About surgery for bone cancer

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1 Useful information for cancer patients Contents This information is about the different types of surgery used for bone cancer. There are sections on How your doctor decides on your treatment Limb sparing surgery Amputation Surgery for secondary cancers Surgery for cancer that has come back You can view this information in a larger print on our website. How your doctor decides on your treatment Surgery is one of the main treatments for primary bone cancers. It is very specialised treatment. You will have your operation at a major centre, with very experienced bone surgeons (orthopaedic surgeons) who have been trained in this type of surgery and are experienced in doing it. The operations for primary bone cancer aim to completely remove the tumour. Sometimes a cancer is in a bone that can be removed. Or part of the bone can be removed. They are called expendable bones because they do not need to be rebuilt (reconstruction) and there is no loss of function. These types of bones include a rib or shin bone (fibula). So the bone or part of it is removed along with the cancer. Most primary bone cancers are in the arms or legs. The main operation used is called limb sparing surgery. This means removing the cancer without removing the affected arm or leg. If the risk of the cancer coming back is too high with limb sparing surgery, then you will have part or all of the arm or leg removed (an amputation). Surgery is sometimes used to remove secondary cancers in the lungs or bones. The operation you have will depend on The size of your cancer Where the primary bone tumour is Whether it has grown into nearby tissues, or has spread elsewhere in the body For most bone tumours, the surgery will also depend on how well your cancer responds to chemotherapy. After chemotherapy to shrink the cancer, many Ewing's sarcomas and osteosarcomas can be treated with limb sparing surgery instead of amputation. Limb sparing surgery If your bone tumour is in an arm, leg, shoulder or hip, your surgeon will want to do limb sparing surgery if at all possible. This means removing the cancer, but not the whole arm or leg. This is the most common type of surgery for primary bone cancer. More than 80 out of every 100 (80%) osteosarcomas are treated in this way. It is often possible to remove just the tumour even if the cancer is in your hip bones (the pelvis). In the past, sometimes the whole leg and hip had to be removed. 01

2 It is often possible to remove just the tumour even if the cancer is in your hip bones (the pelvis). In the past, sometimes the whole leg and hip had to be removed. The surgeon removes the area of bone containing the cancer and replaces it with a metal implant called a prosthesis. If the cancer is near a joint, the surgeon will remove the joint as well and replace it with a false one. This type of surgery is more commonly done to bones in the leg, such as the femur or tibia. These operations are called femoral replacement surgery and tibial replacement surgery respectively. It is also done in the major bone in the upper arm, called the humerus. This operation is called humeral replacement surgery. These diagrams show a prosthesis in the leg and arm. The most important thing is that the surgeon removes all the cancer. So they will make sure that they also take out a margin of healthy bone tissue all around the cancer. They send this to the lab to be carefully checked to make sure all the cancer has been removed. Once the cancer is all out, then the surgeon fixes the prosthesis in place. Once the prosthesis is in place, you should be able to use the limb well, but there are usually some limitations. You will have quite intensive rehabilitation. If you have had surgery to remove cancer from the bone in your arm (humerus), the physiotherapist will show you how to move your elbow to make up for limited movement in your shoulder. If you have had surgery to your leg, the physiotherapist will help you move around and use the limb as soon as possible after your surgery. 02

3 Unfortunately, sometimes limb sparing surgery does not work out. The most common reasons for limb sparing surgery failing are Infection If the cancer comes back Infection Infection is a risk with any bone surgery, and is a particular risk for people having chemotherapy. Once infection develops in the bone, it is very difficult to get rid of it. Your surgical team will do all they can to prevent infection. You will have antibiotics during and after your operation, to try to reduce the risk of an infection. Unfortunately, if you get a severe infection it can break down the bone around the prosthesis. The prosthesis then becomes loose and unstable. It is sometimes possible to cure bone infections, but this usually means more surgery. Your specialist will have to take out the prosthesis, wait for the infection to completely clear and then put in a new prosthesis. This is successful in about 75 out of every 100 people (75%). Unfortunately, if it isn t possible to get the infection under control, you may need an amputation. If the cancer comes back With any cancer surgery, there is always a risk that the cancer could come back in the future. With bone cancer, this can be due to a type of cancer spread called skip metastases. These are small tumours near to the primary tumour but not actually connected to it. They can continue to grow and form a local recurrence of the cancer. Your surgeon will try to make absolutely sure that all the cancer has been removed. But it is just not possible to see tiny groups of cells. If you are going to get a local recurrence of osteosarcoma, it is likely this will be within 3 years of your diagnosis and treatment. It is very rare, but not impossible, for a bone cancer to come back after 5 years. So if your cancer has not come back in this time, it is very unlikely to come back at all. Amputation This means removing a part of the body completely. Usually, the surgeon removes part of an arm or leg rather than the whole limb. But sometimes amputation is extremely major surgery and involves removing a leg and its hip, or an arm and its shoulder. These operations are called hindquarter or forequarter operations. A surgeon will only do this if there is no other option. You may need to have an amputation rather than limb sparing surgery if The cancer has grown into the major nerves and blood vessels around your bone tumour You developed an infection after your limb sparing surgery that meant the false bone had to be removed The position of the tumour means that limb sparing surgery is not technically possible It is not possible to completely remove the cancer with limb sparing surgery You will have chemotherapy after your surgery to kill off any cancer cells that have been left behind. If you do get a local recurrence, you may have to have an amputation after all. 03

4 Amputation can be a very difficult thing to have to face, but sometimes it gives the best chance of curing the cancer. If the cancer can be completely removed, you may not have any further problems from it. Children who have amputations of their leg below the knee tend to do very well. You may have chemotherapy or radiotherapy after your surgery to try to reduce the risk of the cancer coming back. The type of treatment will depend on the type of bone cancer you have. After your surgery, you will have a stump or wound area that is very sore and sensitive. Some of the pain will be due to the damaged nerves in the stump. There are medicines you can have to help with this. Once the stump has healed, if at all possible you will have a prosthesis fitted a false arm or leg. You will see a prosthetist (someone trained to design and fit artificial limbs) who makes a plaster cast of your stump. They use the cast and sometimes computer assisted design (CAD) to create a false limb (prosthesis) that fits over the stump. They work with you to adjust the prosthesis so that it works as well as possible. Remember you may have to go back to the limb centre from time to time. For example, over time, your stump can change shape and your prosthesis may no longer fit. If this happens, you can have a new one made. You will have help from your prosthetist, physiotherapist and occupational therapist to learn to use your prosthesis. This takes a lot of determination. Sometimes, the stump can become sore and the prosthesis may rub. Your prosthetist will advise you about caring for it and stopping this from happening. Surgery for secondary cancers If osteosarcoma has spread to the lungs it may be possible to remove the secondary cancer with surgery. So it may be cured even if it has spread when it is diagnosed. Occasionally it is possible to remove single bone secondaries with surgery. Surgeons occasionally remove chondrosarcoma that has spread. It is much rarer to have surgery to remove Ewing's sarcoma that has spread to the lungs. Generally speaking, your specialist may consider surgery depending on Your type of bone cancer Where the secondaries are in your lungs The size of the secondaries How well your doctor expects your lungs to work after surgery Even if your surgeon is not sure it will be possible to remove your secondary cancers, you can have chemotherapy to try to shrink them. If the chemotherapy works well, they may shrink enough for you to have surgery. If you are diagnosed with osteosarcoma and secondary lung cancer at the same time you will probably have Chemotherapy Surgery to remove your bone tumour More chemotherapy Surgery to remove lung tumours after chemotherapy is finished Sometimes the chemotherapy alone will get rid of the lung tumours, so you will not need surgery to remove them. This is most likely with Ewing's sarcoma, but can also happen sometimes in osteosarcoma. 04

5 Surgery for bone cancer cells growing in the lung is a major operation. As the surgeon needs to operate inside the chest, you have an operation called a thoracotomy. Your surgeon cuts through the bones of your rib cage to get to your lungs. Opening the chest makes the lung on that side collapse. You will need a chest drain after the operation so that your lung fills up with air again (reinflate). The drain is a tube that comes out of your chest and is connected to a bottle with gentle suction. The tube helps blood and fluid to drain out of the wound. The suction helps the lung to inflate again after the operation. Surgery for cancer that has come back You can also have surgery for primary bone cancer that later comes back in the lungs or bones. If the cancer is too widespread, surgery may not be possible. But chemotherapy can be given to try to shrink the tumours. If you have had chemotherapy before, the lung tumours may not respond to the drugs. So, different chemotherapy drugs may be used. Some people may have this procedure done as keyhole surgery. The keyhole procedure to remove bone cancer secondaries growing in the lung is called video assisted thorascopic surgery. And it is less invasive than a normal operation. For more information, visit our website You will find a wide range of detailed, up to date information for people affected by cancer, including a clinical trials database that you can search for trials in the UK. Our information is based on the best current scientific evidence and reviewed regularly by leading clinicians and experts in health and social care. For answers to your questions about cancer call our Cancer Information Nurses on am till 5pm Monday to Friday. Adapted from Cancer Research UK s website in February Cancer Research UK s website is not designed to provide medical advice or professional services and is intended to be for educational use only. The information provided through Cancer Research UK s website and our nurse team is not a substitute for professional care and should not be used for diagnosing or treating a health problem or disease. If you have, or suspect you may have, a health problem you should consult your doctor. Copyright Cancer Research UK Cancer Research UK is a registered charity in England and Wales ( ), Scotland (SC041666) and in the Isle of Man (1103) 05