Surgery for 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 your body.

Most people with bone cancer have surgery. The type of surgery you have depends mainly on where the tumour is, the size of the tumour and the stage of the cancer.

You may have surgery to:

• take a biopsy sample to confirm a diagnosis of bone cancer
• remove all or as much of the tumour as possible
• remove a tumour that has spread to a lung (called lung metastases)
• 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 is often not possible to completely remove bone tumours in the spine, pelvis (hip) and 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 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 lab. If there are no cancer cells in the surgical margin, it is called a negative surgical margin.

Depending on the amount of tissue removed, your surgeon may need to reconstruct the area where the bone was removed. This is 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. It is the surgical method used during limb-sparing surgery.

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 (the limb). 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. They will also remove any tissue from or near the biopsy site. The surgeon will preserve or protect major nerves or blood vessels so the limb works as well as possible after surgery.

Limb-sparing surgery is not always possible. 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 blood vessels or nerves

Sometimes cancer weakens the bone and causes it to break (called a pathological fracture). In some cases, more normal tissue needs to be removed during limb-sparing surgery if you have had a pathological fracture. Your surgeon will need to check if there is enough normal tissue around the fracture to decide if you can have limb-sparing surgery.

Depending on the amount of tissue removed, your surgeon may need to do more surgery to replace the bone and rebuild the limb. This is called reconstruction or reconstructive surgery. It is 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 limb, using bone, other tissues and metal implants. They may use 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 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. You can be physically active after an allograft on a leg or arm, but you will need to avoid activity such as contact sports. The bone graft can easily break if it is hit or stressed too much. Your healthcare team will explain these risks and how you can protect your bone.

Bone cement is used to help hold a bone graft in place. Bone cement is a chemical called polymethyl methacrylate. Bone cement starts off as a liquid that can be poured into any gaps near the graft. Once it’s poured, it hardens and supports the graft.

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.

Arthrodesis (also called fusing the joint or joint fusion) may be used for tumours in or near the spine, 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. Joint fusion is done more often for older adults.

An amputation is surgery to remove part 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 cancer comes back in the same area after limb-sparing surgery.

Different types of amputation are done depending on where the bone tumour is found. Your surgeon and healthcare team will explain the type of amputation that will be done to treat your bone cancer.

Most people who have an amputation will use an artificial limb (prosthesis) after surgery. A prosthesis is attached to the end of the limb that was amputated (called the stump).

After surgery, you will have physical rehabilitation and physical therapy. You will have a rehabilitation team to help you recover from your amputation. They will teach you how to use the prosthesis and help you learn to walk or move again.

People who have had an amputation can generally maintain a good quality of life. They can still be physically active and get back to most of their normal activities.

Find out more about rehabilitation after bone cancer surgery.

Curettage is a procedure that uses a spoon-shaped tool with a sharp edge (called a curette) to scrape a tumour out of the bone. This leaves a hole where the tumour was removed.

With bone cancer, curettage is used in an area where a wide resection can’t be done safely, like in the skull or spine. After curettage, the surgeon may use bone cement to fix the hole left in the bone and destroy any remaining cancer cells. Bone cement starts off as a liquid that can be poured into the hole. As it starts to harden, the bone cement heats up and destroys any cancer cells that are left in the area.

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

• the number of tumours (also called metastases)
• the size of the metastases
• if the metastases are close to important blood vessels or the spinal cord
• your overall health
• if you are having chemotherapy

If surgery can be done for lung metastases, doctors will often perform a wedge resection to remove the tumour along with a triangle-shaped piece of the lung around it.

Surgery to remove lung 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 has come back (recurred) as lung metastases if it has been more than a year since treatment ended.

Find out more about lung metastases.

Before surgery, doctors will do tests to find out the exact location of the tumour, how it has responded to chemotherapy and if it has grown or spread. These tests may include imaging tests such as CT scans, MRIs, bone scans and PET-CT scans.

Based on these tests, the surgeon will let you know the types of reconstruction you can have after your bone tumour is removed. You will work with your healthcare team to decide which option is best for you. It may help to look at pictures or videos of people who have had the type of reconstruction that your healthcare team is suggesting.

You may want to talk to your healthcare team about the following factors to help you make a decision.

Talk to your healthcare team about your lifestyle and the type of activities you want to do after your surgery for bone cancer. With some types of reconstruction, you won’t be able to run or play certain sports.

Some types of reconstructive surgery take a long time to heal. You may have to use crutches for a long time after surgery or avoid heavy lifting. Amputation has a much shorter healing time, with fewer complications. Talk to your healthcare team about support in your community that can help you during recovery and rehabilitation.

Surgery for bone cancer can affect your body image. Body image is how you see your own body. The surgery that will give you the strongest, most useful limb can be different from the surgery that will make your limb look like it did before surgery. Talk to your healthcare team about how your surgery options might affect your appearance and body image.

Side effects of whichever surgery you have will depend mainly on the type of surgery and your overall health. Tell your healthcare team if you have these side effects or others you think might be from surgery. The sooner you tell them of any problems, the sooner they can suggest ways to help you deal with them.

Surgery for bone cancer may cause these side effects:

• pain
• changes in the way you walk, such as a limp
• infection
• bleeding
• wound reopening (separation)
• nerve damage
• swelling in the limbs
• scarring
• a bone graft that doesn’t heal or join properly (called non-union of the bone)
• phantom limb pain after amputation

You may need more surgeries if there are any complications with reconstruction.

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