Management of Soft Tissue Sarcoma

Treatment for soft tissue sarcomas may be either local or systemic. Local treatments remove, destroy, or control the cancer cells in one certain area. Systemic treatments are used to destroy or control cancer cells throughout the whole body. You may have just one treatment or a combination of treatments.

Children With Bone Cancer Are
In Good Hands

Dr. Kenan is an orthopedic surgeon who specializes in pediatric bone cancers and is part of a new initiative at Cohen Children's Hospital of New York to expand services for young people with bone cancer. He is well known for his limb-sparing surgeries and for his bedside manner.

Surgical Management of
Skeletal Metastatic Disease

Bone metastases are the most destructive lesions in adult patients. The development of bone metastasis indicates that a cure is unlikely and the management of symptoms becomes the focus of treatment.

Limb Sparing Surgery in Children with Malignant Bone Tumors Around the Knee Joint: The Biological Solution

Dr Samuel Kenan1, Dr Adam Levin, Dr Carolyn Fein-Levy, Dr Arlene Redner, Division of Musculoskeletal Oncology, Department of Orthopedics, Division of Hematology/Oncology and Stem Cell Transplantation, Department of Pediatrics

**Graphic content below, viewer discretion is advised.

Over the last two decades remarkable progress have been made in the medical management of patients with malignant bone tumors especially osteosarcoma and Ewing sarcoma. Advances in molecular biology have resulted in more accurate diagnoses, allowing for a better understanding of the molecular and cell biology behavior of these tumors. Improved chemotherapy has resulted in dramatic improvement in the survival from less than 20% five year survival to over 75% five year survivals.

The pediatric oncologists at the Steven and Alexandra Cohen Children’s Medical Center of New York (CCMC) have extensive experience in the oncological management and treatment of patients with bone sarcoma. However state-of-the-art systemic therapy while necessary is not sufficient. These tumors require local control. The best method of local control is surgery with adequate margins. Advances in radiographic imaging including MRI and PET scans have led to an extremely precise delineation of the extent of the patient’s tumor. Thus improvements in systemic therapy, shrinking tumors prior to surgery, and advances in imaging have permitted the introduction of newer surgical approaches leading to dramatic improvement in the prognosis and quality of life of affected patients. Historically amputation with wide margins of normal tissue was the only way to remove a tumor prior to these advances. Now patients at CCMC who present with osteosarcoma and Ewing sarcoma can be treated with limb sparing approaches as the treatment of choice.

New innovations at CCMC take advantage of the fact that in the majority of the patients with osteosarcoma and many patients with Ewing sarcoma the tumors are located around the knee joint. Previously if the tumor extended up to the epiphysis (growth plate) then the entire joint needed to be sacrificed and replaced with metal prosthesis in order to insure local removal of the entire tumor. In young patients with an open growth plate this type of surgery results in significant limb length discrepancy; the younger the child the larger the future discrepancy. This problem in young patients can be reduced but not eliminated by the use of an expandable prosthesis. Patient may undergo serial lengthening (operations) to keep pace with the child’s growth until skeletal maturity is attained. Limb sparing in children is associated high morbidity rate related to these multiple surgical procedures.

At Cohen Children’s Medical Center, in an attempt to improve long term functional outcome, we can spare the growth potential of the limb by preserving the growth plate and using a bone graft capable of growth rather than an inert metal prosthesis. These patients are selected and carefully evaluated for this approach by a multi-disciplinary team of pediatric oncologists, pediatric radiologist and orthopedic oncologist to determine if the tumor can be removed while still preserving growth. When we are able to spare the growth plate and the knee joint the child will grow into adulthood with a normal knee, preserving near-normal function without a limb length. The children for whom we have performed this procedure have returned to a normal lifestyle that for most includes participation in sports and other physical activities without any functional deficit. This unique approach provided by our multidisciplinary team at CCMC offers “biological solutions”, providing lifelong durable grafts with excellent function for an ever increasing proportion of our patients with bone sarcoma.

Case One

Ten year old child with osteosarcoma right distal femur. Patient completed chemotherapy and underwent wide segmental resection of the distal femur saving the growth plate and knee joint. The surgical defect was reconstructed by allograft combined with vascularized fibular graft. At one year follow-up patient had full healing of the allograft host bone interface. Patient returned to full level of activity with complete restoration of active knee motion.

Case Two

Thirteen years old child with osteosarcoma of the proximal tibia who underwent presurgical chemotherapy with excellent response. Patient underwent transepiphyseal resection and replacement by segmental allograft sparing the knee joint. At three months post surgery patient is walking with crutches. Patient completed post-surgical chemotherapy, remained disease free.

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