Treatment for different types of bone cancer
Once the diagnosis and stage of bone cancer is determined through various investigations for bone cancer, next step is treatment of disease. The bone cancer treatment options depend on many factors including but not limited to the type of bone cancer, stage of the disease, location of the cancer, performance status of the patient, patient’s preference, along with other factors.
In patients with localized osteosarcoma, surgery involving wide excision (either limb-sparing or amputation) is considered as the preferred treatment. Chemotherapy is recommended before and after surgery.
For patients with metastatic osteosarcoma, chemotherapy is the mainstay of treatment. Rarely, surgical resection of primary and metastatic site may be done if the metastatic disease is completely resectable, as assessed by the surgeon.
In patients with resectable chondrosarcoma, surgery involving wide excision (either limb-sparing or amputation) or intralesional excision is considered the preferred treatment approach. Chemotherapy may be added before and/or after surgery.
For patients with unresectable chondrosarcoma at an unfavorable location such as the base of the skull or in the spine, radiotherapy is employed as the preferred treatment approach.
Patients with localized Ewing sarcoma are usually treated with chemotherapy as first-line treatment. This is followed by local control therapy including surgery or radiotherapy depending upon the resectability and site of cancer. This is usually followed by chemotherapy.
For patients with metastatic Ewing’s sarcoma, chemotherapy is the mainstay of treatment. Rarely, surgical resection of primary and surgery/radiotherapy of metastatic site may be done if possible, as assessed by the oncologist.
In patients with resectable chordoma, surgery involving wide excision with/without radiotherapy is considered the preferred treatment approach.
For patients with unresectable chordoma, radiotherapy or targeted therapy is employed as the first-line treatment approach.
Undifferentiated pleomorphic sarcoma (UPS)
In patients with localized UPS, surgery involving wide excision (either limb-sparing or amputation) is considered as the preferred treatment. Chemotherapy is recommended before and after surgery.
For patients with metastatic UPS, chemotherapy is the mainstay of treatment. Rarely, surgical resection of primary and metastatic site may be done if the metastatic disease is completely resectable, as assessed by the surgeon.
Giant cell tumor of bone
In patients with localized GCTBs, surgery involving wide excision, intralesional excision, or curettage with/without bone cement is considered the preferred treatment approach.
For patients with unresectable GCTBs, radiotherapy or targeted therapy may be employed as the first-line treatment approach.
Types of Surgery for Bone Tumors
Surgery is considered the treatment of choice for almost all bone cancer. Surgery may also be employed to collect biopsy sample. The main goal of surgery is to remove all cancerous tissue. Thus, cancerous tissue along with some nearby normal tissue is usually removed to obtain margin negative for cancer cells. This is known as wide-excision.
Surgery may also be employed in some cases of metastatic disease where complete removal of metastatic cancer tissue is possible. Following are some common surgical procedures carried out for bone cancer treatment:
Limb-Sparing Surgery: In this surgery, all the tissue containing cancer and some of the nearby tissue is removed leaving the working limb (an arm or a leg) in place. This is generally possible in case of early-stage disease where the tumor is limited to a part of bone (not affecting nearby nerves and blood vessels) and the part can be replaced with an endo-prosthetic device (prosthetic device that joins two ends of the same bone or of different bones) or the bone ends can be joined together without the requirement of a prosthesis.
Amputation: In this surgical procedure, the entire limb or a part of a limb is removed leaving behind a shorter limb without or with very little function. This is generally performed when limb-sparing surgery is not possible, for example, in case of a tumor that has invaded nearby nerves, or blood vessels, which required these tissues to be removed during the surgery. A prosthesis may be attached to the amputated limb which may impart some function (depending upon the extent of amputation) with proper rehabilitation.
Reconstructive surgery: In this surgical procedure, a limb is partially reconstructed to restore/maintain functionality even when a part of a limb is required to be removed. For example, if the bones from the mid-thigh including the knee joint are required to be removed, the lower leg and foot can be rotated and attached to the thigh bone in a way that the ankle joint work as a new knee joint. This procedure is known as rotationplasty.
A prosthesis can be used to replace the lost lower length of the leg, which can enable the patient to walk again. Similarly, if some portion of the upper arm is required to be removed due to cancer, the lower part of the arm can be attached to the remaining upper part leaving a short but functional arm. This type of surgery is possible only in selected cases.
Bone Curettage: In this surgical procedure, the cancerous bone tissue is removed by scraping and leaving behind the normal bone of the original size. However, a cavity or a hole is created in the treated bone. The cavity/hole can be filled with a bone cement (a chemical substance – polymethylmethyacrylate that hardens to fill the cavity in a bone). This procedure also helps in killing any remaining cancer cells because the bone cement releases a lot of heat while hardening. Alternatively, this can be achieved with the help of cryotherapy, wherein a very cool liquid is first administered in the cavity to kill remaining cancer cells. The cavity is then filled with a bone graft.
Surgical treatment of bone tumor for bones other than limbs is generally complex. Wherever possible, a wide-excision surgical procedure is carried out and removed bone tissue is replaced with a bone graft or with bone taken from some other body part. For the bones of the spine and skull, wide-excision is usually not possible.