Surgical Procedures: Surgery and Staging for Ewing Sarcoma

Ewing sarcoma is a rare cancer that usually affects the cells of the bones and/or soft tissues. It most often affects children and young adults. The body area affected by Ewing sarcoma of the bone can include the bones of the legs, arms, feet, hands, chest, pelvis, spine, or skull. When Ewing sarcoma affects the soft tissues, it commonly affects the trunk, arms, legs, head and neck, abdominal cavity, and some other parts of the body.

What is staging and how is it performed?

Staging is done to find out how far the cancer has spread in your body. Your provider will have you get a few tests to figure out the stage of your cancer. These tests may be:

Physical Exam: This is a general exam to look at your body and to talk about past health issues.

Blood Testing: You may have labs drawn to check a complete blood count (CBC) and blood chemistry studies to check for certain substances found in the blood when a person has Ewing sarcoma.

Imaging: Radiology tests can look inside your body to look at the cancer and determine if it has spread. These tests can include: 

• CAT scan (CT scan)
• Positron emission tomography scan (PET scan) 
• Magnetic resonance imaging (MRI) 

Procedures: These may include: 

• Bone marrow aspiration and biopsy.

• Biopsy: A biopsy takes cells from the cancer, or a piece of the cancer, to see what type of cancer it is and how it behaves. A doctor called a pathologist looks at the sample in a laboratory. 

Ewing sarcoma spreads to other parts of the body through the tissue, lymph, and blood systems. Cancer stage determines how extensive the cancer is, how far it has spread and what treatment course will be recommended. Ewing sarcoma stages are described as localized or metastatic.

Surgical Procedures Used for the Treatment of Ewing Sarcoma

Surgery is often used to treat Ewing sarcoma. The procedure used will depend on many factors, including the size and location of the cancer. Your surgeon will talk to you about your specific procedure. 

The procedure used depends on the size of the tumor, location, your age, and potential functional changes that would occur from the surgery. Types of surgery include:

• Amputation: Removal of a limb.
• Limb Salvage Therapy for Localized Ewing Sarcoma: The cancer and some surrounding healthy tissue is removed using an incision (cut).
• Surgery for Metastatic or Recurrent Ewing Sarcoma: If Ewing sarcoma metastasizes or recurs, it often travels to the lungs. This condition may require removal of the affected areas of the lungs.
• Reconstructive Surgery: Skin grafts and prosthetic implants may be needed after surgery.
• Rotationplasty: This is a procedure used in patients with cancer in their femur or tibia that leads to amputation. It is the rotation of the leg 180 degrees and reattachment to the thigh to have the ankle become a functioning knee joint.

At times, an internal prosthesis or bone graft may be needed. In cases of disease in the chest, a thoracotomy (removal of lung tumors) may be needed if the sarcoma has spread to the lungs. Some ribs may need to be removed and replaced with prosthetic material. If the tumor is in the pelvis, the pelvis may need to be rebuilt. Your healthcare team will talk to you about the specifics of your surgery.

What are the risks associated with Ewing sarcoma surgery?

As with any surgery, there are risks and possible side effects. These can be:

• Reaction to anesthesia (Anesthesia is the medication you are given to help you sleep through the surgery, not remember it and manage pain. Reactions can include wheezing, rash, swelling, and low blood pressure.)
• Bleeding.
• Infection.
• Blood clots.
• Wound healing issues/skin breakdown.
• Loose or broken bone grafts/prostheses.
• Need for more surgeries, especially in growing children for prosthesis replacement.

What is recovery like?

Your healthcare team will discuss your post-operative plan of care with you and any medications you may be taking such as those for blood clot, constipation and infection prevention, pain management, nausea management, and any others.

They will also talk to you about your activity restrictions, physical therapy plan, and other important information before being discharged from the hospital. The extent of your recovery will depend on the type and extent of surgery you have had. Rehabilitation is a key part of your treatment plan.

How can I care for myself?

You may need a family member or friend to help you with your daily tasks until you are feeling better. It may take some time before your team tells you that it is ok to go back to your normal activity.

Be sure to take your prescribed medications as directed to prevent pain, infection, and/or constipation. Call your team with any new or worsening symptoms.

There are ways to manage constipation after your surgery. You can change your diet, drink more fluids, and take over-the-counter medications. Talk with your care team before taking any medications for constipation. 

Taking deep breaths and resting can help manage pain, keep your lungs healthy after anesthesia, and promote good drainage of lymphatic fluid. Try to do deep breathing and relaxation exercises a few times a day in the first week, or when you notice you are extra tense.

• Example of a relaxation exercise: While sitting, close your eyes and take 5-10 slow deep breaths. Relax your muscles. Slowly roll your head and shoulders.

This article contains general information. Please be sure to talk to your care team about your specific plan and recovery.