Francesca Arnaudo is a girl who defies odds. At age 6 she was diagnosed with osteosarcoma, a bone cancer that afflicts only three in every million children ages 14 and under. At age 8, she was diagnosed with acute myeloid leukemia, a white- blood cell malignancy that occurs as a side effect of treatment in just one in every 100 children who have undergone chemotherapy.

Now, at age 9, the tenacious brown-eyed girl is free of both cancers. And she has kept her right arm, where the bone cancer first arose.

"She's our miracle girl," said Yvonne Roach, a pediatric oncology nurse who has cared for Francesca from the start.

Seeing Francesca through two aggressive malignancies required the skills and expertise of an orthopedic oncologist, three orthopedic surgeons, two surgical oncologists, four pediatric oncologists, a radiation oncologist, a cadre of highly trained nurses, a stem-cell transplant team, radiation therapists and clinical trial coordinators.

It demanded more than 20 hospital stays and more than 100 trips to the medical center for infusions, lab tests, X-rays and doctor visits. Each appointment required a 152-mile round-trip drive from the Arnaudos' home in Ripon, south of Stockton, to Sacramento. Mary Arnaudo, Francesca's mother, quit her job as an English teacher. John Arnaudo, Francesca's father, made perhaps 100 separate trips up Highway 99 to be with his daughter and wife after work and on weekends. Francesca's older brother, Dino, saw his life turned upside down as well.

"Childhood cancer doesn't just affect the child," said Theodore Zwerdling, acting chief of pediatric hematology and oncology and the doctor who has coordinated Francesca's care. "It affects the whole family."

"To ease the stress on Francesca's parents, a social worker was available to help negotiate health insurance requirements, solve schoolrelated problems and find lodging for the family near the hospital during Francesca's hospital stays. Child life specialists, including an art therapist, a music therapist and academic tutors, buoyed Francesca's spirits and helped her keep up with schoolwork.

Survival rates for pediatric cancers have increased dramatically in recent decades. But few people without a personal experience of childhood cancer appreciate how hard-fought the successes often are.

Team assembles

A routine T-ball mishap triggered Francesca's bone cancer diagnosis. The 6-year-old fell during a practice in May 2003, landing on her right arm. The next morning the arm was swollen and hurt to move.

Worried about a possible sprain or fracture, Mary Arnaudo took the athletic first-grader to the local hospital. An X-ray revealed a large tumor on the little girl's right humerus, the long bone extending from shoulder to elbow. By the end of that day, Francesca had been referred to UC Davis Cancer Center.

UC Davis Cancer Center. At the Cancer Center, a team of subspecialists assembled to develop a treatment plan. Francesca would receive chemotherapy every third week for a year. Each treatment would require a three- to six-day stay at UC Davis Children's Hospital.

Francesca's team would also try to save her arm, a feat that her doctors in Ripon and Stockton predicted would not be feasible.

The ambitious surgery took place in October 2003, after five months of chemotherapy to shrink the bone tumor. In a fivehour operation at UC Davis Medical Center, an orthopedic surgeon and two surgical oncologists took out most of Francesca's right humerus, leaving the elbow joint and the bones in her lower arm intact.

Into the end of the remaining humerus, they cemented the stem of a titanium prosthesis. The opposite, rounded end of the metal bone fit into the little girl's shoulder joint. The nerves, tendons and ligaments running from her upper arm to her lower arm and hand were moved back into place.

The metal prosthesis served Francesca well for nearly a year. She kept her arm, had full use of her hand and good range of motion in her arm. But chemotherapy impaired her bone healing, and by the fall of 2004, the metal implant had started to come loose. Rakesh Donthineni, a UC Davis orthopaedic oncologist, was called in to help plan a salvage operation.

Second surgery, cancer

Donthineni is one of only about 200 orthopaedic oncologists — orthopaedic surgeons who specialize in cancer treatment — in the United States. After consulting with half a dozen of his colleagues around the country, Donthineni planned the salvage procedure. He would replace the failed prosthesis with a new one, but this time fix the metal implant in place with cadaver bone rather than cement.

During a three-hour operation in early November 2004, Donthineni and Robert Szabo, a professor of orthopaedic surgery, carefully fashioned a cadaver bone "cap" that tightly covered the stem of the new prosthesis and fit snugly inside Francesca's remaining humerus. Slowly, Francesca's own bone would fuse with the cadaver bone, fixing the prosthesis in place more securely than the cement usually used in such operations.

The Arnaudos had two weeks to celebrate the successful surgery before the next blow. In December, they learned their daughter had a second cancer.

Stem-cell transplant

With Francesca's diagnosis of acute myeloid leukemia, Doug Taylor, director of the UC Davis pediatric stem-cell transplant program, and Janice Ryu, associate professor of radiation oncology, joined the girl's growing treatment team. Along with the rest of the team, they would see Francesca through a stem-cell transplant.

First Francesca would undergo high-dose chemotherapy and total body irradiation to destroy her diseased bloodproducing cells. Then she would receive a transfusion of donor stem cells that would grow into cells capable of making healthy blood.

No one in Francesca's family was a suitable match to donate marrow stem cells. But a match was quickly found through a national cord bank search of donated umbilical cord tissue.

Francesca's stem-cell transplant required a 41-day stay in the pediatric bone marrow transplant unit at UC Davis Children's Hospital. The Arnaudos rented an apartment across the street from the medical center, so that Mary or John could be at Francesca's bedside throughout the grueling procedure.

Every relevant detail of Francesca's transplant was entered into a national database, as part of a clinical trial. The knowledge gained from such trials, rather than the development of any particular drug, is largely responsible for the increased survival rates for pediatric cancers.

"Everything we learned from treating Francesca will be used to help other kids," Taylor said.

In late April 2005, Francesca returned home. Like most survivors of childhood cancer, Francesca has a long road ahead. Immune-suppressed due to the transplant and the anti-rejection drugs she must take, she has to avoid crowds and will be homeschooled this year. Side effects of the treatments that saved her life may become evident later on, from learning disabilities to infertility.

Whatever challenges Francesca's future holds, her care team will be with her every step of the way. By tracking Francesca and other pediatric cancer patients throughout their lives, UC Davis physician-scientists are gathering crucial data about long-term side effects and learning information that will lead to better treatments.

Today Francesca's leukemia is in remission. There is no sign of the original bone cancer. And her arm is healing nicely.

Francesca is putting that arm to use. "She draws, draws, draws," said her mother, Mary Arnaudo. "Throughout everything, her therapy has been drawing. It's what's kept her going."

Zwerdling, Taylor and Donthineni are all proud owners of Francesca originals. Some bear simple inscriptions, as well as the artist's signature.

In one drawing dedicated to Zwerdling, Francesca wrote this: "Dr. Zwerdling, Thank you for being my doctor. I hope you find a cure for me and other kids. Love, Francesca."