Limb Sparing Surgery In Primary Bone Cancer

A limb-sparing (otherwise known as limb-salvage) surgery involves removing a malignant (cancerous) bone or soft tissue tumor without amputation, and replacing the bone and/or joint with an allograft (bone graft), endoprostheses (artificial devices), or composite (combining allograft and endoprothesis). Soft tissue and muscle transfers to cover and close the site and restore motor power also are part of this procedure.

In the past, amputation of the affected arm or leg was the most common treatment for many types of primary bone cancers. Primary bone cancer describes cancer cells that originate from the bone and may locally invade the soft tissues. Due to improvements in chemotherapy, imaging studies, and surgical techniques, limb-sparing surgeries are performed more commonly today.

Primary bone tumors are the sixth most frequent type of cancer in children. In adolescents and young adults, they are the third most frequent cancer.

A patient may be a candidate for limb-sparing surgery depending on the tumor size, location, and whether the cancer has spread to other areas of the body, such as other bones or the lungs. The patient's age and skeletal development also are part of the decision that determines the appropriateness of this surgery. Other considerations for limb-sparing surgery include the response to chemotherapy, the extent of bone and soft tissue involvement, and how functional the limb may be after the procedure.

According to the National Cancer Institute, seventy to ninety percent of extremity osteogenic sarcomas (a type of primary bone cancer) can be treated by a limb-sparing surgery without the loss of the limb.

Prior to performing the actual limb-sparing surgery, the surgeon will order several preparatory procedures. Being knowledgeable of these processes will allow you to be involved in the course of treatment, eliminating some of the fear of the unknown.

Diagnosis: A diagnosis of bone cancer depends on the use of x-ray (radiograph), a CT (computerized tomography) scan, and/or a MRI (magnetic resonance imaging), and a biopsy of the affected limb. The biopsy should be performed by an orthopedic surgeon who is familiar with the management of malignant bone tumors and preferably by the surgeon who will perform the limb-sparing surgery.

Chemotherapy: One of the goals of treatment before limb-sparing surgery is to shrink the tumor, allowing for a more successful surgical outcome. Chemotherapy drugs have been developed to kill malignant (cancerous) cells, while hopefully shrinking the tumor. Specific chemotherapy drugs are part of the treatment plan before and after surgery for the patient with primary bone cancer. Pre-surgical chemotherapy is used in an effort to increase the number of patients who are considered candidates for limb-sparing surgery and to provide a more positive outcome for surgery. Chemotherapy usually is administered for approximately three or four months before the limb-sparing surgery. You will be given more information about the specific chemotherapy plan by a specialist in cancer (oncologist).

Imaging Tests: Before chemotherapy begins, other imaging tests are performed such as a CT scan of the lungs and a full-body bone scan, because often, the first places in the body where primary bone cancer may spread are the lungs or other bones. These tests assist the physicians to know what types of chemotherapy to administer and if limb-sparing surgery is the best type of treatment for the patient. One or more of the imaging tests previously mentioned will be repeated before the limb-sparing surgery to assess the effect of chemotherapy on the tumor.

Before Surgery: It is important to have an understanding of the procedures and how the surgeon will perform the surgery. Ask questions. Ask for drawings or pictures of the procedure. Before you meet with the surgeon and oncologist, or other doctors and nurses, write down your questions and bring them with you to your visits. Being prepared provides a sense of control, which may decrease fear and anxiety.

Definitive Surgery: The length of a limb-sparing surgery depends on the type of surgery (allograft or endoprothesis), the condition of the patient, the surgeon's style, and many other factors. After surgery, the wound will be covered in a bulky, sterile dressing. A drain, which was placed in the wound by the surgeon during surgery to allow drainage of blood outside the skin, may be removed within three to five days after the surgery. The extremity will be placed in an immobilizer. An immobilizer supports the extremity and allows access to dressing changes. After the wound has healed, and depending on the surgeon's protocol, a solid cast may be placed on the extremity for a period of time. When the cast no longer is needed, a removable brace may be fitted to provide support to the limb.

To be sure you understand how pain will be controlled after surgery, discuss the available pain-management treatments with the surgeon and the anesthesiologist before the surgery. Ask them such questions as:

After the limb-sparing surgery, the tumor is evaluated by a pathologist to determine how well it responded to the preoperative chemotherapy treatments. This evaluation is called the degree of response. You will want to know the tumor cell's necrosis. Necrosis is the death of cells or tissue achieved by the preoperative chemotherapy. A high degree of necrosis (95% or greater) indicates that the preoperative chemotherapy successfully "killed" the cancer cells that constituted the tumor. The success of the response is determined by grade. Grade IV which describes near (99%) or complete necrosis, and Grade III, or scattered foci of viable residual tumor (90% - 99% necrosis), are considered a good response to chemotherapy. Grade II (90% necrosis or less), indicates that some of the tumor responded to the chemotherapy as evidenced by cell death, while other areas of the tumor were not affected by chemotherapy. Grade I means that there was little or no response to the chemotherapy drugs which were used before surgery. Both Grade I and Grade II are considered a poor response to the chemotherapy. In these cases, different chemotherapy drugs will be used after recovery from the limb-sparing surgery.

Physical Therapy: The physical therapy plan will be different for each patient, and will depend on the nature and location of the surgery. The goal of the physical therapist is to train, advise, and encourage your return to independent and normal function. Be sure to consult with the surgeon about the physical therapy plan to be implemented. Following the physical therapy plan is essential for good functioning of the affected limb.

The therapist will teach you how to safely transfer, walk, and do basic self-care. You will learn appropriate exercises to strengthen the affected limb, as well as to improve overall strength and endurance. If a joint is involved, you will learn how to regain range of motion and functional use of the joint when appropriate.

If you experience pain during physical therapy, ask the physician, nurse, and physical therapists which medications and methods can be utilized for increased comfort. Because some nerves may have been affected as a result of the surgery, a neurologist may need to be consulted.

Postoperative Chemotherapy: After a recovery period, the patient will start postoperative chemotherapy. The type of chemotherapy drugs used will depend largely on the pathology report and how the tumor responded to the preoperative chemotherapy. The interval between surgery and the start of chemotherapy again depends on a number of factors such as wound healing, complications, and the protocol or plan of the oncologist.

Possible Complications: Fifteen to forty percent of patients develop complications that result in additional surgeries after limb-sparing surgery. Contributing to this wide range is the type of surgery performed, the tumor site, and the age of the patient at the time of the first surgery. You can recognize the onset of certain complications by keen awareness to a number of symptoms.

Words Used When Talking About Limb-Sparing Surgery
Adjuvant Chemotherapy:	The use of anticancer drugs before and after surgery.
Allograft:	The bone obtained from a surgical patient or cadaver donor that is used to replace diseased bone.
Biopsy:	The removal and microscopic examination of tissue from the body in order to diagnose disease.
Cancer:	The term used to describe the uncontrolled, abnormal growth of cells. The resulting mass, or tumor, can invade and destroy normal tissue which surrounds it.
Chemotherapy:	The treatment used to destroy cancer cells with drugs.
CT Scan (computerized tomography):	A diagnostic procedure in which a computer is used to generate a three-dimensional image.
ECG:	An electrocardiogram (also known as EKG) is a graph of electric impulses from the heart.
EMLA:	A cream which produces temporary numbness of the skin in order to decrease pain during needle injections.
Grade of Tumor:	Used to provide consistency in assessing the tumor's response to pre-surgical chemotherapy.
Immobilizer:	A cast or splint placed on an extremity or other part of the body to cause it to be immovable.
Infection:	The invasion of disease-producing organisms in the body.
Limb-Sparing Surgery:	(Also known as limb-salvage) The removal of a malignant bone tumor without amputation, and replacing the bone and/or joint with a bone graft or artificial devices.
Malignant:	The condition of a tumor consisting of cancerous cells.
Metastasis:	The process when cancer cells break from their original site and move to another site in the body.
MRI (magnetic resonance imaging):	A technique that uses magnetic fields and radio waves linked to a computer to create pictures of areas inside the body.
Oncologist:	A medical doctor who treats cancer.
Oncology:	The branch of medicine that studies cancer.
Osteogenic Sarcoma:	A type of bone cancer. Sarcoma means cancer arising from connective tissues such as muscle or bone. Osteogenic means sarcoma composed of bone or bone-like tissues.
Pathologist:	A doctor who studies cells to determine if disease is present.
PCA (patient-controlled analgesia):	A method of pain control consisting of a machine that delivers a regulated dosage of pain medication through the patient's IV.
Physical Therapy:	A type of rehabilitation concerned with restoration of function. Physical therapists may use exercise, heat, cold, electricity, massage, and other therapies in order to strengthen muscles and encourage return of motion.
Prognosis:	An estimate of the outcome of a disease; a prediction.
Prosthesis:	An artificial limb.
Sarcoma:	Cancer arising from connective or supportive tissues, such as muscle or bone.
Tissue:	Cells that perform a similar function.
Tumor:	An abnormal growth of cells or tissues. Tumors may be benign (non-cancerous) or malignant (cancerous).
X-Rays:	High energy radiation used to assist in diagnosis.

Brien,E.W., Terek, T.M., Healy, J.H. & Lane, J.M. (1994). Allograft reconstruction after proximal tibial resection for bone tumors. Clinical Orthopaedics and Related Research, 303, 116-127.

Husdon, M.M., Tyc, V.L., Cremer, L.K., Luo, S., Li, H., Rao, B.N., Meyer, W.H., Crom, D.B., & Pratt, C.B. (1998). Patient satisfaction after limb-sparing surgery and amputation for pediatric malignant bone tumors. Journal of Pediatric Oncology Nursing, 12 (2), 60-69.

Leukemia Society of America. (1997). Understanding Chemotherapy, January 1997 (No. P-037 20M). [Brochure]. New York, N.Y.: Author.

McCaffery, M. & Pasero, C. (1998) Pain: Clinical Manual. C.V. Mosby Company: Philadelphia.

National Cancer Institute. (1993). Young People with Cancer: A Handbook for Parents. [Brochure]. Bethesda, MD.: Author.

Pearson, M. (198). Living Legends: Historical Perspective of the treatment of osteosarcoma: An interview with Dr. Normal Jaffe. Journal of Pediatric Oncology Nursing, 12 (2), 90-94.

Provisor, A.J., Ettinger, L.J., Nachman, J.B., Krailo, M.D., Makley, J.T., Yunis, E.J., Huvos, A.G., Betcher, D.L., Baum, E.S., Kisker, C.T., & Miser, J.S. (1997). Treatment of nonmetastatic osteosarcoma of the extremity with preoprative and postoperative chemotherapy: A report from the Children's Cancer Group. Journal of Clinical Oncology, 15 (1), 76-84.

Smith, N.K., Pasero, C.L., & McCaffery, M. (1997). Non-drug measures for painful procedures. American Journal of Nursing, 97 (8), 18-20.

U.S. Department of Health and Human Services. (1992) Acute Pain Management in Children: Operative Procedures, February 1992. [Brochure]. Rockville, MD.: Author.

Reviewed by:
Jerry Z. Finklestein, M.D.
Medical Director, Jonathan Jaques Children's Cancer Center

Joetta DeSwarte-Wallace, R.N., M.S.N.
Clinical Nurse Specialist, Jonathan Jaques Children's Cancer Center

To order these free publications and others, call: Publications Ordering Service of the National Cancer Institute Cancer Information Service at 1-800-4-CANCER

National Cancer Institute
Publications Ordering Service
P.O. Box 24128
Baltimore, MD 21227
Website: http://rex.nci.nih.gov

(800) 366-2223 or (301) 657-8401
The Candlelighters Childhood Cancer Foundation
7910 Woodmont Avenue, Suite 460
Bethesda, MD 20814

The U.S. Department of Health and Human Service's Agency for Health Care Policy and Research provides information regarding pain control after surgery for adults and pediatrics.
AHCPR Clearinghouse
(800) 358-9295
P.O. Box 8547
Silver Spring, MD 20907
Website: www.ahcpr.gov