“For patients diagnosed with osteosarcoma of the femur (a tumor of bone origin) and a pelvis damaged by Ewing’s sarcoma (a soft tissue tumor), we performed extremely large-scale operations, during which the patients’ own bones irradiated with a high dose of ionizing radiation were used,” says the Vilnius University Hospital Orthopedic traumatologist Rimantas Zagorskis, doctor of the Children’s Surgery, Orthopedics and Traumatology Center of Santara Clinics. – These are life-saving operations, with which we sought to cure the disease and had the goal of making the limb functional and avoiding its amputation.
The pain prompted me to seek medical attention
Patients applied to the Children’s Admission-Emergency Department of Santara Clinics because of pain: “Pain is a symptom of bone tumors. Patients complained of excruciating pain, swelling of the limb, especially at night. The above symptoms occurred without any previous trauma or contusion. The tests performed showed changes in the bone.
In both cases, the patients were immediately admitted to the hospital and thoroughly examined within a few days: radiological tests were performed (in search of possible metastases – computer tomography, magnetic resonance), blood tests. A biopsy was also performed – a piece of bone was examined at the State Pathology Center and the composition of the tumor was determined,” R. Zagorskis, an orthopedic traumatologist, comments on the wide range of tests performed.
Treatment scheme
The treatment of such patients consists of several stages: first, patients fall into the hands of oncohematologists. Depending on the composition of the tumor, treatment protocols include chemotherapy, which can take up to 10 weeks. During this time, a surgical operation is planned – together with doctors of other specialties, a detailed operation plan is drawn up.
“The surgical part of the treatment consists of several stages, which are combined with other types of treatment: removal of the primary tumor, followed by chemotherapy again to destroy any remaining cancer cells. If metastases in other organs are detected, they are operated on or a decision is made as to how they can be destroyed. If they are not there, the patient is recovering after the surgical operation and his medical condition continues to be monitored by doctors,” explains the orthopedic doctor.
Surgical operation: what makes it unique?
After the tumor has grown into the bone, the level of damage is determined during the operation, and the damaged part of the bone is removed together with the tumor. It can be replaced with a prosthesis, donor bone can be implanted, another way is limb amputation.
“Our goal is to preserve the function of the limb and aim to avoid the need for other operations (the prosthesis will need to be replaced later). Therefore, biological reconstruction was undertaken – using the patient’s own natural biological materials, explains orthopedic traumatologist R. Zagorskis.
During the first surgical operation, 19 cm of the femur had to be removed, because there was no way to remove the tumor otherwise: “I will explain the technique of the surgical operation. The bone is removed, the soft tissue, the tumor, everything inside that bone is removed on the operating table, leaving a completely “bare” bone. In order to eliminate everything that is alive in that bone (devitalization), we took one of the methods – irradiation (other possible methods are soaking the bone in saline solution, using high / low temperature, etc.).
Irradiation is the fastest method that is 100 percent guaranteed to kill any life in the bone. In both cases, the bone is irradiated with an extremely high dose of ionizing radiation. Only the bone structure remains, the bone corresponding to the child’s physiology. During surgery, this dead bone is attached to healthy bone structures with a plate. The child’s body tends to adapt and adapt – the ossification of the connected structures takes place”, the doctor explains the methodology of the surgical operation.
The second patient underwent surgery for a tumor-damaged bone in the pelvis. In this case, the soft tissue tumor – Ewing’s sarcoma – was very large, with a tumor volume of about 1.5 liters. After chemotherapy, its volume decreased to about 300-400 ml.
“In order to be able to determine the limits of the cuts, how much and where we can cut, magnetic resonance was performed. After removing the tumor and a large part of the pelvis, we couldn’t just leave it like that because the child wouldn’t be able to walk, so the removed part had to be filled with something. In world practice, there are various applied methodologies – for example, after such operations, adapting the child’s own fibula, but this method is not very reliable. So we chose the same methodology as in the first case.
We operated on the tumor together with part of the pelvis, cleaned the bone affected by the tumor, took it to the National Cancer Institute for irradiation, and the dead bone was implanted in the same place, reinforced with plates, explains orthopedic traumatologist R. Zagorskis. – We always talk a lot with patients and their parents and explain what kind of treatment it is, what complications are possible, that surgical operations may be needed later.”
Treatment: multidisciplinary team work
These two cases are different, only the same method is applied: “Different places of bone damage, different tumors, different operations. Common to both cases is the “cleansing” of bone structures from tumor cells using a high level of ionizing radiation, says the orthopedic traumatologist. “Another common essential feature is the work of a large team of different doctors.”
Multidisciplinary collaboration begins already with the preparation of the treatment plan: “Oncohematologists are an especially important part of the team, because the treatment plan begins with the treatment they prescribe. The surgical operation is planned with radiologists – the limits of the possible resection (incisions) are measured in the radiological images.
The course and duration of the operation are discussed with the anesthetists, as these operations are long – they can last 7-12 hours, the possibility of bleeding and other complications are discussed, as patients have weak immunity after chemotherapy treatment, therefore careful preparation is made for such a patient’s health condition, – the joint work of colleagues named by the doctor. – Huge contribution of operating room nurses. In the first case, plastic surgeons had to be called in later for help – after a femur operation, a fibula had to be implanted into the dead bone structure to strengthen the bone. That’s not all – consultation with angiosurgeons is also necessary.
The continuous efforts of the medical staff of the Department of Pediatric Orthopedics and Traumatology at the Children’s Surgery, Orthopedics and Traumatology Center, who care for and treat patients after surgery, treatment and care. This treatment also requires inter-institutional cooperation – the bone is irradiated at the National Cancer Institute (NCI): the operated bone is taken by ambulance to the NCI, the irradiation procedure is performed and the bone is brought back to the operating room.
The aim is to shorten the time, because the child lies in the operating room while waiting for the bone to be restored. After surgery, patients are given chemotherapy again to kill potentially “escaped” cancer cells. After chemotherapy, metastases are treated, if there are no metastases, the patient’s state of health is monitored,” orthopedic traumatologist R. Zagorskis mentions a long list of work done by his colleagues.
Patient history: The first news was the hardest to bear
Vilnius resident Ernestas Velička, walking with his son along the path of his illness, says that the first news – hearing the diagnosis – was the most depressing: “At that time, it seemed that we would not be able to endure the panic and such horror. The feeling of guilt that we did not notice the signs of my son’s illness earlier, so that then there might have been more opportunities to treat the child, was overwhelming.”
Before coming to terms with the shocking mood, the parents had to prepare for the child’s treatment, which consisted of several complicated and difficult stages – chemotherapy, surgery, chemotherapy again, and another surgery: “All stages were extremely difficult. The complete unknown was tiring – what kind of treatment, what is waiting, you don’t know anything and you don’t know anything. The treatment began – the hardest part was seeing how the child suffered from the side effects of chemotherapy, then the surgery – we waited with horror to know if it would be possible to save the leg. The doctors also explained the possible outcome of the operation. And then you feel like you can’t hear anything anymore and you can’t understand the further explanations of the doctors.”
Ernestas Velička says that the treatment routine turns into its own vortex and some internal forces start to help him concentrate, he starts to communicate more with other treated children and their parents. The world of patients and their relatives is completely different, you live closed in the hospital with your child, you communicate with other parents and share their pain and experiences.
According to E. Velička, it was much more difficult to communicate with loved ones, it was easier to stay away from the outside world. When asked when it all started and what stage of treatment took place, E. Velička lists all the dates to the exact day – the difficult moments that changed his life are stuck deep in his memory: “Since December 2022, we have been living a different life. And when I now see Emil walking, albeit with crutches, but already kicking a ball, riding a bicycle, swimming in a kayak – I am glad that the difficult experiences have already passed,” says the father, who was by his son’s side during the complex treatment. When asked what was the most difficult thing for Emil, he replied: “The biggest test was not being able to walk. Now I’m happy that I can do it myself and I don’t need a wheelchair anymore!”
Quality of life: treating the disease requires everyone’s attitude and focus
The news about the disease is shocking. According to the doctor, one always tries to have a three-way conversation – with the participation of the doctor, the parents and the child: “The question of whether to tell the child always arises. Since the treatment is long and difficult, we always strive to keep the child informed. It is very difficult for parents because they have to prepare the child for such a message.
Parents must be psychologically very strong, – doctor R. Zagorskis names the psychological aspects. – The relationship between the doctor and the patient and his parents is especially important to us, because communication takes a long time. The conversations are medical, a lot of complex information needs to be discussed – possible complications, we provide an adequate realistic forecast regarding the postoperative period, activities after treatment, sports, etc. During the entire treatment, the children try hard and listen to the doctors’ advice.
We are happy that usually after a long treatment they gradually return to normal life. After the femur operation, the patient has already been kayaking and riding a bicycle with his parents.”
2024-08-22 18:50:14