Surgery for childhood bone cancer

Surgery is a medical procedure to examine, remove or repair tissue. Surgery, as a treatment for cancer, means removing the tumour or cancerous tissue from the body. Most children with bone cancer will have surgery. The type of surgery used depends mainly on the size and location of the tumour and whether or not the cancer has spread.

When planning surgery, your child’s healthcare team will also consider other factors, such as your child’s age and overall health. Your child may have surgery to:

• take a biopsy sample to confirm a diagnosis of bone cancer
• remove the tumour, or as much of the tumour as possible
• remove a lung metastases (cancer that has spread to a lung)
• rebuild the area after a tumour is removed (called reconstruction)

Tumours that can be completely removed with surgery are called resectable. Bone tumours in a limb (an arm, leg, hand or foot) can often be removed with surgery.

Tumours that can’t be completely removed with surgery are called unresectable. It’s often not possible to completely remove bone tumours in the pelvis (hip), spine or base of the skull, so doctors will use other treatments along with surgery for these tumours.

The following types of surgery are used to treat childhood bone cancer.

In a wide resection, the surgeon removes the bone tumour and a small amount of tissue and bone around it (called the surgical margin). A sample of the surgical margin is sent to the pathology lab for review. If there are no cancer cells in the surgical margin, it’s called a negative surgical margin. If there are cancer cells in the margin, it’s called a positive surgical margin and more treatment will be needed.

Depending on the amount of tissue removed, your child’s surgeon may need to reconstruct the area where the bone was removed. This is often done at the same time as the surgery to remove the cancer.

Doctors may use other terms for wide resection, such as en bloc resection or wide excision.

Limb-sparing surgery is often done when a bone tumour is in a limb. Limb-sparing surgery removes the tumour without removing (amputating) the whole arm or leg. This type of surgery is also called limb-salvage surgery.

During limb-sparing surgery, the surgeon performs a wide resection to remove all of the tumour and any of the soft tissues where the bone cancer has spread to. The surgeon will preserve or protect major nerves or blood vessels so that the limb works as well as possible after surgery.

Limb-sparing surgery is not always possible for children who have a tumour in the arm or leg. Surgeons can do limb-sparing surgery if:

• the tumour responded well to chemotherapy
• there is enough skin and soft tissue to cover the wound after the tumour is removed
• the cancer has not spread to any major arteries, veins or nerves

Sometimes cancer weakens the bone and causes it to break (called a pathologic fracture). If your child has had a pathologic fracture, more normal tissue may need to be removed during limb-sparing surgery. The surgeon will check if there is enough normal tissue around the fracture to help decide if your child can have limb-sparing surgery.

Depending on the amount of tissue removed, the surgeon may need to do more surgery to replace the bone and rebuild the body part. This is called reconstruction or reconstructive surgery. It’s often done at the same time as the surgery to remove the cancer. If wide resection is used to remove a tumour from the smaller bones of the ribs, collarbone, leg, arm, toes or fingers, reconstruction is not usually needed.

Surgeons have different ways that they can reconstruct a body part, using bone, other tissues and metal implants. They may use one of the following reconstruction techniques.

A bone graft is a piece of bone taken from another part of the body to rebuild the area that has had bone removed. A bone graft can be used to rebuild the jaw, a leg, an arm or other areas. The graft may be taken from your child’s body (called an autograft) or from a donor (called an allograft). When an allograft is used, there is a higher chance that the bone graft won’t heal properly (called non-union) or will become infected.

An endoprosthesis is an internal prosthesis or prosthetic implant placed in the remaining bone. It’s used to replace joints that have been removed by surgery, like the knee, hip or shoulder joints. This allows the joints to move and bend. An endoprosthesis is usually made of metal and plastic. Endoprostheses come in different types and sizes. Some can be expanded. A child who has an endoprosthesis may need surgery every 6 to 12 months to lengthen the endoprosthesis until the skeleton is fully grown.

Arthrodesis (also called fusing the joint or joint fusion) may be used for tumours in or near the knee or shoulder joint. The surgeon removes the whole joint and inserts a metal implant, such as a rod or plate, into the 2 remaining bone ends to join them together. After a fusion, the joint no longer moves and the affected limb has to make up for the loss of motion.

Having a bone graft or endoprosthesis means wearing a brace or cast after surgery for a long period of time. The brace or cast supports the limb and limits how much it can be used. This allows time for healing and for the bone graft or endoprosthesis to join to the remaining bone in the limb.

Children who have limb-sparing surgery will need intensive rehabilitation and will take part in a rehabilitation program to be able to use the limb. It can take up to a year to learn to walk again after limb-sparing surgery in a leg.

Children 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. A bone graft can easily break if it is hit or stressed too much. Your child’s healthcare team will explain these risks and how your child can protect their bone. They may need more surgery later in life if the bone graft or endoprosthesis wears out or is damaged.

An amputation is surgery to remove part of, or all of, the arm or leg with the tumour. Amputation is mainly needed when bone cancer grows into nerves or blood vessels, or when the tumour is so large it affects all of the soft tissues around it. An amputation may also be done if the bone cancer has come back in the same area after limb-sparing surgery.

An advantage of your child having an amputation is that it has a shorter healing time than other types of surgery such as limb-sparing surgery. There are also no restrictions to activity, especially if they have an artifical limb in place. Your child can participate in activities involving running and contact sports because there is no risk of damaging a bone graft or endoprosthesis, which they would have if they had limb-sparing surgery. The disadvantages of amputation include having to use an artificial limb (prosthesis), being upset about the appearance of the stump and phantom limb pain.

In some cases, your child can be provided with something called an immediate fit prosthesis (a temporary artificial limb) while still under anesthesia. For example, in the case of a leg amputation, a cast is put on the stump (what remains of the limb) in the operating room. A basic post with an artificial foot is then attached. When waking from anesthesia, your child can look down and see 2 feet under the covers. One to 2 days after surgery, your child can get up and start walking with crutches. This gives a big boost to their morale. The cast helps to control swelling of the stump, allowing it to be ready for the permanent prosthesis more quickly. It takes about 3 to 4 weeks after surgery for the swelling to decrease enough for the first fitting for a permanent prosthesis.

After surgery, your child will have physical rehabilitation and physical therapy. A rehabilitation team will help your child recover from the amputation. They will teach your child how to use the prosthesis and help them learn to walk or move again. Exercises usually focus on getting the other, whole limb as strong as possible, and on strengthening the part of the amputated limb that remains. These exercises will prevent the muscles from shortening. Specialized joints and devices that help a permanent prosthesis function as naturally as possible are usually discussed once your child is fully rehabilitated. It takes about 6 months for children to walk comfortably after surgery. Active teens need a new artificial leg or prosthesis about every 2 years.

Your child can still have a very good quality of life after amputation. They can be physically active and get back to most of their normal activites.

Sometimes surgery is done to remove bone cancer that has spread to the lung (called lung metastases) or to other bones (called bone metastases). The type of surgery that may be offered depends on:

• the number of metastases (cancer that has spread to another part of the body)

• the size of the metastases and where they are in the body
• if the metastases are close to important blood vessels or to the spinal cord
• your child’s overall health
• whether or not your child is currently having chemotherapy

If surgery is an option for lung metastases, doctors often use a wedge resection to remove the tumour, along with a triangle-shaped piece of the lung around it.

Before surgery, your child will have tests (MRI, CT or PET-CT) to assess the tumour. These tests tell doctors where the borders of the tumour are, how it has responded to chemotherapy before surgery, and if cancer has spread. This helps plan surgery and the next steps of treatment. The size and location of the tumour are key to planning how to completely remove the bone cancer along with a margin of normal tissue. It may be necessary to remove some additional soft tissues surrounding the bone or a joint next to the affected bone. It may also be necessary to reconstruct the bone or joint.

For the large bones of the arm and leg, reconstruction is often done at the same time as the surgery for removing the cancer. The healthcare team may suggest different options for you and your child to choose from.

In thinking about the options, it will be important to consider:

• your child’s age, lifestyle and activity levels

• how much care and support you have available after surgery
• how your childʼs body image may be affected

It may help to look at pictures or videos of people who have had the type of surgery that your childʼs healthcare team is suggesting.

Side effects of surgery will depend mainly on the type of surgery, the size and location of the tumour, how much tissue is removed and your childʼs overall health. Tell the healthcare team if you think your child has side effects from surgery. The sooner you tell them of any problems, the sooner they can suggest ways to help your child deal with them.

Surgery for childhood bone cancer may cause these side effects:

• pain
• wound infection
• bleeding
• wound separation (the edges of the wound donʼt meet together)
• nerve damage
• swelling in the limbs
• scarring
• phantom limb pain (if the limb has been amputated)
• non-union (improper healing) of the bone

Other side effects can develop months or years after treatment for childhood bone cancer. These are called late effects. Find out more about the late effects of treatments for childhood bone cancer.

Find out more about surgery and the side effects of surgery. To make the decisions that are right for your child, ask the healthcare team questions about surgery.