SUPPORT CANADIANS LIVING WITH CANCER
Surgery for childhood bone cancer
Most children with bone cancer will have surgery. Tumours that can be removed with surgery are called resectable. Those that can’t be removed with surgery are called unresectable. The location of the bone tumour often determines if surgery is possible. It is often difficult for doctors to completely remove bone tumours in the spine, pelvis and base of the skull, so they will use other treatments for these tumours. It is easier to completely remove tumours in an extremity (arm, leg, hand or foot) with surgery.
The most important goal is to remove the tumour completely with a margin of normal tissue around it. Where the tumour is determines what tissues or structures need to be removed.
When the tumour occurs in a limb, in most cases it can be removed without amputating the limb. Reconstruction can also be done to rebuild the affected limb. The type of reconstruction used will depend on your child’s age, remaining growth and desired lifestyle. Your child’s surgeon will discuss the pros and cons of each type of reconstruction with the goal to have the reconstructed limb function as normally as possible.
Surgery may be done for different reasons. Your child may have surgery to:
- collect a biopsy sample to make a definite diagnosis of bone cancer
- remove all or as much of the tumour as possible
- remove a metastatic tumour in a lung
- rebuild, or reconstruct, a limb after a tumour is removed
Choosing the type of surgery
Before surgery, doctors will use diagnostic and staging tests to find out where the borders of the tumour are, how it has responded to the neoadjuvant chemotherapy and if it has grown or spread. This includes imaging tests such as CT scan, MRI, bone scan and PET-CT where available. Based on these tests, the surgeon will let you know the types of reconstruction options available following removal of your child’s bone cancer. You and your child will have to decide what works best. Talk to your child’s healthcare team about the following factors to help you make a decision. It may also help to talk to someone who has had the surgery that your child’s healthcare team is suggesting and to look at pictures or videos of people who have had the surgery.
Location and size of the tumour
Surgeons use the location and size of tumour to plan how to completely remove the bone cancer along with a margin of normal tissue. This may involve removing some of the soft tissues surrounding the bone or a joint next to the affected bone. Amputation is usually only necessary when the bone cancer affects vital nerves or blood vessels to the limb or the tumour is so large it affects all of the soft tissues surrounding the bone cancer.
It is important to consider a child’s age and whether or not they have finished growing. For example, if a child has limb-sparing surgery when they are still growing, their limbs may grow to different lengths. Sometimes simple measures, such as a shoe lift, can make limbs the same length. In other cases, the child may need more surgeries to lengthen the shorter limb or control the growth of the longer limb.
Needing more surgeries
Depending on the type of surgery used to treat bone cancer, a child may need more surgeries later in life. For example, they may need surgery to replace a worn internal joint prosthesis. Surgery may also be needed to lengthen an extendable internal prosthesis if the child is still growing.
Lifestyle and activity level
It is important to think about lifestyle and level of activity when deciding which type of surgery to have. These factors can also affect career goals and choices later in life.
Certain types of surgery, such as rotationplasty, may be a good option if the child is active and wants to participate in sports. Children with active lifestyles will wear out a total joint prosthesis, which will require more major surgery.
Limb-sparing surgery involving joint replacement or reconstruction may be a good option for children with a less active lifestyle. After many types of limb-sparing surgery, the child will have to avoid contact sports because they could damage the bone graft or prosthesis and they would need to have major surgery to repair the limb.
Care and support available after surgery
A child will need care and support for months to years after surgery for bone cancer. The child may need wound care, physical therapy and more surgeries. Children who have limb-sparing surgery often need extensive rehabilitation after surgery.
Talk to your child’s healthcare team about the rehabilitation resources and support available in your community. This information can help you decide which type of surgery is best for your child.
Surgery for bone cancer can affect a child’s body image. Body image is how a child feels about their body. It is important to keep in mind that the surgery that will give the strongest, most useful limb can be different from the surgery that will give the most normal appearance. Talk to your child’s healthcare team about the surgery options and how they might affect appearance and body image. They can also suggest resources to support children struggling with their body image after surgery.
Types of surgery
The following types of surgery are used to treat childhood bone cancer. The child may also have other treatments before or after surgery. Surgery to treat bone cancer involves 2 parts. The first is wide resection to completely the remove the tumour in one large piece along with a margin of healthy tissue around it. The amount and type of normal tissues or structures removed depends on where the tumour has grown. There are no choices or options available. The second phase of the surgery is the reconstruction of the defect caused by the complete tumour removal. There may be several options for reconstruction available depending on your child’s age, future growth and desired lifestyle.
Wide resection removes the bone tumour along with a wide margin of normal bone and tissue around the tumour. Any tissue from or near the biopsy site is also removed along with the tumour. This type of surgery is also called en bloc resection.
Depending on the amount of tissue removed, your child’s surgeon may need to use skin or tissue from another part of the body (called a graft) to replace it. This is done at the same time as the surgery to remove the cancer.
Limb-sparing surgery, or limb-salvage surgery, is used to treat bone cancer in an upper or lower limb. This surgery removes the tumour without removing, or amputating, the entire limb. Surgeons remove all of the tumour and all of the affected soft tissues surrounding the area of affected bone that the bone cancer has grown into. The surgeon must be able to preserve or protect major nerves or blood vessels so the limb works as normally as possible after surgery.
Limb-sparing surgery is not always possible. Surgeons will do this surgery only if it is possible to remove all of the tumour along with a wide margin of healthy tissue around it. They will also consider the following to decide if limb-sparing surgery is possible:
- the tumour responded to, or was smaller after, chemotherapy
- there is enough skin and soft tissue to cover the wound after the tumour is removed (this often depends on where the biopsy was taken and whether or not it was planned along with surgery)
- the cancer has not spread to any major arteries, veins or nerves
- the cancer hasn’t weakened the bone and caused breaks (called pathological fractures)
Depending on the amount of tissue removed along with the tumour, the surgeon may need to take skin or tissue from another part of the body (called a graft) to replace it. Graft surgery is often done at the same time as the limb-sparing surgery.
Bone is removed to treat the cancer, so surgeons often need to rebuild, or reconstruct, it. They may use a bone graft or replace the bone with an endoprosthesis, or internal prosthesis, which is made of metal and plastic and contains an artificial joint.
Reconstruction techniques for limb-sparing surgery
For bone cancer in some locations such as the fibula, ribs, collarbone, toes, fingers and ulna, reconstruction following wide resection is usually not required.
In the majority of sites, surgeons will reconstruct the limb with a variety of techniques using bone, other tissues and metal implants. Reconstruction is done at the same time as surgery to remove the cancer. Complications following these major surgeries are quite common requiring additional surgeries for some children. Surgeons may use some of the following materials for reconstruction:
Bone graft is a piece of bone taken from another part of the body. Metal rods, screws or plates may be used to secure the bone graft to the bone at the surgery site. Depending on the amount of bone needed, it may be taken from the child’s own body (called an autograft) or from a donor (called an allograft). When an allograft is used, there is a higher chance that the bone won’t heal properly (called non-union) and a higher chance of infection. Active sports should not be done following reconstruction with allografts due to the high risk of fracture of the brittle bone graft.
Endoprosthesis is a prosthesis or prosthetic implant placed in the remaining bone. An endoprosthesis is usually made of metal and plastic. It is used to replace joints that are removed by surgery, including the knee, shoulder and hip joints. Endoprostheses come in different types and sizes. Some can be expanded if the child is still growing. A child may need surgery every 6–12 months to lengthen the endoprosthesis until the skeleton is fully grown.
Fusing the joint may be used for tumours in or near the knee or shoulder joint. This involves removing the joint surfaces and making the bones surrounding the joint one solid piece. The surgeon removes the whole joint and inserts a metal implant, such as a rod or plate, into the 2 remaining bone ends joining the bone ends on each side of the removed joint. After a fusion, the joint no longer moves and the affected limb has to make up for the loss of motion.
Healing and rehabilitation after limb-sparing surgery
It takes time for a bone graft to heal. It also takes time for a bone graft or endoprosthesis to join to the remaining bone in the limb. Children who have a bone graft or endoprosthesis will wear a brace or cast after surgery. The brace or cast supports the limb and limits how much the child can use it, which gives the bone graft or endoprosthesis time to join to the bone in the limb. The child may not be able to participate in some activities because bones with a bone graft or endoprosthesis may not be as strong as normal bones and joints.
Children who have limb-sparing surgery need intensive rehabilitation. They must actively take part in a rehabilitation program to be able to use the limb. For example, it can take up to a year of rehabilitation for a child to learn to walk again after limb-sparing surgery in a leg.
Children may need more surgery later in life to repair or replace a bone graft or endoprosthesis if it wears out or is damaged.
An amputation is surgery to remove part or all of a limb. Surgeons use amputation when the tumour is affecting vital structures and these vital structures must be removed to allow removal of the entire tumour. This most often occurs in children with osteosarcoma where radiation is not effective at treating the cancer. Amputation also has a shorter healing time than other types of surgery. A lot of rehabilitation may be necessary to help the child learn to walk again. Although part of the limb is permanently gone, there are no restrictions to activity and the child may participate in activities involving running and contact sports because there is no risk of damaging the limb. Disadvantages of amputation include phantom limb pain (a sensation that the removed limb is still present), having to use an artificial limb and the appearance of the stump.
People can still have a good quality of life and do most of their normal activities if part or all of these bones are removed.
An amputation may also be needed if the bone cancer has come back in the same limb after limb-sparing surgery.
In some cases, it is possible to provide an immediate fit prosthesis while the child is still under anesthesia. A cast is put on the remaining limb (stump) in the operating room. A basic post with a foot is then attached. When they awake from anesthesia, the child can look down and see 2 feet pushing up the covers. This allows the child to get up and start walking with crutches 1 to 2 days following surgery. This gives a big boost to their morale. The cast helps to control swelling of the remaining limb and allows it to shrink to be ready for the prosthesis in a shorter time frame. It takes about 3 to 4 weeks after surgery for the swelling in the remaining limb to decrease enough for the first fitting for a permanent prosthetic.
A variety of prosthetics are available. Specialized joints and devices are usually discussed later when the child is fully rehabilitated. These options allow children who have an amputation to participate in different sports, remain physically active and have a good quality of life. Physiotherapy to learn to walk is usually started a few weeks following amputation. Resuming chemotherapy after surgery usually makes it difficult for the child to be involved in intense physiotherapy. Emphasis is put on exercises involving partial weight bearing, strengthening of muscles and prevention of shortening of muscles or joints next to the remaining limb. It usually takes about 6 months for children to walk well after surgery. Active adolescents need a new artificial leg or prosthesis about every 2 years.
A rotationplasty is a procedure where the bone tumour is removed from the lower thigh or upper leg by a wide resection. The surgeon rotates the remaining limb 180 degrees so that the foot faces backward, then re-attaches the parts together with a plate and screw or a rod. The rotated ankle joint now functions as a new knee joint, and a prosthesis is attached to the reconstructed limb to equalize the limb lengths. The only requirement is that the main nerve of the lower limb (sciatic nerve) is not near the tumour. The main artery and vein can be cut and removed with the tumour since they are often covered by tumour. Following rotation, the main artery and vein will be reattached. When the child wakes up in the recovery room, they can usually wiggle their ankle and toes.
When the tissues have healed, usually after a month or so, a prosthesis (artificial leg) is made for the child. The child’s foot fits into a socket inside the prosthesis. The ankle acts like a new knee joint. The foot is rotated 180 degrees from its normal position – the toes now face backward – and is now resting at a level close to the position of the opposite knee. As a result, when the foot pushes straight down, it moves the prosthesis up. When the foot and ankle lift up, it moves the prosthesis down.
Children with very large tumours involving large amounts of soft tissue around the bone often require an above knee amputation to completely remove the tumour. A rotationplasty is a good alternative to an above knee amputation as it gives the same function as a below knee amputation. With an above knee amputation, the child needs a mechanical knee joint, which does not work as smoothly as an anatomic joint because it is more difficult to speed up and slow down. A mechanical knee joint is also more prone to breakage, particularly in a young, active child. Children with a below knee amputation or rotationplasty are able to walk without a limp. Very young children with a lot of future growth also benefit from a rotationplasty because change in limb lengths as the child grows can be accommodated by adjusting the prosthesis length. Rotationplasties are very durable. There is nothing to wear out and future surgery is not necessary. There are also no restrictions to activities, such as swimming, riding a bike, climbing and skateboarding.
With a rotationplasty, there is no phantom limb pain. The child feels like the whole limb is still present including their knee. Many studies on quality of life have demonstrated that children with rotationplasties are very satisfied.
Sometimes surgery is done to remove bone cancer that has spread, or metastasized, to the lung. Whether or not surgery is an option and the type of surgery done depends on:
- the number of tumours, or metastases
- the size of the metastases and where they are in the body
- if the metastases are close to important blood vessels or the spinal cord
- the child’s overall health
- whether or not the child is currently having chemotherapy
If surgery is an option for lung metastases, doctors often use a wedge resection to remove the metastasis along with a triangle-shaped piece of the lung around the tumour. Lobar resection or pneumonectomy are other options. Lobar resection removes the lobe of the lung that has the metastasis. Pneumonectomy removes all of the lung.
Surgery to remove metastases is often done at the same time as surgery to remove the primary bone tumour. Surgery may also be used to remove osteosarcoma that recurs as lung metastases if more than a year has passed since the child finished treatment.
Side effects can happen with any type of surgery for childhood bone cancer, but every child’s experience is different. Some children have many side effects. Other children have few or none at all.
Side effects can develop any time during, immediately after or a few days or weeks after surgery. Most side effects will go away on their own or can be treated, but some may last a long time or become permanent.
Side effects of surgery will depend mainly on the type and location of surgery and how much tissue is removed, as well as the child’s overall health. Side effects also depend on the effects of other treatments. For example, tissue treated with radiation may not heal well after surgery. General side effects of surgery for bone cancer include:
- wound infection
- wound separation
- nerve damage
- swelling in the limbs
Children who have an arm or leg amputated may believe they can still feel pain or other sensations in the limb that was removed. This is called phantom limb pain. It occurs when nerves are cut and damaged during surgery, which causes the body to send abnormal nerve impulses. Symptoms of phantom limb pain include pain, burning, throbbing or itching. Symptoms are usually worse when there was a lot of pain in the limb before the amputation. Phantom limb pain can be quite annoying. Sometimes medications can help to ease the sensation, and symptoms usually improve when a prosthesis is worn regularly.
A bone graft can take 6–8 months to heal. Sometimes the bone that was replaced or reconstructed with a bone graft may not heal and join properly. This is called non-union of the bone. Non-union of the bone can lead to fractures, and the child may need more surgery to fix the bone graft.
Sometimes side effects develop months or years after surgery. Find out more about late effects of treatments for childhood bone cancer.
Tell the healthcare team if your child has any side effects you think might be from surgery. The sooner they are aware of any problems, the sooner they can suggest ways to help your child deal with them.