Paediatric osteosarcoma of thigh bones treated with complex biological limb salvage surgery

An 8 year old girl presented to the team of Musculoskeletal Oncosurgeons at Manipal Hospital, Bangalore with history of pain and swelling of left thigh bone since 5 months. Biopsy revealed diagnosis of Osteosarcoma left femur. A metastatic lesion was identified in opposite femur, near knee joint. High dose chemotherapy was provided by Medical Oncology team with subsequent plan of limb salvage. Treating the child was unlike routine limb salvage surgeries. Osteosarcoma around the knee joint are treated by megaprosthesis replacement worldwide, but the same cannot always be the solution in children of age group of 6-14 years because the growing ends of bone on either side of knee joint is removed to facilitate megaprosthesis placement. Considering her young age and need to preserve the growing ends of the bone, the patient’s parents were counselled regarding the need for limb salvage surgery with biological means. Limb salvage in this situation required a complex joint preserving removal of tumour and subsequent reconstruction involving large bone grafts. Large bone allografts from donors as such are in acute shortage in India, while importing would have exponentially increased the cost of procedure.

Faced with challenge of complete removal of visible cancer in the body and subsequent reconstruction, Dr Srinivas Chirukuri and Dr Srimanth B S-team of Musculoskeletal Oncosurgeons at Manipal Comprehensive Cancer Centre proposed a rare surgery called Extracorporeal radiation and reimplantation (ECRT) for both femur bones. This is a safe technique where the tumour affected bone is removed, subjected to high dose radiation (killing cancer cells in bone) and reinserted into the defect joining with special plates and screws. The reinserted bone acts as a support until the body takes over and lays new bone. The surgery was first performed for left thigh followed by right thigh in same anaesthesia over 6 hours. The child was able to move both legs using a special protective brace in post operative period. Post operative chemotherapy was provided. Seven months have passed and she walks with both feet on the ground. This rare and complex treatment process was possible due to comprehensive cancer centre facilities, extensive planning and a high level of coordination with radiation oncology team. The family also received aid to reduce the financial burden which is encouraging.

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