A Guide to Osteosarcoma Surgical Options

Removing the Primary Tumor

Osteosarcoma is a rare bone cancer that requires multiple doctors and specialists for treatment. The most common treatment protocol involves chemotherapy, surgery, and then more chemotherapy. Osteosarcomas can affect patients of all ages and arise from any bone in your body, but we see this cancer most commonly in 10- to 30-year-old patients with either an arm bone or leg bone being the primary tumor site. Surgery to remove the cancer is a critical component of successful treatment..

“Our goal is to walk that tightrope of finding a way to cure cancer while restoring function as best as possible,” Dr. Callan says.

The goal of every osteosarcoma surgery is to remove all the cancer with a cuff of normal tissue around the tumor; this is a negative margin resection. These surgeries require surgically resecting large segments of bone. The next goal is to offer the best reconstruction possible to restore quality of life and function.

The best choice for surgery can vary based on the age of the patient, how much growth they have left to do, their hobbies and interests, and what their goals are after surgery for osteosarcoma.

Dr. Callan outlines the options for patients and families using five “A’s:” amputation, allograft, arthroplasty, allograft prosthetic composite, and autograft. Each surgery discussion is personalized to the patient, the tumor, and the optimal reconstruction.

1. Amputation

“The elephant in the room for anyone that gets a new diagnosis of bone sarcoma is amputation. Everyone is always worried that they’re going to lose their limb,” Dr. Callan says. She points out that 92 percent of the time, limb-saving surgery is possible. In the remaining eight percent, amputation may be the best choice.

Some patients who need amputation are candidates for rotationplasty, especially if their tumor is close to the knee. In this procedure, surgeons remove the leg, then reverse and reattach the lower leg to the upper leg so that:

• The heel sits where the knee used to be
• The ankle functions as the new knee joint
• The foot can attach to a prosthesis

“Rotationplasty is a compelling option for young patients, because it gives them a great functional outcome without repeated surgeries,” Dr. Callan says.

2. Allograft

An allograft reconstructs the bone using a donor bone from a cadaver. “In the United States, we’re lucky. We have large bone banks that can match the child’s body,” Dr. Callan says.

3. Arthroplasty (Joint Replacement)

Arthroplasty reconstructs the bone with metal components, known as an endoprosthesis. It’s like a more extreme version of a knee, hip, or shoulder replacement used to treat arthritis. This is the most common reconstruction option for most patients.

“With advancements in biomedical engineering, we can design custom implants to match patient anatomy,” Dr. Callan says. This is extremely helpful for young, small children or tumors found in the pelvis.

“For growing kids, I love having the option to custom design a magnetic expandible endoprosthesis that allows me to lengthen a leg with a magnet in clinic to extend the metal component over time, allowing the replacement to grow along with the child.”

4. Allograft Prosthetic Composite

This approach combines both metal and cadaver bone in a single reconstruction. “Sometimes it makes sense for me to combine the two, especially if I need soft tissue and tendon to reconstruct a joint and gain function,” Dr. Callan says.

5. Autograft

This reconstruction uses the patient’s own bone to rebuild another bone. The most common autograft reconstruction is a trans-physeal vascularized fibula transfer. This means moving the small fibula bone in the lower leg to rebuild a humerus or shoulder. It’s often an option for younger children who do not have good matches available from bone banks or metal replacements. With autograft, surgeons can preserve blood supply to the growth plate, allowing the limb to keep growing normally.

Creative Solutions

Every osteosarcoma case is different, and standard reconstructions don’t always fit a patient’s anatomy or tumor location. When that happens, surgeons design individualized procedures. For example, Dr. Callan once used part of a female patient’s pelvic bone to rebuild her hip. “I was able to preserve her hip, clear her cancer, and get her back to riding horses,” she says.

Lung Surgery Options

Because osteosarcoma often spreads to the lungs, surgeons remove any cancer they find there. Most patients begin four months of MAP chemotherapy beginning two weeks after their initial surgery, then move to lung surgery, if needed, once chemotherapy is complete.

“Lung surgery is a critical component of osteosarcoma treatment,” says Dr. Talbot. “We want to remove all the nodules we can see or feel, and we want to keep as much of the patient’s lung intact as possible in the process.”

Surgeons weigh two main decisions for lung surgery: open versus thoracoscopic (minimally invasive) technique, and whether to operate on one lung, both lungs in separate surgeries, or both lungs at once.

Open vs. Thoracoscopic Procedures

Historically, surgeons almost always removed lung nodules with open surgery. “With open procedures, we may be able to feel very small nodules. They can feel like a grain of sand,” Dr. Talbot says. Locating nodules by hand increases the odds of finding all of them, not just the ones visible on a scan. At the same time, thoracoscopic or minimally invasive options may be appropriate in patients with low numbers of nodules. These options may make it easier for surgeons to perform additional thoracic procedures if the osteosarcoma comes back in the lungs.

Many patients worry about the recovery from open surgery, but modern early recovery protocols and pain control methods such as nerve freezing, or cryoablation, help patients recover quickly and with less pain than in the past.

An ongoing national clinical trial is evaluating whether outcomes differ between open or minimally invasive techniques for patients who would be eligible to have either kind of operation.

Thoracoscopic surgery tends to work best when there are fewer nodules, and when they sit along the edge of the lung rather than in the center. A patient’s individual anatomy also factors into the decision.

Single Lung or Both Lungs

CT scans guide the decision to operate on one or both lungs. Scans may not pick up tiny nodules, though, so if nodules appear on one lung, surgeons weigh the odds that undetected nodules may be hiding in the other. Most of the time, though, only a lung that has visible nodules on CT scans will be operated on.

In many cases, surgeons operate first on the lung with larger or more complex nodules, then operate on the second lung one to two weeks later. Some surgeons prefer to operate on both lungs in the same surgery, though recovery may be a little harder.

Making a Decision

Weighing surgical options in the middle of a cancer diagnosis is overwhelming, and no family should have to sort through it alone.

A good place to start? The Osteosarcoma Decision Aid, developed by Osteosarcoma Collaborative, explains these surgical options in further detail with resources and patient stories to help guide decision-making.

But most importantly, rely on the medical experts and care team members assigned to the case. Surgeons like Dr. Callan and Dr. Talbot have walked this road with many families. A patient’s medical and care teams work with the whole family to determine the best course of action to help the patient live a full and happy life.