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(HealthNewsDigest.com) – When little Mark Blinder was diagnosed with a rare bone cancer, doctors at Lucile Packard Children’s Hospital gave his parents three agonizing options: amputate the affected arm at the shoulder, irradiate the tumor and risk a second malignancy, or try a limb-preserving surgery that had never been attempted in a toddler.
Nearly a year later, Mark, now 4, is thriving with a surgically implanted artificial humerus inside his cancer-free right arm. He’s believed to be the first small child ever to receive a high-tech, telescoping prosthesis to replace the entire upper arm bone.
“There’s no pre-existing prosthesis for a child this small,” said Packard Children’s orthopedic surgeon Lawrence Rinsky, MD, who implanted the one-of-a-kind artificial bone he also helped design. Rinsky is also professor of orthopedic surgery at the School of Medicine.
“Little children with humerus tumors have very few limb-sparing options,” added Neyssa Marina, MD, the pediatric oncologist who oversaw Mark’s chemotherapy before and after surgery. Marina is a professor of pediatrics in hematology/oncology at Stanford.
Mark’s custom-made prosthetic bone differs in several ways from those used in adults and older children. It had to be small enough to fit in a 3-year-old’s arm, strong enough to last a lifetime, and expandable, to allow for growth. Balancing these demands presented a significant engineering challenge, especially because of the need for moving parts that would allow Rinsky to expand the prosthesis in later surgeries. On top of that, because Mark’s entire humerus had to be removed, the prosthesis could attach only to soft tissue. Most bone prosthetics replace half of a bone and are cemented to healthy bone; Rinsky had to find another way to hook up this implant. Even when the design was finalized with Warsaw, Ind., prosthetic manufacturer Biomet Inc., Rinsky wasn’t sure the prosthesis would fit inside Mark’s arm.
Mark’s parents, Alla Ostrovskaya and Gene Blinder, felt trepidation, too. They first realized something was wrong when, in April 2008, Mark complained of severe pain in his right arm, hand and wrist. After his July 2008 diagnosis with a rare bone tumor called Ewing’s sarcoma, Mark began chemotherapy. The medications helped: The pain subsided, and Mark began using his arm normally. But chemotherapy alone wouldn’t vanquish the tumor. Blinder and Ostrovskaya had to decide what to do next.
“It was hard because if we had chosen just radiation, no surgery, that would not have been as physically painful for him,” Ostrovskaya said. Still, surgery seemed the best choice for Mark’s long-term well-being, a decision that was informed not just by their feelings as Mark’s parents, but also by the fact that Ostrovskaya is a medical student. Even so, the night before Mark’s operation, Ostrovskaya couldn’t sleep.
Early on Dec. 4, 2008, Mark was wheeled into the operating room. Rinsky and his team, encased in space-suitlike outfits to reduce infection risk, worked with utmost care. “The surgery involved taking out the entire bone without touching it,” Rinsky said. The bone had cancer cells on its surface, which could easily have spread to surrounding healthy tissue. “It was like carving out a peach pit without ever touching the pit, staying in the pulp.” He removed the bone along with a thin, protective layer of soft tissue and muscle.
Once the cancerous bone was out, Rinsky implanted the artificial bone. The prosthesis had a piece of Dacron fabric at the top, which he sewed to soft tissue in Mark’s shoulder. At the elbow, Rinsky saved Mark’s ligaments and placed those around the prosthesis as best he could. Then he started sewing up Mark’s arm. Luckily, the incision closed. “Dr. Rinsky came out of the operating room and said, ‘The prosthesis fit perfectly fine, he is doing great,'” remembered Blinder.
Soon, there was more good news: Mark’s tumor was confined to the bone that had been removed, and its malignant cells were dead, killed by chemotherapy. He spent a month healing from surgery, then received more chemotherapy to reduce the chance the cancer would return.
Mark willl have three to four minor surgeries over the next several years, in which Rinsky will make a small incision at the shoulder and use a few turns of a screwdriver to lengthen the implant.
After obtaining more follow-up data, Rinsky’s team plans to write up the case for inclusion in the scientific literature.
In the meantime, Mark’s parents could see that he was truly feeling better—he began getting into mischief again. In June, just before his final round of chemotherapy, he was playing “strongman” and accidentally dropped a 2-pound dumbbell on his head. “It was pure 4-year-old,” said Rinsky with a grin. (A CT scan showed no harm had been done by the bump.) “He is a very spunky kid,” said Marina.
At home in Palo Alto, Mark is gradually re-learning to use his right hand and arm. He had switched from being right-handed to left-handed after the surgery, but is now gradually shifting some tasks back to his right hand. He’s moving his right wrist and fingers, can pick up small objects, and is receiving physiotherapy to rebuild strength and flexibility in his elbow and shoulder joints. Although Mark won’t ever regain full function in those joints, he’s using the arm more each day, Ostrovskaya said. He tells his parents, “I have a special arm.”
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