The surgery performed to remove soft-tissue and bone cancer in the limbs while retaining the unaffected parts is limb salvage surgery. The procedure is done to remove cancer and avoid amputation (while retaining the greatest possible degree of function and preserving the patient’s appearance). Limb salvage surgery is a common procedure to treat bone sarcomas and tumours and soft tissue sarcomas that affect the extremities.
In essence, limb salvage surgery has become an alternative to amputation and is performed to treat cancers that originate in the limb and those cancers that have not invaded the soft tissues yet. Decades ago, the standard treatment route for patients with cancer in the limb was amputation of the affected extremity. Fortunately, thanks to dramatic improvements in surgical techniques (resection and reconstruction), imaging methods (CT scans and MRIs), and high survival rates of patients treated using chemotherapy, limb cancer treatment will no longer always involve losing the extremity affected.
Otherwise known as limb-sparing surgery, limb salvage surgery entails removing cancer and a margin of the surrounding healthy tissues. Once removed, the bone will be replaced. The replacement can be in the form of a synthetic metal implant (prosthesis) or a piece of bone (graft). The graft can be taken from the patient’s own body (autologous transplant) or it can come from a donor body (cadaver) and frozen until needed for the transplant (allograft). In time, the transplanted bone will eventually grow into the patient’s remaining bone. Radiation, chemotherapy, or a combination of both may be used to shrink the tumour before surgery is carried out.
Limb-sparing surgery is done in three stages:
- Surgeons remove cancer (and a margin of the surrounding healthy tissues)
- A prosthesis or a bone graft is implanted (whichever is necessary)
- The wound is closed (by transferring muscle and soft tissue from other parts of the patient’s body to the surgical site)
Techniques Used in Limb Salvage Surgery
Bone Tumors – To treat low-grade bone tumours or its components, surgeons will remove the malignant lesion and a cuff of normal tissue (wide excision). In the case of high-grade tumours, the bone, muscle, and other tissues that have been affected by the tumour (radical resection) will be removed.
Soft Tissue Sarcomas – Limb salvage surgery is used to treat around 80 per cent of soft tissue sarcomas that affect the extremities. The tumour, lymph nodes, other tissues where cancer has spread, and at least 2.54 cm of healthy tissues surrounding the tumour will also be removed.
Chemotherapy or radiation may be administered pre- or post-surgery. Radiation may also be administered during the procedure. External beam (linear accelerator) is most commonly used. In brachytherapy, a special applicator will be placed against the bed where the tumour has been removed and tubes containing radioactive pellets will be inserted at the tumour site. The tubes will only be removed several days later.
Before deciding if limb-sparing surgery is the best option for a patient, doctors will take into consideration several key factors—the type of cancer, the location and size of the tumour, the progression of the condition, and the patient’s general health and age.
Candidates for limb salvage surgery will be given insights on the likely surgery outcome. They will also be informed that should the implant fail, additional surgery (and even amputation) might be necessary. Occupational and physical therapists will also help prepare the patient for the procedure by teaching ambulation (walking), range of motion (ROM), and muscle-strengthening exercises the patient will begin performing post-surgery.
Typically, limb salvage surgery patients will remain in the hospital for 5 to 10 days after the procedure. Nurses will monitor the blood flow and sensation in the affected extremity and will check for signs of possible surgery complications like deep-vein thrombosis, pulmonary embolism, or pneumonia. Broad-spectrum antibiotics will be given in the first 48 hours after the surgery and medications (prophylactic anticoagulants) to prevent blood clots may also be prescribed.
A drainage tube will be placed in the wound (at least for the first 24 to 48 hours) to prevent hematoma (blood) and seroma (fluid) from accumulating in the surgical site. Since limb salvage surgery requires extensive surgical incisions and loss of functional tissues, patients will also need extensive rehabilitation after. The type of reconstruction done and the amount of bone removed will often dictate how much the patient can exercise and how soon.
However, most patients begin continuous passive motion (CPM), muscle-strengthening, and ROM exercises at least a day after the surgery and will continue to do them for the next 12 months or so. Also, before the patient is sent home, the doctor will decide whether a brace, walker, cane or other assistive devices will be needed. While salvaged limbs often function better than artificial ones, it may take at least a year before patients who have undergone lower-extremity limb salvage to learn to walk again. Patients who have upper extremity salvage will also have to master new ways of using the affected extremity.