Orthopedic Oncology

Over the past twenty years, the survival rate for sarcoma patients has improved radically. Where at one time, treatment was limb amputation, with a high mortality rate, most sarcomas can now be treated with limb–sparing surgery followed by reconstruction.

Arthritic Knee Cut Bone Picture Shows X–ray of a 10–year old girl, a mid–shaft osteosarcoma of the right femur (left). Following tumor resection, limb salvag included an allograft and intramedullary rod for fixation. The patient’s range of motion returned quickly but weight bearing remained limited until the bone graft healed in approximately six months.

“If we identify it as a cancerous tumor, our goals are simple: to save the life and then to save the extremity”, said Penn orthopedic oncologist and surgeon Philip Z. Wirganowicz, MD, who also treats patients with carcinomas which metastasize to bone, causing breakage or weakness which requires Orthopedic implants. “The overall survival from sarcoma now is about 75% in some cases higher than with more common forms of cancer–thanks to the sophisticated forms of treatment developed by medical oncologists and radiation oncologists.”

“While his primary concern when treating bone sarcomas is to save the patient’s life, his concern with a metastasized carcinoma is to preserve function. “A carcinoma in the limb destroys the bone and leads to a pathologic fracture,” he explained. “Surgery helps improve the quality of their life by allowing them to do basic activities on their own.” Sarcomas, which develop within mesothelial tissue, attack bone and surrounding tissue such as muscles, nerves, connective tissue, and blood vessels.

Multidisciplinary Approach Wirganowicz is part of a multidisciplinary team developed to treat the diseases of bone and soft–tissue sarcoma. Picture Shows X–ray of a 16–year old girl with a Ewing’s sarcoma (top) of the proximal radius shows destruction of bone and the soft tissue extent of tumor. A postoperative radiograph after tumor resection (bottom) shows an endoprosthetic reconstruction. The lucent are at the radio–humeral joint represents polyethylene bearing surface. Patient returned to full range of motion two weeks postoperatively.

Ewing’s sarcoma

In most cases, the team first performs a biopsy. If it reveals a malignancy, the patient is treated initially with chemotherapy or radiation followed by surgery and reconstruction, and then further chemotherapy or radiation.

Each patient presents a unique problem. Even the patient’s occupation is taken into consideration. For example, a pianist was recently diagnosed with a chest sarcoma near the top of his arm. “The safest and most effective treatment would be a forequarter amputation of the arm and shoulder to the chest wall, but that’s not what the patient will accept”, Glatstein said.

In the initial evaluation of bone or soft tissue tumors, plain radiographs help determine how aggressive the lesion is and which further studies may be necessary. For large benign–appearing tumors, those of indeterminate status, or aggressive malignancies, MRI and CT scans may be the next step to determine the full extent of the lesion and its relationship to surrounding structures. Bone scans help determine multiple bone involvement. Occasionally, positron emission topography (PET) scans are used to help determine the grade or aggressiveness of the lesion, any possible metastatic disease, effectiveness of chemotherapy and radiation on tumors, and may help in the early detection in the case of local recurrence.