motion.

Surgical treatment of metastases

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

Osteosarcoma most often spreads to the lungs. If surgery can be done to remove these metastases, it must be planned very carefully. Things to be considered before the operation include:

• The number of tumors
• The location of the tumor(s) (one lung or both lungs)
• The size of the tumor(s)
• How well the tumor(s) responded to chemotherapy
• The person's overall health

Since the chest CT scan done before surgery might not show all of the lung tumors, the surgeon will have a treatment plan in case more tumors are found during the operation.

Patients who have tumors in both lungs and respond well to chemotherapy can have surgery on one lung at a time. Removing tumors from both lungs at the same time may be another option.

Some lung metastases may not be able to be removed because they are too big or are too close to important structures in the chest (such as large blood vessels). Patients 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.

A small number of osteosarcomas 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.

Side effects of surgery

Short-term risks and side effects: Surgery to remove an osteosarcoma is often 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 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. Most osteosarcomas 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 bone grafts or prostheses that might become loose or broken. This is more likely than with bone surgery done for other reasons because the chemotherapy used before and after surgery can increase the risk of infection and affect wound healing. 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.

As mentioned before, physical therapy and rehabilitation are very important after surgery for osteosarcoma. Following the recommended rehab program offers the best chance for good long-term limb function. Even with 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.