Osteosarcoma and other bone cancers are rare, with fewer than 3,500 cases diagnosed in the United States each year, yet they are some of the more common tumor types in children and young adults. Thanks to advances in osteosarcoma treatment, cure rates have improved in recent years.
Surgeon John Healey, who has been at Memorial Sloan Kettering since 1984 and has led the Orthopedic Service since 1991, specializes in diagnosing and treating both cancerous and benign tumors of the bone and soft tissues. This summer, the Sarcoma Foundation of America honored Dr. Healey with its Nobility in Science Award for “his distinguished career as a surgeon and his dedication to finding a cure for sarcoma.”
We spoke with Dr. Healey recently about how advances in imaging and treatment have extended survival and improved quality of life for people with osteosarcoma and other bone cancers.
What is osteosarcoma?
Osteosarcoma is a cancerous tumor that produces bone. That’s true whether it initially develops in the bone or the soft tissues. There are some known risk factors for developing osteosarcoma — such as radiation treatment for other cancers, certain bone diseases, and a few rare hereditary cancer syndromes — but 90% have no known cause.
These tumors can arise at any age, but two-thirds of them occur in children and young adults. The most predominant age is the late teenage years. Osteosarcomas can occur anywhere in the body, but the most common location is in the large bones, like the femur. The bigger the bone, the more frequently a tumor will occur there.
What are some other types of bone cancer that you treat?
Ewing sarcoma is the second most common bone cancer in children, after osteosarcoma. It too occurs most commonly in the large bones, such as the leg bones and pelvis. It can also develop in soft tissues in the body, including in the torso.
Chondrosarcomas are composed of the cells that produce cartilage. They develop much more commonly in adults than in children and are more difficult to treat because they don’t respond to chemotherapy or radiation.
You’ve been at MSK for more than three decades. How has treatment for osteosarcoma and other bone cancers changed?
MSK developed the standard of care for treating osteosarcoma. The usual treatment is chemotherapy to shrink the tumor, surgery to remove it, and “clean-up chemotherapy” to destroy any remaining tumor cells, including those that may spread to other parts of the body. Ewing sarcoma is treated in a similar way, but radiation therapy may also be used.
Recently there have been numerous changes and improvements in treating bone cancer, many of these led by MSK.
One thing that has improved significantly is imaging, so we know exactly where the tumor is. This enables us to successfully remove it while preserving as much normal tissue as possible. In many cases we can preserve the joint near the tumor, which makes reconstruction more effective. There also have been many advances in surgical techniques.
What are some of those surgical advances?
For many patients, after diseased bone is removed, we can combine bone grafts taken from donors with metal implants to reconstruct what has been taken out. We are indebted to the generosity of the organ donors who donate these grafts.
It can be very hard to attach muscle to a metal implant, but bone grafts have natural muscle attachments. Using a bone graft can work very well with joints, especially the rotator cuff, hip, and knee. These advances allow people to function much better with their reconstructed parts, for example enabling them to climb stairs and more easily get out of chairs.
Could you talk about the procedure called bone transport and tissue regeneration?
This is a newer approach that’s very exciting. You take out the section of diseased bone and use what’s called an external fixator — like an erector set — on the outside of the body to support the limb. We cut off a piece of healthy bone about the size of a napkin ring and move it along the length of the limb, one millimeter each day. As it’s being moved along, it leaves new, healthy bone in its wake. When it gets to the other end, you have reconstituted a whole new bone. Sometimes we can cut healthy bone from both ends, and the two rings “kiss” in the middle to make the new bone.
This technique was developed by Dan Prince, a member of our team, and can now be used in about one-quarter of patients who have sections of their long bones removed. We’ve been doing it for about two years.
Amputation used to be the standard treatment for people with tumors in their arms or legs. Is it still used?
About 90% of people with bone cancer in the limbs can now avoid amputation. But in some cases, amputation actually may help to preserve the way a limb functions. For example, people who have amputations below the knee can run with a prosthetic limb — something that may actually be harder for someone who has other types of reconstruction such as a metal implant.
Sometimes amputation is the best option for younger kids because it helps them to avoid additional surgeries. It gets them out of the hospital and back home much sooner, allowing them to grow up healthy instead of sick.
What are the special considerations in treating bone cancer in children and young adults?
Because these patients are young, quality of life is so important. For patients with localized disease, cure rates for osteosarcoma and Ewing sarcoma are 75 to 80%, so we really think about how surgery and reconstruction will affect the rest of their lives.
In addition, because many of our patients are still small, we need to find the best methods to rebuild their bodies so that their reconstructed parts will be able to grow with them.
What’s different about having surgery for bone cancer at MSK?
One new technique we have that we’re very excited about is intraoperative navigation, which incorporates CT scans in the operating room to get the best view of where a tumor is located in three dimensions. It is particularly valuable for tumors around the pelvis, where the anatomy is complicated and reconstruction is a big challenge.
I can’t say enough about the skill and expertise of our surgeons. Dr. Prince’s work with bone transport has been a major advance. In addition, Edward Athanasian is the only hand surgeon in the country who’s also a sarcoma expert. Patrick Boland is a genius in handling the most difficult cases, for example removal of the sacrum.
With many other cancers, you hear about chemotherapy and other targeted therapies that are tailored to patients’ individual tumors. And that’s what we do at MSK with surgery for bone cancer: We individualize care for each patient based on their age and the location of their tumor to achieve the best functional outcome while at the same time having the best cure rates possible.