In Oncology, there are three clinical disciplines - Medical Oncology, Surgical Oncology and Radiation Oncology. Medical Oncology, involves treating cancer with chemotherapyRadiation Oncology, involves treating cancer with radiation therapySurgical Oncology, involves surgical removal of the tumour and affected surrounding tissues Depending on the cancer grade/stage and individual case history, the treating oncologist may prescribe either one or combination of chemotherapy, radiation therapy and/or surgery.
Bone neoplasms constitute about 1% of all neoplasm diagnoses and about 2% of Orthopaedic diagnoses. Of these roughly 40% constitute malignant bone tumours and are seen in the first two decades of life. Malignant bone tumours grow locally by expansion and flattening of normal surrounding tissue (compression) and locally infiltrating the soft tissues around the bone (invasion). Due to their sheer size at the time of diagnosis local destruction of bone and surrounding musculature with or without nerve and blood vessel involvement, the treatment proffered was ablative surgery (amputations). Despite amputations there would be metastases in more than 70 % of patients due to spread via blood vessel and lymphatics (again due to sheer size and close proximity to these structures) and the outcome would be fatal. These patients thus did not have much hope.
With the advent of modern chemotherapy the survival of cancer patients in general improved and more so in cases of malignant bone tumours. The neoplasms could be better contained locally and distally at the metastases site (mainly lungs). This lead to focus on function preserving surgery. The resections which were initially very radical and compartmental became Wide (en bloc) and Marginal resections. From the point of view of Oncologic principles it is necessary to resect the bone in a manner that at least 5 cms of disease free marrow margin be obtained for a successful outcome.
So the challenge posed to the surgeons pursuing the field of Orthopaedic Oncology was to obtain oncologically adequate margins while preserving the musculature, nerve and blood supply for adequate function and to reconstruct such large defects created by means that would not only restore near normal function but also withstand the stresses of wear and tear. This was complemented by studies to understand the biomechanics and design better implant for a good functional outcome.
The job of an Orthopaedic Oncosurgeon is to assess the individual case for feasibility of limb preserving surgery, plan and execute a successful biopsy, team with a medical oncologist for chemotherapy, successful removal of the tumour with a wide margin for tumour control but at the same time leaving enough tissue behind for a good functional outcome, reconstructing the tumour defect with mechanically sound prosthesis or adequate Osteosynthesis, oversee functional rehabilitation whilst planning chemotherapy for distant metastatic control. The pattern of reconstructions done vary from case to case individually.
Q: What is so special about an Orthopaedic Oncosurgeon? Can not a regular Orthopaedic surgeon do the same job?
A: The difference can be compared to hammering a nail into a wall for hanging an expensive painting. While anybody can do the same using a tool box and do it yourself kit, but only a skilled carpenter will assess the load to be hung and shall not only hammer the right nail into the wall but shall also give a small support at the bottom of the painting so that not only the painting tilts in a way that gives maximum effect on viewing but also gives adequate strength to the construct.
Similarly an Orthopaedic Oncosurgeon is trained in all the aspects of Orthopaedics and Oncology to give the best result to the patient.
Q: Can this treatment be offered at any centre?
A: A team of well trained radiologist, pathologist, medical oncologist, Orthopeadic onco surgeon, radiation oncologist and rehabilitation therapist is needed for optimal functional outcome. Any centre which has the requisite skilled team can deliver optimal results.
Q: Cost of treatment apart, what is the commonest pitfall in the treatment?
A: Technically an improperly done biopsy can have an adverse outcome. Conceptually lack of awareness of treatment modality and functional outcome amongst health care providers. Hence we need to educate health care providers that treatment offered at the right time can make the patients afflicted with bone tumour live a near normal life.
Q: What can a patient of bone tumour expect in today’s world?
A: When diagnosed early and treated adequately approximately 80 % or more patient can expect to live a fully functional life for 10 years or beyond.
Q: When should a person suspect that he has a bone tumour?
A: Bone tumours are painful swellings in the bone with pain usually more pronounced at night. So if a person has a painful swelling in the bone which has not been amenable to treatment with regular pain medications for more than 2- 3 weeks then it would be reasonable to see a specialist.
Q: Whom should a person go to Orthopaedic surgeon or Orthopaedic Oncosurgeon?
A: Whenever facilities are available one should see the right specialist – which would be Orthopaedic Oncosurgeon in the current instance.
Q: How is a diagnosis of bone tumour made?
A: The diagnosis is made by performing a biopsy. While it is tempting for any surgeon to perform a biopsy, it is important to perform the biopsy in such a way that the future surgery for limb salvage should not be jeopardized (the technical limitation as discussed above). Generally it is advocated that the surgeon performing the final limb salvage procedure should be the one performing the biopsy. THE FIRST SURGEON HAS THE BEST CHANCE OF CURE.