Surgery for bone cancer

Most people with bone cancer will have surgery. The type of surgery you have depends mainly on where the tumour is, the size of the tumour, the stage of the cancer and the type of bone cancer.

Tumours that can be completely removed with surgery are called resectable. Tumours that can’t be completely removed with surgery are called unresectable. It is often harder to completely remove bone tumours in the spine, pelvis and base of the skull, so doctors will use other treatments along with surgery for these tumours. It is easier to completely remove tumours in an extremity (arm, leg, hand or foot) with surgery.

The main goal of surgery is to remove the whole tumour along with a margin of normal tissue around it. The other tissues or structures that have to be removed will depend on where the cancer has spread.

Reconstruction is usually done at the same time as the surgery to remove the cancer. The type of reconstruction used will depend on your age, health and desired lifestyle. Your surgeon will talk to you about how each type of reconstruction can help the reconstructed limb work as normally as possible.

Surgery may be done for different reasons. You may have surgery to:

• take a biopsy sample to confirm a diagnosis of bone cancer
• remove all or as much of the tumour as possible
• remove a metastatic tumour in a lung
• rebuild the area after a tumour is removed (reconstruction)

Before surgery, doctors will do tests to find out the borders of the tumour, how it has responded to chemotherapy so far and if it has grown or spread. These tests may include imaging tests such as CT scans, MRIs, bone scans and PET-CT scans.

Based on these tests, the surgeon will let you know the types of reconstruction you can have after your bone tumour is removed. You will work with your healthcare team to decide what option is best for you. It may help to talk to someone who has had the surgery that your healthcare team is suggesting and to look at pictures or videos of people who have had the surgery.

You may want to talk to your healthcare team about the following factors to help you make a decision.

It is important to talk to your healthcare team about your lifestyle and the type of activities you want to do after your surgery. With some types of reconstruction, you won’t be able to run or do sports.

Some types of reconstructive surgery, such as an allograft, take a long time to heal. You may have to be on crutches for a long time after surgery or avoid any heavy lifting. Amputation has a much shorter healing time, with fewer issues. Talk to your healthcare team about support in your community that can help you during recovery and rehabilitation. This may help you decide which surgery is best for you.

Surgery for bone cancer can affect your body image. Body image is how you see your own body. The surgery that will give you the strongest, most useful limb can be different from the surgery that will give your limb the most normal appearance. Talk to your healthcare team about how your surgery options might affect your appearance and body image.

The following types of surgery are used to treat bone cancer. You may also have other treatments before or after surgery.

Wide resection removes the bone tumour and a wide margin of normal bone and tissue around the tumour. Any tissue from or near the biopsy site is also removed. This type of surgery is also called en bloc resection.

Depending on the amount of tissue removed, your surgeon may need to use bone, skin or tissue from another part of the body (called a graft) to replace the removed bone and cover the area. This is done at the same time as the surgery to remove the cancer.

Limb-sparing surgery, or limb-salvage surgery, removes the tumour without removing (amputating) the whole arm or leg (the limb). It is used to treat bone cancer in an upper or lower limb. Surgeons remove all of the tumour and any of the soft tissues where the bone cancer has spread. The surgeon needs to preserve or protect major nerves or blood vessels so the limb works as normally as possible after surgery. After this type of surgery, the limb is reconstructed using bone and skin grafts.

Limb-sparing surgery is not always possible. Surgeons will do this surgery only if they will be able to remove all of the tumour and a wide margin of normal tissue around it. They will also consider the following to decide if limb-sparing surgery is possible:

• the tumour responded well to chemotherapy (it got smaller)
• there is enough skin and soft tissue to cover the wound after the tumour is removed
• the cancer has not spread to any major arteries, veins or nerves

Sometimes the cancer weakens the bone and causes it to break (called a pathological fracture). Limb-sparing surgery may not be an option if there was a lot of bleeding or nerve damage caused by the fracture. But research has shown that limb-sparing surgery may still be an option if there is still a wide margin of normal tissue around the fracture.

An amputation is surgery to remove part or all of the arm or leg with the tumour. Amputation is mainly needed when bone cancer grows into nerves or blood vessels or when the tumour is so large it affects all of the soft tissues around it. An amputation may also be done if the cancer has come back in the same area after limb-sparing surgery.

Different types of amputation are done, depending where the bone tumour is found. Your surgeon and healthcare team will talk with you and explain the type of amputation that will be done to treat your bone cancer. Most people who have an amputation will use an artificial limb (prosthesis) after surgery. A prosthesis is attached to the end of the limb that was amputated (called the stump).

Amputation has a shorter healing time than other types of surgery.

You will probably start physiotherapy a few weeks after amputation. Your healthcare team will give you exercises that will help you get strength back in your muscles and stop the joints and muscles next to the remaining limb from becoming shorter. Prosthetic joints and devices are usually discussed after rehabilitation.

Many people who have had an amputation have a good quality of life. They can remain physically active and get back to most of their normal activities.

Curettage is a procedure that uses a spoon-shaped tool with a sharp edge (a curette) to scrape a tumour out of the bone. This leaves a hole where the tumour was removed. With bone cancer, it is used in an area where a wide resection can’t be done safely, like in the skull or spine. After curettage, the surgeon may use cryosurgery or bone cement to kill any remaining cancer cells.

Cryosurgery uses very cold liquid to kill cancer cells. Liquid nitrogen is poured into the hole left in the bone after curettage. It may be done to treat small, low-grade bone tumours.

Bone cement is a type of chemical called polymethyl methacrylate. It may be used after curettage to fix the hole left in the bone. Bone cement starts off as a liquid and can be poured into a hole in the bone. As it starts to harden, the bone cement makes a lot of heat to kill any cancer cells that are left in the area. Bone cement may be used instead of cryosurgery in some situations. It is also used to help hold a bone graft in place.

Sometimes surgery is done to remove bone cancer that has spread (metastasized) to the lung. The type of surgery that may be offered depends on:

• the number of tumours or metastases
• the size of the metastases and where they are in the body
• if the metastases are close to important blood vessels or the spinal cord
• your overall health
• if you are currently having chemotherapy

If surgery is an option for lung metastases, doctors will often use a wedge resection to remove the tumour along with a triangle-shaped piece of the lung around the tumour. A lobar resection or pneumonectomy are other options. Lobar resection removes the lobe of the lung that has the metastases. Pneumonectomy removes the whole lung.

Surgery to remove metastases is often done at the same time as surgery to remove the primary bone tumour. Surgery may also be used to remove osteosarcoma that has come back (recurred) as lung metastases if it has been more than a year since treatment ended.

If wide resection is used to remove bone cancer from the smaller bones of the leg, arm, ribs, collarbone, toes or fingers, reconstruction is not usually needed.

For the large bones of the arm and leg, reconstruction is done at the same time as surgery to remove the cancer. Surgeons have different ways that they can reconstruct a limb.

A bone graft is a piece of bone taken from another part of the body to rebuild the area that has had bone removed. A bone graft can be used to rebuild the jaw, leg, arm and other areas. The bone graft is attached to the bone where it is needed during surgery. Depending on the amount of bone needed, it may be taken from your body (called an autograft) or from a donor (called an allograft). When an allograft is used, there is a higher chance that the bone graft won’t attach properly (called non-union) or will become infected. You can be physically active after an allograft on the leg or arm, but you will need to avoid activity such as contact sports. The bone graft can easily break if it is hit or stressed too much.

An endoprosthesis is used to replace joints that have been removed by surgery, like the knee, hip or shoulder joints. This allows the joints to move and bend. An endoprosthesis is usually made of metal and plastic.

Fusing the joint (arthrodesis) may be used when tumours are in or near the knee or shoulder joint. The surgeon removes the whole joint and inserts a metal implant, such as a rod or plate, into the 2 remaining bone ends to join them together without an actual joint. After a fusion, the joint no longer moves.

Rotationplasty may be used when a bone tumour is removed from the lower thigh or upper leg by a wide resection. In rotationplasty, the surgeon turns the leg so that the foot faces backward, then joins the lower part of the leg to the upper part with a metal plate and screw or a rod. The rotated ankle joint acts as a new knee joint and a prosthesis is attached to the reconstructed limb to make the limbs the same length.

A rotationplasty is done more often for children than adults. This is because the ankle joint moves differently in adults. But it may be an option for some adults with bone cancer.

Side effects can happen with any type of treatment for bone cancer, but everyone’s experience is different. Some people have many side effects. Other people have only a few side effects.

If you develop side effects, they can happen any time during, immediately after or a few days or weeks after surgery. Sometimes late side effects develop months or years after surgery. Most side effects will go away on their own or can be treated, but some may last a long time or become permanent.

Side effects of surgery will depend mainly on the type and site of surgery and how much tissue was removed, as well as your overall health.

Surgery for bone cancer may cause these side effects:

• pain
• infection
• bleeding
• wound separation
• nerve damage
• swelling in the limbs
• scarring
• non-union of the bone when a bone graft does not heal or join properly
• phantom limb pain after amputation

Tell your healthcare team if you have these side effects or others you think might be from surgery. The sooner you tell them of any problems, the sooner they can suggest ways to help you deal with them.

Complications after reconstructive surgery are quite common. You may need more surgeries to fix problems with the reconstruction.

Find out more about surgery and side effects of surgery. To make the decisions that are right for you, ask your healthcare team questions about surgery.