Bone and Joint Cancers

Types of Cancers

• Soft tissue sarcomas (cancers) occur anywhere in the body, but the majority arise from the large muscles of the extremities, the chest wall, the mediastinum and the retroperitoneum. They constitute about 1 percent of all cancers.
• Rhabdomyosarcomas are the most common soft tissue sarcomas of childhood with about 15 percent located in the extremities.
• Osteosarcomas are the most common primary malignant bone tumors in children.
• Ewing's Sarcomas are the most lethal of bone tumors, occurring almost exclusively in the first two decades of life.
• The most common presentation is an enlarging deep-seated mass.

Biopsy Techniques

Several biopsy techniques are available including fine-needle aspiration, core-needle biopsy, incisional biopsy and excisional biopsy. The choice of biopsy is dictated by the size and location of the mass, and is decided upon after consultation with the pathologist.

Once the diagnosis is established, the extent of the primary tumor must be assessed and a search conducted for spread of disease. In addition to careful physical examination, x-rays of the chest, CT scans, bone scans and MRI scans may be necessary.

Treatment

The Musculoskeletal Tumor Society recognizes a wide local excision, either by amputation or limb-salvage procedure, as the recommended surgical approach for musculoskeletal sarcomas. A wide excision removes the tumor in one piece along with a surrounding high-risk zone. This strategy is applicable to all highly aggressive sarcomas, and successfully eliminates the local disease in greater than 90 percent of patients. This is the result of advances in the understanding of the biology of the tumors, improvement in reconstructive techniques and development of effective adjuvant chemotherapy and radiotherapy.

Chemotherapy is administered according to established protocols for specific musculoskeletal sarcomas. Frequently, this is utilized before and after definitive surgical treatment of the lesion. Newer techniques for delivering radiation have improved local control and, in some cases, have been effective in preventing recurrence even when only a bare removal can be achieved surgically. Most current treatment protocols include provisions for radiotherapy, either before or after surgery.

Despite the enthusiasm for limb-salvage surgery for both bone and soft tissue sarcomas, certain contraindications remain. These include:

1. Extremely large tumors with obvious neurovascular involvement
2. Tumors that cause fracture and subsequent contamination of multiple tissue compartments by the malignancy
3. Lesions of the distal lower part of the extremity, where the functional results of amputation and prosthetic fitting are generally good
4. Local recurrences after a previous attempt at limb salvage

Reconstruction

Reconstruction after tumor resection is evaluated with the utmost respect for the welfare of the patient. Techniques, such as free tissue transfers for wound closure, tendon transfers and joint surgery for restoration of function, biologic implants or bone grafts are all considered. After the initial treatment, all patients are followed and watched for recurrences and approximately 80 percent of the tumors that are destined to recur locally will do so within two years.

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