Bone & Soft Tissue Cancer Surgery

Bone cancer and soft tissue cancer arise from mesenchymal tissues of the body such as bone, muscle, cartilage, fat and connective tissue. They are also termed as “Sarcoma”. Sarcomas of bone and soft tissue comprise around 2-3 % of all cancers. Malignant tumors (sarcoma) are capable of spreading to other parts of the body, whereas benign tumors can be aggressive and destroy the native bone or soft tissue only.

The line of treatment for sarcoma is based on the histological type, its stage, grade, size, and whether the cancer cells are sensitive to chemotherapy or radiotherapy. This process may require clinical and radiological evaluation and often followed by a biopsy which provides tissue for histological evaluation and staging investigations.

Multi-disciplinary treatment with chemotherapy, limb-saving surgery and/or radiotherapy is the mainstay of sarcoma treatment.

 

Surgical options used to treat Bone & Soft tissue Sarcoma include:

  1. Neo-Adjuvant Chemotherapy & Radiotherapy for Malignant tumors

  2. Limb Salvage (Limb Saving-Function Preserving) Surgeries  for Extremities & Pelvis

    1. Megaprosthetic Reconstructions (Prosthetic Joint Replacement after Tumor Removal)

    2. ECRT (Extracorporeal Radiation & Reimplantation technique)

    3. Cryotherapy and reimplantation

    4. Vascularised Fibula Reconstruction

    5. Allogenic Bone Graft Reconstruction

    6. Allograft-Prosthetic Composite Reconstruction

    7. Hemipelvectomy and Custom Hemi-pelvic prosthetic reconstruction

    8. Rotationplasty

    9. Arthrodesis

  3. Pediatric Bone Tumor Surgeries

    1. Expandable Megaprosthetic Reconstructions

    2. Growth Preserving  & Joint Sparing Limb Salvage Surgeries

  4. Benign Bone Tumor Surgeries

    1. Extended Curettage and bone grafting/cementing

    2. Radiofrequency Ablation

    3. Angioembolisation

    4. Sclerotherapy

  5. Sacrectomy and or spino-pelvic reconstruction

  6. Soft tissues tumors: Wide Excision & Soft Tissue Reconstruction

  7. Metastatic & Palliative Care Surgeries

    1. Megaprosthetic Reconstruction

    2. Nail Cement Spacer Reconstruction

    3. Palliative Chemotherapy & radiotherapy

    4. Pain & Palliative Care procedures

In the event that amputation is required to control a tumor, the requisite skills and experience are available to perform these procedures safely and effectively, including technically demanding amputations around the limb girdles such as hemipelvectomy (removal of one leg and half of the pelvis) and forequarter (arm and shoulder) amputations. These individuals are then rehabilitated with excellent prosthetic replacement.

 

Symptoms of bone and soft tissue sarcoma

  • Pain which is persistent and progressive, even at rest

  • A lump or swelling, changing in size

  • Pain or fracture following trivial trauma

  • Rarely, weakness, numbness or paralysis

Any rapidly progressive pain or swelling, larger than 5 cm in dimension (size of the lemon) within a short duration should raise suspicions of sarcoma.

 

Diagnosis of bone and soft tissue sarcoma

An individual with above-mentioned symptoms undergoes a thorough physical examination followed by imaging (X-ray) of involved part. This is followed by imaging studies such as Ultrasound/MRI/CT scan and relevant hematological investigations. A working clinical diagnosis is made which is confirmed by a properly planned Biopsy by the Treating surgeon.

 

Staging Diagnosis of bone and soft tissue sarcoma

If a diagnosis of a Bone or Soft Tissue Sarcoma is made, investigations should be performed to stage the disease involving CT Thorax and Bone Scan or PET CT (18-FDG or Sodium Fluoride).

Stage of sarcoma is one of the important factors in evaluating treatment options, as well as providing a prognosis. Most commonly followed staging systems as AJCC (American joint commission on cancer) TNM system and Enneking Staging system for musculoskeletal tumors.

 

Risks of the procedures

  • Bleeding: This may depend on the extent of both disease and procedure. May require transfusion of blood & blood products, continuous monitoring in a ward or intensive care and mechanical Ventilation.

  • Infection: May depend on risk factors associated with patient, disease and procedure performed. May require multiple surgeries, antibiotic treatment and rarely amputation.

  • Injury to major blood vessels of limb: May lead to loss of blood or sequelae of ischemia to limbs. May require vascular repair and rarely amputation (Permanent loss of limb).

  • Injury to major nerves – May require repair of nerves and may to temporary or permanent loss of sensation and weakness  

  • Shortening of limb, weakness of joint and stiffness of joints which may require multiple surgeries.

  • Implant related complications like aseptic loosening, breakage of a prosthesis, wear and tear of bushing component and periprosthetic fracture all of which may require revision surgery or alternative surgery.

Before the procedure

  • Your doctor will explain the surgical procedure to you. Ask any questions that you might have about the procedure. Be sure you understand what the extent of the surgery is likely to be and what you should expect afterward.

  • In case you have been administered chemotherapy, you may to meet with a medical oncologist to be cleared to undergo surgery. You may also be advised to undergo an ECG and 2D ECHO scan of the heart prior to surgery.

  • If you’re planning to have radiation therapy after surgery, meet with a radiation oncologist before surgery to discuss benefits and risks.

  • You may be asked to sign a consent form that gives your permission to do the procedure. Read the form carefully and ask questions if something is not clear.

  • Ask your doctor if you will possibly need a blood transfusion. If the doctors think a transfusion might be needed, you may require your family or friends to be asked to donate blood beforehand.

  • Your doctor will go through your full medical history and additionally may perform a complete physical examination to ensure you are in good health before undergoing the procedure. You may undergo blood tests or other diagnostic tests.

  • Notify your doctor if you are sensitive to or are allergic to any medications, latex, tape, and anesthetic agents (local and general).

  • Notify your doctor of all medications (prescribed and over-the-counter) and herbal supplements that you are taking.

  • Notify your doctor if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for you to stop these medications prior to the procedure.

  • Notify your doctor if you are pregnant or suspect pregnancy.

  • You will be asked to fast for eight hours before the procedure, generally after midnight.

  • You may receive a sedative prior to the procedure to help you relax.

  • You may meet with a physical therapist prior to your surgery to discuss rehabilitation.

  • Stop smoking, as smoking can delay wound healing and slow down the recovery period.

Based on your medical condition, your doctor may request other specific tests or examinations.

 

After the procedure (Rehabilitation & Follow up)

Rehabilitation starts soon after treatment, once a patient is surgically and medically stable. Patients who undergo megaprosthetic reconstructions can weight bear and ambulate from next day of surgery compared to the sustained prolonged period of protected weight bearing in biological reconstructions in bone tumors. Inpatient rehabilitation focuses on teaching patients how to move and function safely with reconstructed limbs which continue on an outpatient basis.

You will have a follow-up with your surgeon about 10-14 days after the surgery to go over the results of your pathology report and talk about any further treatment. If you need more treatment, your doctor may refer you to:

  • A medical oncologist to discuss other forms of treatment after the operation, such as chemotherapy or hormone therapy or both.

  • A radiation oncologist to discuss radiation treatments, which may be recommended if there was a large tumor, or traces of cancer is excised the tumor.

  • A counselor or support group to help you cope with having sarcoma

You may be required to periodically undergo x-rays CT scans at intervals suggested by your surgeon to assess the healing process, rehabilitation process and treatment results. Musculoskeletal tumors are prone to recur either locally or in other parts of the body which may endanger both limb and life. It is also important to identify metastases during follow-up. Presence of recurrence or metastases changes the outlook of treatment and may need further aggressive intervention in form of surgery, chemotherapy or radiotherapy.