Surgery for osteosarcoma
Surgery is an important part of treating nearly all osteosarcomas (although chemotherapy is typically given first to try to shrink the cancer and make it easier to remove).
Surgery includes both the biopsy to confirm the cancer and the surgery to take out the tumor(s).
When possible, it is very important that the biopsy and surgery be planned together, and that the same orthopedic surgeon at a cancer center does both the biopsy and the surgery to remove the tumor.
The main goal of surgery is to remove all of the cancer. If even a small number of cancer cells are left behind, they might grow and make a new tumor. To lower the risk of this happening, surgeons remove the tumor plus some of the normal tissue around it. This is known as wide excision.
The type of surgery done depends on where the tumor is. Some tumors are much harder to treat. These include tumors at the base of the skull, or in the spine or hip bone (pelvis).
Tumors in the arms or legs
Surgery can be either the kind that saves the arm or leg (limb-sparing) or removes the cancer and all or part of an arm or leg (amputation).
Limb-sparing surgery (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 if it has grown into nearby structures.
This type of surgery is very complex and should be done by a doctor with special skill and experience. The surgeon will try to remove all of the tumor while saving the nearby tendons, nerves, and blood vessels. But 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 part of the bone that is removed is replaced with a bone graft (piece of bone from a different part of the body or from another person), or with a device made of metal or other materials. Some metal rods are designed to grow with the child and can be made longer later on without any extra surgery. They have tiny devices in them that can lengthen the “bone” whenever needed to make room for a child’s growth. But even these may need to be replaced with something stronger once the child’s body stops growing.
More surgery may be needed during the years after the first operation, and some patients might still need an amputation later on. There can be a danger of infection, and grafts or rods can become loose or break. It takes about a year, on average, for patients to learn to walk again after this surgery on a leg. If the person does not keep up with rehabilitation, the arm or leg may become useless.
Amputation: If the tumor is large and extends into the nerves or the blood vessels, an amputation might be the best choice. Surgery is planned so that muscles and the skin will form a cuff around the end of the remaining arm or leg bone. This cuff will fit into an artificial limb (prosthesis). With physical therapy, the patient is often walking within 3-6 months after a leg amputation.
Sometimes, if the bone has to be removed in the middle of the thigh, the lower leg and foot is turned and attached to the thigh bone. The ankle now functions as a knee joint. This surgery is called rotationplasty. Of course, the person will need an artificial leg to make the leg long enough.
If the cancer is in the upper arm, the tumor may be removed and the lower arm reattached. Then the person will have a working, but shorter, arm.
Rehabilitation after surgery: This might turn out to be the hardest part of treatment. You (or you and your child) should meet with a rehabilitation expert before surgery to learn what will need to be done after surgery.
If a limb is removed, the patient will need to learn how to use an artificial limb. This can be hard for growing children when the artificial limb needs to be changed to keep up with their growth.
If limb-sparing surgery is done, the situation can be even more complex. Further operations might be needed in the coming years to replace the metal rod with one more suited to their growing body size.
Each of these surgeries can have pros and cons. Most people would prefer limb-sparing surgery, but it can sometimes actually lead to more problems over time, such as the need for more surgery. It turns out that there is little difference in terms of people’s quality of life. Often the biggest problem is for teens who fear the social effects of their operation. These feelings and concerns are very important, and support and encouragement are needed for all patients. (Please see the section “Impact of treatment for osteosarcoma.”)
Tumors that start in other places
Pelvic tumors can often be hard to remove with surgery. But if the tumor responds well to chemotherapy first, then surgery (sometimes followed by radiation treatment) may get rid of all of the cancer. Pelvic bones can sometimes be reconstructed after surgery, but in some cases the hip bone and leg might need to be removed.
For a tumor in the lower jaw bone, the whole bone 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 treatment 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 need a combination of treatments like chemotherapy, surgery, and radiation.
Surgery for metastases
If the osteosarcoma has spread to other parts of the body, these tumors need to be removed for there to be a chance of curing the cancer.
If the cancer has spread to the lungs, surgery must be planned very carefully. The doctor must have a plan in case there are more tumors than the CT scan showed. There could be some areas of spread that cannot be removed because they are too big or are too close to major structures in the chest, such as large blood vessels. Also, some patients may not be healthy enough to go through such surgery.
A small number of osteosarcomas spread to other bones or to other organs like the kidneys, liver, or brain. Whether these tumors can be removed with surgery depends on their size, place, and other factors.
Side effects of surgery
Short-term risks and side effects: Surgery for 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 surgery, and it might require strong pain medicines for a while as the surgery 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 rods that might become loose or broken. 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.
Physical therapy and rehab is very important after surgery for osteosarcoma. It offers the best chance for good long-term limb function. Even with proper 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 how they look. Physical, occupational, and other therapies can often help people adjust and cope with these challenges.
For more on surgery as a treatment for cancer, see our document Understanding Cancer Surgery: A Guide for Patients and Families.
Last Medical Review: 06/13/2014
Last Revised: 01/06/2015