Surgeon Edward Athanasian, an expert in treating bone and soft tissue tumors, examines a patient. Surgery is often the primary treatment for bone cancer.
Treatment for primary bone cancers can include surgery, chemotherapy (treatment with drugs that kill cancer cells), other novel therapies, or radiation therapy, alone or in combination. The type of treatment used depends on the type, location, and size of the tumor, as well as the patient’s age and general health.
Surgery is often the primary treatment for bone cancer. When operating to remove bone tumors, surgeons remove some of the surrounding bone and muscle to be sure that they are removing as much cancerous tissue as possible. If the operation is on an arm or leg, the surgeon will try to preserve the limb and maintain its functionality. Sometimes the bone that is removed will be replaced with bone from another part of the body, or with a prosthesis (an artificial replacement).
Surgeons at Memorial Sloan Kettering are able to save the limb in most bone cancer surgeries and have developed new replacements that are more durable and functional than standard replacements. Even if the entire limb cannot be preserved, surgeons will try to spare as much as possible in an effort to optimize functionality. In some cases, doctors can even recreate functioning joints, such as knees, so that a leg will flex naturally even after the natural knee has been removed.
Memorial Sloan Kettering doctors have participated in clinical trials to evaluate new limb replacement devices that may last longer than conventional prostheses. We led studies to create longer-lasting prostheses, such as the CompreSs implant — a novel method to secure a knee replacement to the thighbone. We are also using specially designed expandable prostheses in children that “grow” as a child grows.
Chemotherapy is often used in combination with surgery, to either shrink the tumor before surgery or manage and control the tumor after surgery.
Cryosurgery is sometimes used in addition to surgery for some patients with bone cancer. After a bone tumor is removed, liquid nitrogen is used to freeze the tumor cavity to subzero temperatures, killing microscopic tumor cells and decreasing the chance of tumor recurrence. The frozen bone is stabilized by filling the tumor cavity with bone graft, cement, or rods and screws to prevent fracture.
Memorial Sloan Kettering surgeons were the first to use cryosurgery for bone cancer, and we have perfected its use to reduce tumor recurrence while preserving limb and joint function.
Adjuvant Approaches in Bone Cancer
Many patients will be free of all cancer following surgery. However, in some patients microscopic tumor cells that were not detectable before or during surgery will eventually grow. As a result, many patients now receive chemotherapy or chemotherapy and radiation therapy in addition to surgery. At Memorial Sloan Kettering, it is common for bone cancer patients to receive various forms of therapy following surgery — a practice known as adjuvant therapy. Adjuvant therapy increases the chances for a complete cure by destroying microscopic accumulations of cancer cells before they have an opportunity to grow larger.
Radiation therapy is sometimes given in combination with surgery, to destroy tumors or to reduce the size of the tumor. Radiation therapy may also be used to kill remaining cancer cells after surgery, or to treat tumors that cannot be surgically removed — sometimes in combination with chemotherapy. In patients with cancer that has spread to the bones, radiation therapy may also be used to relieve symptoms, including pain.
External-Beam Radiation Therapy
The most commonly used type of radiation therapy in bone cancer treatment is external-beam radiation, which uses doses of radiation delivered from outside the body, focusing on the region of the tumor and surrounding tissues. After postoperative recovery, a course of external-beam radiation therapy is usually given, but it may also be given before surgery.
Memorial Sloan Kettering doctors are using a novel form of radiation therapy in some patients with sarcomas. Called intensity-modulated radiation therapy (IMRT), this technique targets tumors so precisely that it leaves surrounding healthy tissue unharmed.
Stereotactic radiosurgery, or image-guided radiation therapy (IGRT), is a highly specialized and extremely precise way of delivering very high doses of radiation into tumors while minimizing the effects of radiation on surrounding normal tissue. Because of the strength of the doses, the probability of tumor control is high. Since the surrounding normal tissues receive much lower radiation doses, the risk of side effects is low. At Memorial Sloan Kettering, an experienced team of radiation oncologists, surgeons, and medical physicists work together to perform stereotactic radiosurgery on primary or metastatic bone tumors in the spine and other parts of the body.
Research is also underway to evaluate the application of radiation directly to the bone during surgery, a process known as intraoperative radiation therapy.
Brachytherapy involves the delivery of radiation therapy directly to the tumor site, and for bone cancer treatment it can be administered in two different ways. In one approach, during surgery, after the surgeon removes the tumor, special tubes called catheters are inserted into the tumor bed, which is the site where the tumor originally existed before being surgically removed. After allowing the surgical wound to heal for five to six days, a radiation oncologist inserts radioactive seeds into each of the catheters. The seeds stay in place for several days, delivering a high dose of radiotherapy to the site.
When the treatment is completed, both the radioactive seeds and the catheters are removed. A patient may finish the entire course of treatment within ten to 14 days. In certain situations, brachytherapy may be administered for two to three days combined with external-beam radiation that is administered for five weeks.
Chemotherapy is often used to treat primary bone cancers, in conjunction with surgery. Chemotherapy is commonly given after surgery to kill any cancer cells that remain in the body after the main tumor is removed surgically. Sometimes chemotherapy is given before surgery to reduce the size of the tumor before surgeons try to remove it. This type of treatment is called induction chemotherapy.
- Chemotherapy and Novel Therapies for Ewing Sarcoma
Once a diagnosis of Ewing sarcoma has been confirmed, patients will be treated with chemotherapy to shrink the tumor and to prevent new tumors from forming. Doctors will usually treat Ewing sarcoma with chemotherapy that involves a combination of drugs. The standard treatment includes vincristine, doxorubicin, and cyclophosphamide (a combination known as VAdriaC), alternating with ifosfamide and etoposide. These drugs can cause damage to the bone marrow, so doctors may also need to treat the bone marrow damage as well.
In the event of a recurrence, new treatment agents that have proven successful in treating Ewing sarcoma may be employed. Additional surgery and/or radiation therapy are also possible treatment approaches. For this group of high-risk patients, we also offer a series of innovative, disease-specific clinical trials, such as those involving what are known as IGF1-receptor antagonists, which are monoclonal antibodies that trigger the body’s own immune system to target cancer cells.
Myeloablative therapy with hematopoietic stem cell support is currently being studied at Memorial Sloan Kettering for certain high-risk patients with appropriately matched sibling donors. Myeloablative therapy is a very intense regimen of chemotherapy designed to destroy all cells that divide rapidly. These cells include some blood cells and hair cells, as well as cancer cells. Hematopoietic stem cells are self-renewing cells from which the various types of blood cells are formed. Stem cell support involves enriching the stem cells and increasing the number of such cells after chemotherapy has been administered.
- Chemotherapy for Osteosarcoma
If chemotherapy is needed after surgery for osteosarcoma, treatment usually consists of a regimen of the drugs ifosfamide, cisplatin, methotrexate, and doxorubicin.
For patients with relapsed or metastatic disease, treatment is highly individualized. Treatment options include surgery, radiation therapy, and chemotherapy agents that may not have been used previously. Based on laboratory studies conducted at Memorial Sloan Kettering, we offer a series of innovative, disease-specific clinical trials for this group of high-risk patients.
New approaches to treating bone cancer at Memorial Sloan Kettering are constantly being developed to improve upon or enhance treatment options. Research protocols involving the study of investigational approaches are sometimes offered to eligible patients through the clinical trial process. Clinical trials are designed to advance the current standards of care.
For example, clinical trials are now underway to assess potentially more effective chemotherapy drugs and novel therapies for different kinds of bone cancer. One study will examine and evaluate the use of a new monoclonal antibody, R1507, for the treatment of recurrent or refractory Ewing sarcoma and osteosarcoma.
Another study is examining the effects of a novel therapy using the lung cancer drug pemetrexed, which works by preventing cancer cells from using folate, a naturally occurring vitamin that the body uses to help normal cells keep growing. Since cancer cells usually grow faster than normal cells, cancer cells should be affected by pemetrexed more than normal cells.
For up-to-date details about current clinical trials at Memorial Sloan Kettering, please visit our clinical trial database.