Cancer; Orthopaedics and Rehab

Advances in sarcoma surgery help preserve life and limbs

Cancer; Orthopaedics and Rehab

X-ray of shoulder replacement after sarcoma surgery
An X-ray shows the result of limb salvage surgery with a proximal humerus replacement after removal of a tumor of the left shoulder.

Historically, the sole focus of sarcoma surgery was to remove the cancerous tumor in the soft tissue or bone, which in most cases meant amputation. Saving the arm or leg usually was an afterthought, even if it meant less function after surgery.

As a result, daily tasks that we often take for granted, such as walking, running, or clothing and feeding yourself, became impossible for many sarcoma patients. The unfortunate reality was that we had to choose life over limb.

Today, we almost always can prioritize life and limb thanks to logic-defying limb-salvage techniques and rapidly evolving technology. Decades of surgical innovation, research, and advances like programmable implants, 3D-printed patient-specific models, and regenerative reconstructions allow more patients to avoid amputation and regain function.

I’ll give you an example. A patient with a pelvic bone sarcoma, in addition to removing the tumor, used to automatically require removal of the corresponding leg (external hemipelvectomy).

Today, internal hemipelvectomy is the standard limb-preservation approach in high-volume centers like UT Southwestern’s Harold C. Simmons Comprehensive Cancer Center. While we still remove a significant portion of the pelvic bone, the leg can often be saved.

In many cases, the defect in the pelvic bone does not even require a bulky prosthesis or replacement, decreasing risks of infection and failure. Instead, under the guidance of expert physical therapists, we can allow natural scar tissue to fill the void over time and organically bridge the leg and pelvis. Patients can resume normal leg function, walking and even running again despite missing half their pelvic bone.

Results like these make it an exhilarating time to be an orthopedic-oncology surgeon because we can give our patients renewed hope and a high quality of life after sarcoma without sacrificing long-term cancer remission.

A brief history of sarcoma treatment

Sarcomas are tumors that form in the bone or soft tissue, such as fat, joint tissues, muscle, nerves, tendons, or blood vessels. There are more than 60 described types of sarcomas and many more that have not been officially named.

We typically find sarcomas in the arms, legs, abdomen, or pelvis, and they can form in adults or children. Though less common than cancers of the breast or colon, sarcomas carry a higher mortality rate. Fewer than 15,000 people are diagnosed with soft-tissue sarcomas in the U.S. each year, and about 3,000 are diagnosed with bone sarcomas, such as osteosarcoma or Ewing’s sarcoma.

Symptoms vary based on the tumor’s location, size, and whether it is pressing against nerves or organs. Patients may notice:

  • Asymmetry, swelling, or a mass or lump under the skin
  • Pain in the torso or limb
  • Weakness or numbness in an arm or leg
  • Bowel or bladder incontinence (in the case of pelvic or spine tumors)

With sarcoma surgery, the goal is to achieve margin negative resection, which means, in theory, there are no tumor cells found at the edge of the tissue that was removed around the tumor. Thirty years ago, amputation was typically the most common surgical technique to ensure safe margins for the patient. Fewer than 5% of sarcomas result in amputation now.

Team-based sarcoma care

Limb salvage techniques evolved from rapid research in team-based care planning: medical oncology, radiation oncology, interventional radiology, orthopedic oncology, surgical oncology, plastic surgery, and physical and medical rehabilitation (PM&R). Now every patient gets a personalized plan to treat their cancer, save their limb whenever possible, and maintain function for a better quality of life.

Female patient smiling at her doctor in hospital.
Curing cancer will always be the top goal of sarcoma surgery, but limb salvage techniques allow us to focus more energy on preserving function and quality of life.

UT Southwestern is a high-volume center for sarcoma, which means we see more cases – and typically more complex cases – than most other hospitals in North Texas. Our Multidisciplinary Sarcoma Conference is a weekly meeting where the entire team comes together to create dynamic care plans for patients with complex sarcomas.

Each type of sarcoma responds differently to treatment options, such as chemotherapy, radiation therapy, and surgery. Together, our team analyzes data from a biopsy of the tumor, which provides confirmation of the type of sarcoma.

We review the patients’ imaging to understand which blood vessels, nerves, tissues, and bone are involved and how much will remain to be reconstructed after tumor removal. Using these details, we determine whether limb salvage is possible. Almost always, the answer is “yes.”

Surgical limb salvage innovations

Imaging: Advanced imaging is essential in diagnosing and managing sarcomas, as well as determining treatment response. Novel imaging techniques such as diffusion weighted imaging, which assesses diffusion of water in human tissues, may in the future help predict tumor behavior and personalize treatment.

Plastic surgery reconstruction: This field has seen major innovations in microvascular and nerve surgeries. Specially trained surgeons can transfer skin, muscle, and bone and reconnect the nerves and blood vessels to initiate healthy blood flow, promoting function.

For example, if a patient has a large sarcoma in their leg, nearly all the surrounding muscles and part of the bone may be removed. Our plastic surgeons can perform free-flap reconstructive surgery, moving tissues from another part of the body to help reconstruct the defect, allowing appropriate wound healing and maintaining leg function.

Image Here
This X-ray shows a proximal tibia (shinbone) replacement following removal of a tumor of the right knee.

We’ve also learned that the fibula, which is the small bone in the leg, is fairly dispensable – but it is also transferable and growable. For example, in a child with a sarcoma of the humerus, we could move the fibula to the arm, and the plastic surgeon can connect it to existing blood vessels, allowing the bone to grow along with the child.

3D printing and personalized biomechanical models: Using a 3D-printed model of a patient’s own arm, leg, or joint, we can plan more precise surgeries and help educate patients about their treatment process.

While not the standard of care today, individualized computer-simulated models may prove to be a valuable in personalizing surgery and optimizing limb function. In a study published in Frontiers in Bioengineering and Biotechnology, we found that sparing certain hip muscles may help improve gait after internal hemipelvectomy. Continued research in physical therapy and surgical techniques may shed more light on how to preserve patient function.

Programmable implants: Patients are living longer with improved, holistic cancer care. Some are even outpacing the intended lifespans of their prostheses. So, medical device companies are designing new implants that “grow” with the patient.

For pediatric sarcoma, we can program metal prostheses to lengthen as the child grows, decreasing the chance for deficits in limb length and reducing the need for major surgery to replace the device before adulthood.

In adults, traditional implants use a stem placed in the remaining bone. One of the newer bone-preserving implants devices instead uses a short spindle that applies compression to help the bone heal, compromising a much smaller bone segment and leaving more tissue to work with if the patient needs a revision 15 years down the road.

Post-operative rehabilitation

Physical therapy is the key to maintaining function and quality of life after sarcoma surgery. Most patients can regain full ability to walk, do daily tasks, and enjoy light exercise without pain. Some return to higher-impact exercise, such as running, hiking, or tennis.

UTSW’s Physical Medicine and Rehabilitation specialists help patients set and achieve appropriate goals as they recover. Part of this is managing expectations – despite innovations, there are some situations in which returning to pre-surgery levels in a sport is not safe or realistic. PM&R specialists also help patients balance healing with managing side effects of chemotherapy and radiation therapy.

Full recovery from sarcoma surgery is a multistage process. The skin may heal within a few weeks, while bone and muscle strengthen over several weeks or months. Along with physical therapy, many patients benefit from sarcoma support services, such as peer groups, nutrition guidance, or individual mental health care to work through the complicated emotions that come with cancer and treatment.

During my career, I’ve seen a rapid shift from “save a life” to “improve a life” with sarcoma cancer treatment. Procedures we can only imagine today likely will become commonplace 10 to 20 years from now.

Curing a patient’s cancer will always be our top priority. But with continued advancements in limb salvage, we can increase efforts to help more patients live a longer, healthier life after sarcoma treatment.

To talk with a sarcoma specialist about treatment options, including limb salvage, call 214-645-8300 or request an appointment online.