Surgery for osteosarcoma includes the diagnostic biopsy and the surgical treatment. It cannot be emphasized enough how important it is that the biopsy and surgical treatment be planned together. If possible, the same orthopedic surgeon at a cancer center should do both the biopsy and the surgical treatment. If the osteosarcoma is localized but cannot be removed surgically after chemotherapy, a cure is not likely even if the cancer responds well to chemotherapy. Examples of tumors that are difficult to remove are those at the base of the skull, or in the spine or pelvis.

The surgical treatment can be limb-salvage (limb-sparing) surgery (removing the cancer without amputation) or amputation (removing the cancer and all or part of an arm or leg).

Limb-salvage surgery

Limb-salvage surgery is a very complex operation. The surgeons performing this type of operation must have special skills and experience. The challenge for the surgeon is to remove the entire tumor while still preserving the nearby tendons, nerves, and vessels. The bone that is removed is replaced with a bone graft or with an endoprosthesis (an artificial bone replacement within the body) made of metal and other materials.

Anywhere from 50% to 80% of patients are eligible to have their limbs spared. Ask the surgeon to explain the best way to remove the cancer and keep as much use of the involved arm or leg as possible. Endoprostheses have become very sophisticated. Because they are often implanted in growing children, they are designed to grow with the child. They can be made longer without any extra surgery. Some have tiny devices in them that can lengthen the prosthesis whenever needed to make room for a child’s growth.

Complications of limb-salvage surgery include infection and grafts or rods that become loose or broken. Limb-salvage surgery patients may need more surgery during the following 5 years, and some may eventually need an amputation.

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

Amputation

For some patients, amputation may be the only option. If the patient has a large tumor that extends into the nerves and/or the blood vessels, it may not be possible to save the limb. 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 amputated. Surgery is planned so that muscles and the skin will form a cuff around the amputated bone. This cuff will fit into the end of a prosthetic (artificial) limb. With proper physical therapy the patient is often walking on his/her own 3 to 6 months after leg amputation.

Reconstructive surgery

Reconstruction techniques have been developed to help patients with limb loss function as well as possible. Sometimes, if the leg must be amputated mid-thigh, the lower leg and foot is rotated and attached to the thigh bone, and the ankle functions as a knee joint. This surgery is called rotationplasty. Of course, the patient will need a prosthetic device to extend the leg.

If the osteosarcoma is located in the upper arm, the tumor may be removed and the lower arm reattached so that the patient has a functional but much shorter arm. If the osteosarcoma is located 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.

Rehabilitation after surgery

This may be the most difficult part of all the treatments, and this discussion cannot describe this completely. The patients and parents must meet with a rehabilitation specialist to understand all the options.

If an amputation is done, the patient must learn to deal with a prosthesis. This is particularly hard for growing children when the prosthesis needs changing to keep up with their growth. Devices have been developed that can be expanded to keep up with the growth of children.

When only the tumor and part of the bone is removed in a limb-sparing operation, the situation is even more complicated. One approach is to transplant bone grafts from donors. Another way to deal with the missing segment of bone is to implant a metal prosthesis.

All of these procedures have problems associated with them as well as unique benefits. For example limb-sparing surgery, although more acceptable than amputation, leads to more complications because of its complexity. When people have looked at the final result of the different procedures in terms of quality of life, there has been little difference in how people react. Perhaps the biggest problem has been for teen-agers who fear the social effects of their operation. Also emotional issues can be very important and support and encouragement are needed for all patients.

Surgical treatment of metastasis

Osteosarcoma is not curable without surgery, and this includes the treatment of the metastases. Surgical treatment to remove osteosarcoma metastases to the lungs must be planned very carefully. Before the operation, the surgeon considers the number of tumors, their location (one lung or both lungs), their size and response to chemotherapy, and the general condition of the patient.

Since 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..

Patients who have had a good response to chemotherapy and have tumors in both lungs can have surgery on one side of the chest at a time. Removing tumors from both lungs at the same time is another alternative.

Removing all the lung metastases is probably the patient's only chance for cure. However, some lung metastases may not be able to be removed because they are too big or are too close to important structures in the chest (such as large blood vessels) that interfere with the surgery. Patients whose general condition is not good (because of 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.

Last Medical Review: 01/14/2009
Last Revised: 01/14/2009