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Johns Hopkins surgeons work with patients to balance the options between preserving the function of a limb and removing the entire tumor with a margin of normal tissue. Their philosophy is that each patient deserves the best chance for a cure. Johns Hopkins surgeons have completed specialized training in orthopedic oncology, surgical oncology, or neurosurgery and use the most advanced technology to guide their surgical skills.
Importance of Sarcoma Surgery Done Right The First Time
Johns Hopkins surgical oncologist, Nita Ahuja, M.D. discusses the importance of having sarcoma surgery done right the first time.
Surgical Oncologist, Nita Ahuja, M.D. Discusses Sarcoma
Meet Johns Hopkins surgical oncologist, Nita Ahuja, M.D. and hear her discuss sarcoma treatment options including surgery./p>
Now that oncologists have improved chemotherapy regimens, surgeons can be more aggressive in saving the limb affected by the sarcoma without undue risk to survival. Since chemotherapy kills much of the tumor, surgeons cut away less tissue, providing more opportunities to save muscles, ligaments and nerves necessary for the limb to function well. Limb-sparing surgery can be performed in 90 percent of patients. If possible, wide margins of tissue around the tumor are removed, while major blood vessels and soft-tissue flaps are preserved.
Advances in imaging techniques have allowed surgeons to see exactly where the tumor lies in the bone or soft tissue, including throughout the bone marrow. MRI technology is the main imaging source used for patient with bone or soft tissue sarcomas. More on Diagnosing Sarcomas.
Options for reconstruction after limb-sparing surgery include:
Allograft reconstruction involves the use of cadaver bones, which are supplied by companies similar to those that provide organs for transplants. These companies follow strict procedures to screen for infection and blood-borne disease. The type of allograft required depends on the extent of surgery. Freeze-dried cadaver bone can be packed into small areas of bones where benign tumors have been removed. Larger intact bones can be used to replace sections of long bones or the pelvis after sarcoma removal and are size-matched to fit the patient. The allograft serves as a scaffolding for the body and provides structural support as the patient's bone grows over the cadaver bone. Allografts carry a higher risk of infection than metal prosthesss and can break and disintegrate over time. Many surgeons are using allografts less often for these reasons. Still, allografts, a biologic material, provide a more long-term solution for saving limbs as long as the patient's bone heals to the graft. They more frequently are used for repairing areas in the middle of the bone not involving the joint - these are termed intercalary allografts. In a highly-specialized intercalary allograft procedure, surgeons may insert vascularized fibular grafts that deliver critical blood supply to the grafted cadaver bone in order to speed up the healing process. Another use for allografts is to fuse a joint after a large segment of bone is removed around the hip, knee, ankle or shoulder. The allograft fills the space that the joint once occupied and is held in place with a metal rod or plate. Johns Hopkins experts believe this reconstruction is very durable after the allograft heals, but the patient will not be able to move the joint.
Replacing diseased bone with a metal prosthesis is the most commonly used option. Surgeons fit together modular pieces of metal, like building blocks or an "erector-set," to reconstruct the bone. Additional pieces can be added in young patients as they grow. However, all metal prosthesis will fail (loosen) over time and require revision surgery. Occasionally, surgeons at Johns Hopkins use combinations of allografts and prostheses to combine the best aspects of both types of reconstruction.
For pediatric patients, new options in prosthetic devices can mimic healthy growing limbs. This option is available for patients with tumors in the bone that extend into the growth plate and who are expected to grow more than 4 cm. A special prosthesis can be placed to reconstruct the limb after the tumor is removed, and different surgical or non-surgical techniques are used to periodically lengthen it to keep up with the growth of the appropriate limb. Early versions of the device failed often, requiring additional surgeries and exposure to infection. Now, a new prosthetic device expands without surgical procedures. Instead, an electromagnetic field is generated on the skin near the implant. The "heat waves" melt material surrounding a compressed spring inside the implant without harming other tissues. This procedure is done in an outpatient office visit at regular intervals to coincide with growth of the healthy limb.
An allograft can be combined with a metal prosthesis in the shoulder, hip or knee. The procedure is more complicated, but the patient's remaining tendons connect better to the allograft tendons than to metal. This allows patients to walk more reliably without a limp or raise their arm higher than with a prosthesis alone.
The smaller of the two calf bones, called the fibula, can be transplanted to replace an arm bone in pediatric patients. If the growth plate of the fibula can be successfully transplanted by a team consisting of an orthopaedic surgeon and a plastic surgeon, the arm can continue to grow! As living bone, it will mend the arm naturally. The procedure is an option for young patients with tumors that affect the upper part of the arm (humerus) and would require removal of the growth plate, have a favorable prognosis and are expected to grow significantly. Since the surgery is indicated for patients who have significant growth left, it is typically not an option for adults.
Other options/techniques used for tumor removal
RF ablation can destroy cancers by inserting an electrical probe into the tumor. An electric current from the probe burns through the tumor. The procedure can be done as an outpatient procedure through a tiny incision, and placement of the probe is directed by a CT scan.
RF ablation is standard treatment for osteoid osteoma - a small benign bone tumor that is often painful and very difficult to locate by traditional surgery. Complications in mobility, fractures, and recurrence were frequent problems in attempts to surgically remove these tumors. Studies (Rosenthal DI, et al., Radiology 2003; 229:171-5.) showed the rate of complications in 263 patients was less than one percent and 91 percent of tumors were completely removed. 60 percent of those with recurrent tumors were successfully removed in a second RF procedure.
Interventional radiologists perform RF ablation often for patients whose cancer (breast, prostate, kidney, lung, colon) has metastasized to the bone or other organs. It is not an option for sarcomas since the goal of surgery is to remove a wide area around the tumor to keep cancer cells from escaping the mass and to capture microscopic cells that have begun to spread. Inserting a large probe into the middle of a sarcoma may contaminate other tissues with cancer cells.
In addition to typical chemotherapy that flows through veins throughout the body, some centers give the drugs through an artery close to the tumor. Studies evaluating this option have not shown improvements in survival, and skin complications near the artery may be severe. We are not currently using this technique at Johns Hopkins.
Some sarcoma centers freeze tumors with liquid nitrogen in a process called cryosurgery, but Johns Hopkins specialists have found that the procedure makes the bone around the tumor very brittle and prone to fractures. Instead, after removal of aggressive benign bone tumors, such as giant cell tumors, with curettes and a high speed burr, Johns Hopkins surgeons paint a chemical called phenol on the remaining bone surface to prevent recurrence.