Saving the limb in osteosarcomaMay 29, 2018
Can limb salvage surgery be used successfully in a patient diagnosed with osteosarcoma of the right elbow?
Orthopaedic Oncology deals with bone and soft tissue tumours, and accounts for about 1-2% of all cancers in India, according to Dr Pramod Chinder, an orthopedic oncologist at HCG, Bengaluru. In his experience, these types of tumours typically affect the younger population, predominantly in the age group of 5-20 years, who do not have any known etiology.
The primary treatment strategy in most patients includes reconstructive surgery where the tumour is resected, and the bone defect replaced by bone allografts or metal plates. This procedure involves complex surgical techniques that are primarily designed to save the limb, and hence is aptly termed ’limb salvage surgery’. While about 80% of those diagnosed with these tumours can be treated with the limb salvage surgery, unfortunately, when the tumour is located in anatomical locations where it cannot be accessed or when the tumour is big and recurrent, limb saving may not be a plausible option, and the amputation of the limb becomes an inevitable.
Here is the case of a young medical student diagnosed with osteosarcoma of the right elbow, an extremely rare site for such tumours. The patient was told by multiple oncology surgeons across the country that her only option was to undergo an above-the-elbow amputation. At her age and time in life, an amputated limb would most definitely have halted her blossoming medical career and perhaps shattered her professional dreams and aspirations.
After several physician visits and consultations, she was eventually referred to HealthCare Global Enterprises Ltd. (HCG) and evaluated by their multi–disciplinary team (MDT) with the standard investigative tests including X-Ray, 3D Local MRI, and whole-body PET CT scan. She was diagnosed with an aggressive, non-metastatic, malignant, intermediate grade tumour of the ulna. With limb salvage surgery as the goal, she was started on a neo-adjuvant chemotherapy with a high dose methotrexate regimen. However, this treatment resulted in a moderate clinical response, with the tumour size decreasing only marginally. Considering the size of the tumour, the location and the complexity of the reconstructive surgery, questions were again raised whether it was feasible to save her limb. However, after discussions with the patient and her family, the MDT decided to go ahead with limb salvage surgery. Additionally, it also helped that the patient, with her medical background and understanding, was able to fully comprehend the situation and take an informed judgement call on her treatment plan.
Allograft prosthetic composite was the primary choice of implant for the reconstructive surgery, and the MDT team acquired fresh frozen allograft of the elbow from collaborators in Italy. Considering the location of the tumour, the surgery to be performed was quite delicate. However, all the nerves and arteries were carefully dissected and salvaged. The bone was cut, the tumour resected, and the area was reconstructed with the allograft prosthetic composite and the fresh frozen allograft. The patient tolerated the surgery well, and today, after one and a half years, the patient is disease-free and has a fully functional hand allowing for normal daily activities, and is on her way to treat patients herself.
In this relatively new, niche field of orthopedic oncology in India, several factors play a role in determining the treatment option. First, the facilities and technological expertise that the doctors can provide is a fundamental factor in the decision making for treatment options. The absence of a bone bank in India hinders the availability of bone allografts. However, for successful treatment options, it is a requirement for any orthopaedic oncology department and a good organ donation programme would considerably help in maintaining such a bone bank. Second, the location of the tumour also plays an important role in deciding the outcome. Typically, if the reconstructive surgery is too complicated due to the location, or the tumour is recurrent or large, the natural treatment choice is amputation. Surgeries need to be well planned and complications need to be considered. Tumour recurrence, infection, prosthesis loosening, restricted range of motion, and limb shortness are some of the major complications observed. Recent advances in imaging, allograft retrieval, as well as custom implant designing have led the path to dramatic improvements in the surgical outcomes. Long term chemotherapy and radiation may also be necessary to manage outcomes.
Awareness of technological advances is important for the medical community. What may have been considered impossible a few years ago may be possible today. As seen in this case, limb salvage surgeries are not impossible, even for rare and difficult sites such as the elbow, it is possible to have successful outcomes where the patient continues to be able to perform daily activities.
At her age and time in life, an amputated limb would most definitely have halted her blossoming medical career and perhaps shattered her professional dreams and aspirations