Surgery for Ewing tumors

Several types of surgery can be used for Ewing tumors. The choice depends on the tumor's size and location, and how surgery would change the function of the affected part of the body.

Many of the tumors in soft tissues and certain bones can be removed without causing major disability or deformity. Other tumors, such as those in most bones of the arms and legs, cannot be completely removed without affecting the limb's function.

Tumors in the arms or legs

In most cases, limb-sparing operations can be done to remove part or all of the affected bone while leaving the arm or leg basically intact. The bone that is removed is replaced with a bone graft (piece of bone from another part of the body or from another person) or with an internal prosthesis (a man-made device used to replace part or all of a bone) made of metal and other materials.

If the tumor is in the upper part of the leg, the femur (upper leg bone), including the knee, can be removed. A prosthesis for the bone and knee can then be placed to connect to the lower leg. It is harder to remove and reconstruct parts of the lower leg. The humerus (upper arm bone) is also suitable for limb-sparing surgery because it does not support the weight of the body.

Limb-sparing surgery is a very complex operation. The surgeons who do this type of operation must have 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. But if a cancer has grown into these structures, they will need to be removed along with the tumor. In such cases, radiation therapy or amputation may sometimes be the best option.

Using an internal prosthesis in a growing child is especially challenging. Traditionally, it has required occasional operations to replace the prosthesis with a longer one as the child grows. Newer prostheses have become very sophisticated. Some 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 an adult prosthesis once the child's body stops growing.

It takes about a year, on average, for patients to learn to walk after limb-sparing surgery on a leg. If the patient does not take part in the rehabilitation program, the salvaged arm or leg may become useless.

Some children may not be able to have limb-sparing surgery because their tumors are in parts of bones that are hard to replace or because the tumors also extend into vital nerves or blood vessels that cannot be removed without severely damaging the limb. These children usually get radiation therapy instead of surgery. In rare cases, amputating the affected limb may be the best option.

Tumors in the chest wall or pelvis (hip bones)

For a Ewing tumor in the chest wall, the surgeon often must remove the diseased area and also remove nearby ribs. The ribs are replaced with a man-made material to close the chest wall defect. If the child's tumor has spread to the lungs, the chest can be opened and the lung tumors can be removed. This operation is called a thoracotomy. Often radiation therapy to the chest is also given to these children.

Pelvic tumors can be hard to treat with surgery, and in many cases radiation therapy may be the preferred treatment. But if the tumor responds well to initial chemotherapy, surgery (sometimes followed by radiation therapy) may be an option. Pelvic bones can often be reconstructed after surgery.

Possible side effects of surgery

The short-term side effects of surgery can include poor wound healing, bleeding at the surgery site, and infection. Complications of limb-sparing surgery can include grafts or rods that become loose or broken. These complications are more likely than with surgery done for other reasons because chemotherapy or radiation therapy used before and after surgery may interfere with wound healing.

Rehabilitation after surgery: This may be the most difficult part of treatment, and this discussion cannot describe this completely. Patients and parents must meet with a rehabilitation specialist to understand all of their options.

If a limb is amputated, the patient must learn to live with and use a prosthetic limb. This can be particularly hard for growing children if the prosthetic limb needs changing 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 be even more complicated, especially in growing children. Children who have had limb-sparing surgery may need more surgery during the following years to replace the internal prosthesis with one more suited to their growing body size, and some may eventually need an amputation.

Both types of surgery can lead to problems as well as having possible benefits. For example, limb-sparing surgery, although 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 down the road.

When researchers have looked at the final results of the different surgeries in terms of quality of life, there has been little difference between them. Perhaps the biggest problem has been 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.

For more information on surgery as a treatment for cancer, see our document called Surgery.