Surgery is the primary (main) treatment for most bone cancers. Surgery may also be needed to obtain a biopsy of the cancer. The biopsy and the surgical treatment are separate operations, but it is very important that the doctor plans both together. Ideally, the same surgeon should do both the biopsy and the main surgery. A biopsy taken from the wrong place can lead to problems when the surgeon does the operation to remove the cancer. Sometimes a poorly placed biopsy can even make it impossible to remove the cancer without cutting off the limb.
The main goal of surgery is to remove all of the cancer. If even a few cancer cells are left behind, they can grow and multiply to make a new tumor. To try to be sure that this doesn’t happen, surgeons remove the tumor plus some of the normal-appearing tissue that surrounds it. This is known as wide-excision. Removing some normal-looking tissue helps ensure that all of the cancer is removed. After surgery, a pathologist will look at the tissue that was removed under the microscope to see if the margins (outer edges) have cancer cells. If cancer cells were 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 is seen at the edges of the tissue, the margins are said to be negative, clean, or clear. A wide-excision with clean margins minimizes the risk that the cancer will grow back where it started.
Tumors in the arms or legs
Sometimes the entire limb needs to be removed in order to do a good wide-excision (and remove all of the cancer). This operation is known as an amputation. But most of the time the surgeon can remove the cancer without amputation. This is called limb-salvage or limb-sparing surgery. In going over treatment options, it is important to realize that there are advantages and disadvantages with either type of surgery. For example, although for many people limb-salvage seems more acceptable than amputation, it is more complex and so can have more complications. Both 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. Perhaps the biggest concern was seen in teenagers who worry about the social effects of their operation. Emotional issues can be very important and support and encouragement are needed for all patients.
No matter which type of surgery is done, rehabilitation will be needed afterward. This can be the hardest part of treatment. If possible, the patient should meet with a specialist in rehabilitation before surgery to understand what will be involved.
Amputation: Amputation is surgery to remove part or all of a limb (an arm or leg). When used to treat cancer, amputation removes the limb part with the tumor, some healthy tissue above it, and everything below it. In the past, amputation was the main way to treat bone cancers found in the arms or legs. Now, this operation is only chosen if there is a reason not to do limb-salvage surgery. For example, an amputation may be needed if removing all of the cancer requires removing essential nerves, arteries, or muscles that would leave the limb without good function.
MRI scans and examination of the tissue by the pathologist at the time of surgery can help the surgeon decide how much of the arm or leg needs to be removed. Surgery is 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 (or prosthesis). After surgery, a person must learn how to use the prosthesis in rehabilitation. With proper physical therapy they are often walking again 3 to 6 months after leg amputation.
Limb-salvage surgery: The goal of limb-salvage surgery is to remove all of the cancer and still leave a working leg (or arm). Over 90% of patients with bone cancer in a limb are able to have their limb spared. This type of surgery is very complex and requires 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 vessels. This is not always possible. If a cancer has grown into these structures, they will need to be removed along with the tumor. This can sometimes result in a limb that is painful or can’t be used. In that case, amputation may be the best option.
In this type of surgery, a wide-excision is done to remove the tumor. A bone graft or an endoprosthesis (en-doe-pros-THEE-sis, meaning internal prosthesis) is used to replace the bone that is lost. Endoprostheses are made of metal and other materials and can be very sophisticated. Because they may be used in growing children, some can be made longer without any extra surgery as the child grows.
Further surgery could be needed if the bone graft or endoprosthesis becomes infected, loose, or broken. Limb-salvage surgery patients may need more surgery during the following 5 years, and some may eventually need an amputation.
Rehab is much more intense after limb-salvage surgery than it is after amputation. It takes an average time of a year for patients to learn to walk again after limb-salvage of a leg. If the patient does not take part in the rehabilitation program, the salvaged arm or leg may become useless.
Reconstructive surgery: If the leg must be amputated mid-thigh, the lower leg and foot can be rotated and attached to the thigh bone. The old ankle joint becomes the new knee joint. This surgery is called rotationplasty (roh-TAY-shun-PLAS-tee). A prosthesis is used to make the new leg the same length as the other (healthy) leg.
If the bone tumor is located in the upper arm, the tumor may be removed and then the lower arm attached again. This leaves the patient with an arm that works but is much shorter.
Tumors in other areas
Bone cancer in the pelvis is treated with a wide-excision when possible. If needed, bone grafts can be used to rebuild the pelvic bones.
For a tumor 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.
For tumors in areas like the spine or the skull, it may not be possible to safely do a wide-excision. Cancers in these bones may require a combination of treatments such as curettage, cryosurgery, and radiation.
Curettage (kur-uh-TAHZH): In this procedure, the doctor scoops out the tumor from the bone without removing a section of the bone. This leaves a hole in the bone. In some cases, after most of the tumor has been removed, the surgeon will treat the nearby bone tissue to kill any remaining tumor cells. This can be done with cryosurgery or by using bone cement.
Cryosurgery: For this treatment, liquid nitrogen is poured into the hole that is left in the bone after the tumor was removed. This extremely cold material kills tumor cells by freezing them. This treatment is also called cryotherapy. After cryosurgery, the hole in the bone can be filled by bone grafts or by bone cement.
Bone cement: The bone cement PMMA (polymethylmethyacrylate) starts out as a liquid and hardens over time. It can be put into a hole in the bone in liquid form. As PMMA hardens, it gives off a lot of heat. The heat helps kill any remaining tumor cells. This allows PMMA to be used without cryosurgery for some types of bone tumors.
Surgical treatment of metastasis
To be able to cure a bone cancer, it and any existing metastases must be removed completely with surgery. The lungs are the most common site of distant spread for bone cancer. Surgery to remove bone cancer metastases to the lungs must be planned very carefully. Before the operation, the surgeon will consider the number of tumors, their location (one lung or both lungs), their size, and the person’s general condition.
The chest CT scan may not show all the tumors that truly exist. The surgeon will have a treatment plan in case more tumors are found during the operation than can be seen in the chest CT scan.
Removing all the lung metastases is probably the only chance for a cure. However, not all lung metastases can be removed. Some tumors are too big or are too close to important structures in the chest (such as large blood vessels) to be removed safely. People whose general condition is not good (due to poor nutritional status or problems with the heart, liver, or kidneys) may not be able to withstand the stress of anesthesia and surgery to remove metastases.
For more information about surgery, see our document Understanding Cancer Surgery: A Guide for Patients and Families.
Last Revised: 01/21/2016