Bone Cancer: Can the Limb be Spared?

An otherwise healthy patient has been having knee pain for a few months and ends up visiting the local emergency room where she is diagnosed with an osteosarcoma of her lower extremity. She initially sees an old-time general practitioner in the area who discusses the serious potential of requiring an amputation for treatment and refers her to a local surgeon. The patient searches at length and finally finds Dr. James Wittig, and is told that the limb can be spared. It is important to spread the word that nowadays, most patients with sarcomas can safely undergo limb sparing surgery, says Dr. Wittig, Chief of Orthopedic Oncology and Sarcoma Surgery and Associate Professor of Orthopedic Surgery at Mount Sinai Medical Center in New York City.

Avoiding Amputation

Dr. Wittig, one of only approximately 150 orthopedists in the U.S. who handles bone and soft tissue cancers that threaten life and limb, states, “There have been such extraordinary advances in chemotherapy and limb saving surgical techniques that the majority of patients with bone and soft tissue sarcomas can have their extremities salvaged. This is in contrast to our situation pre-1979 where the majority of patients were treated with amputation. We now have a better understanding of the tumor and how sarcomas grow locally, not to mention the improved radiological imaging that enables us to view the tumor with more accuracy. Also making a significant difference are the advances in surgical techniques and prosthetics. With regard to the all-important chemotherapy regimen, for sarcomas it is now given preoperatively and results in a dramatic killing of the tumor—making it easier to remove the tumor without removing as much soft tissue.”

Biopsying a tumor carefully, says Dr. Wittig, can determine whether Mr. Jones leaves the hospital with his extremity intact.

The number one reason that unnecessary amputations are performed is that the biopsy is done incorrectly. The patient goes to see a general surgeon or orthopedist, perhaps someone who doesn’t have experience in treating these tumors, and undergoes a biopsy. If the biopsy is placed in the wrong position or results in bleeding that contaminates the surrounding tissue, this can preclude a limb sparing surgery.

“Any time physicians encounter a musculoskeletal tumor, ” continues Dr. Wittig,

it should be biopsied by the surgeon who will perform the limb sparing surgery or by a radiologist under the surgeon’s direction. Why? Because it is important that the incision for the biopsy be small, and placed in a position where there is no contamination of the neurovascular structures or important muscles. It needs to be placed longitudinally in line with the planned skin incision that is used to save the extremity. If the incision is placed transversely, the surgeon must remove an enormous piece of skin or other soft tissue because that has been contaminated. This can often preclude a limb sparing surgery and leave no other alternative but an amputation.

Then there are the fortunate patients who select Dr. Wittig for a second opinion. “On many occasions patients come to me after seeing another doctor…someone who has told them, essentially, ‘You have sarcoma, and that means you will need an amputation.’ Honestly, where they get their information and why they are so steadfast in their opinions puzzles me to say the least.

“Where they see something daunting, I often see something straightforward. For example, let’s say the tumor is relatively small, would involve a straightforward operation, the bone is not fractured, and the tumor isn’t wrapped around the neurovascular structures. In that situation the person would receive three months of chemotherapy, undergo limb salvage surgery, followed by more chemotherapy.

“Or, perhaps it’s a large tumor where there is some question if it is pushing up against or involving the neurovascular structures. You can still give that patient preoperative chemotherapy. They will likely have a good response to this, and then during surgery it will be easier to separate the sarcoma from the neurovascular structures and from the normal surrounding tissues. So in the end, there is no need for amputation—you can save the extremity.”

Working from Years of Experience

How can Dr. Wittig be so sure? Experience. Volume. “So much depends on the experience level of the surgeon and how much of any type of tumor he or she has treated. If the tumor is wrapped around the neurovascular structures or involving so much soft tissue in the extremity that removal of the tumor would be dangerous, then you can’t proceed. I look at a lot of large tumors and say to the patient, ‘I think we can get this out safely and save your extremity, ’ but another surgeon could say, ‘This will never come out safely.’ It’s not only experience and science behind the surgical procedures but also the art and one’s own creativity.”

In addition to these skills, one must also follow the guidelines, advises Dr. Wittig. “There are specific indications for an amputation. Unless the situation fits this to a ‘T, ’ we should think more critically about how to handle the case. Some things are controversial, naturally. Patients who have sarcomas that develop from the bone rarely fracture in the area of the sarcoma…that is a relative contraindication for saving the extremity. When the bone fractures, it bleeds, the theory being that if the fracture has displaced sufficiently and has bled, that the tumor has dispersed into the surrounding soft tissue, thus precluding limb saving surgery.

“In certain instances, however, the extremity can be immobilized—particularly in osteosarcoma and Ewing’s sarcoma. If the tumor responds to chemotherapy, meaning more than 90% of it is killed, then the fracture will heal and then you can often safely salvage the extremity without compromising the patient’s survival. Much of it depends on the severity and displacement of the fracture and whether you can resect the entire area that was likely contaminated. If the patient responds well to chemotherapy, then the microscopic cells that escaped with the hematoma are often killed, thus making the surgery safer.”

Educating Patients and Surgeons

Surgeons must be bold in order to manage the difficult situations they encounter, but they can’t walk on water...they must realize when they have reached their limits. “Other surgeons should know that any type of soft tissue, bony mass, or lump should be referred to an orthopedic oncologist. In particular, they should not operate on these lumps or bumps without an MRI. Many times tumors are dismissed as lipomas based on how they feel. Some surgeons may proceed to operate, try to remove the tumor, and contaminate the entire area—meaning that an amputation is now unavoidable.”

So a bit of enlightenment for many parties is in order.

Because the majority of people can have limbs salvaged, if someone is being told that an amputation is necessary, they should seek a second opinion. Also, we should educate health care professionals in other fields on how to recognize, diagnose and treat sarcomas since these individuals are the first line of defense for patients with such a tumor. Yes, we have courses on musculoskeletal tumors; however, after medical school, most familiarity comes from working with these very rare types of tumors on a regular basis.

And yet, there are times when even the most experienced orthopedic oncologist must deliver the news no patient wants to hear. “In the event that the tumor is infected, it may mean that limb sparing surgery is impossible. Some tumors can get infected after inappropriate biopsies or can grow to a large size and fungate through the skin resulting in an infection. In these instances it can be very difficult to eradicate the infection and save the limb at the same time trying to expeditiously save the patients life.”

“Or, if the tumor is recurrent, and the patient has already been treated with limb salvage, you might not be able to do the same surgery again. If it is relatively large or in a bad location (involving a muscle that you had to remove that provided the majority of functioning to the extremity), then you might not want to attempt the surgery. Or let’s say the patient previously had the tumor removed and the tissue was irradiated. In that case you would have to operate through those irradiated tissues, something that would hold a high risk of complications, and the wound would likely not heal properly. If the tumor recurs so many times, there are likely microscopic cells that are growing back that could not be previously removed…you would have to do an amputation.”

Fortunately, says Dr. Wittig, those are rare cases indeed.