indiacancer.org - Bone Cancers

Bone Cancers

		What are Bone Cancers?
		How does osteosarcoma present?
		How is osteosarcoma detected?
		What are staging and grading?
		How is osteosarcoma treated?
		What are the side effects of treatment for osteosarcoma?
		What is the importance of follow up?

What are Bone Cancers?

Bone Cancers are those cancers in which the malignant cells originate from the bones. Commonly seen in children, especially in the long bones in the lower limbs, but this is not a rigid rule.

The common types of bone cancer are osteosarcoma, which is usually seen affecting the bones in children around the knee, and the Ewing's groupof tumours, which are another type of bone cancer, but the cells are totally different from the osteosarcoma cancer cells. Ewing's sarcoma has been covered in another place on this site.

	How does osteosarcoma present?

	The usual symptoms are the following:
		Pain and swelling of a bone or a bony region.
		Sometimes the tumour may fungate through the skin that is, come out of the skin, to be exposed as an ulcerating mass outside the body.
		There may be bleeds inside the tumour causing severe pain.

	How is osteosarcoma detected?

Once the patient starts developing these symptoms, the doctor will probably order x-rays of the knee or the joint involved or the bone involved and special blood tests.

The doctor may also perform a bone biopsy using something called a Jamshidi needle or a J-needle, and a small piece of the bone is taken out to be studied under the microscope.

	What are staging and grading?

	These are terms with which you must become familiar, if you are dealing with any form of cancer. When we stage a cancer, we try to establish carefully degree of spread of the cancer and if indeed there is spread, to what extent and involving which organs. The grading of a cancer is a microscopic issue, in which the pathologist lets you know how aggressive this particular type of cancer is; well differentiated means less aggressive, moderately differentiated intermediately aggressive and poorly differentiated more aggressive. Both grading and staging help your clinician to establish the prognosis or how serious your disease is and what is going to be the likely outcome. Staging may require additional imaging tests such as CT Scan, MRI, Sonography of the abdomen, IVU, Bone scan or chest X-ray. A working staging for general purposes is the following:
		Localised osteosarcoma, where the cancer has not spread beyond the bone or nearby tissues in which the cancer originated.
		Metastatic osteosarcoma, where the disease has spread beyond the bone and has gone to distant parts of the body. Usually, the organs involved are the lungs, although other bones may also get involved.
		Recurrent osteosarcoma. This is a disease which has come back after the primary therapy for the bone cancer is over. It may recur in the bone itself or in other parts of the body.

	How is osteosarcoma treated?

	A lot depends on the patient's constitution, the grade of his disease and its staging. Patients are usually treated by a team of specialists which utilizes a multipronged approach. This includes an an oncosurgeon and a chemotherapist. The plan of treatment is tailored to fit a patient's requirements. If necessary, radiotherapy may become an add on. Treatment strategies. The bastions for treatment of osteosarcoma are surgery, chemotherapy and radiotherapy. The commonest treatment still being used for osteosarcoma is surgery. In this, previously the arm or the leg had to be sacrificed in order to ensure that this aggressive type of cancer was totally taken out. Along with this, sometimes the neighboring lymph nodes to which the cancer may have drained were also taken out in a procedure called lymph node dissection (Lymph nodes are small bean-shaped structures, which act as stations for drainage of lymph, a clear watery fluid, which courses through out the body in transparent, thin tubes called lymph channels or lymphatics from various organs). But in recent times, limb sparing procedures have become more and more common as state- of - the- art surgery is promoting restricted removal of the lesion by sparing the limb and its nerve supply and blood supply. This is especially made possible with the help of excellent modern chemotherapy, which can be given in a neoadjuvant manner ( neoadjuvant means given before surgery). Following an amputation, artificial devices or bones from other places in the body can be used to replace bone that was removed. Besides local therapy, the best attempt to control cancer cells circulating in the body and lodged at places other than the bone is by using systemic therapy (therapy which affects the entire systems of the body) which is in the form of injections or oral drugs. This form of treatment is called chemotherapy. This form of treatment is given in a cyclical manner (each set of drugs is repeated usually after every 3-4 weeks. Chemotherapy can also be used in combination with surgery, radiotherapy or both, either before or after. Chemotherapy can also be given in a regional manner in which the limb's blood supply is isolated using a tourniquet and chemotherapy is directly injected in the region of the tumour. The alternative local therapy to surgery is radiation therapy. This involves the use of high energy, penetrative rays to destroy cancer cells. It affects cancer cells only in the zone treated. Radiation therapy is also employed for palliation i.e. control of symptoms alone in an advanced cancer. Radiation therapy can also be used in adjunct to surgery or chemotherapy, either before or after. Teletherapy or external radiation is given via a machine remote from the body while brachytherapy or internal radiation is given by implanting a radioactive source within the involved tissues. Patients may or may not require both modalities of radiation. Radiotherapy, after initial planning, usually takes just 5 to 10 minutes per day, 5 days a week for about 6 weeks. This time period is flexible depending upon the modality of radiation used. For localised osteosarcomas, one of the following treatment options may be entertained:
		Chemotherapy followed by surgery, followed by adjuvant chemotherapy.
		Amputation of the limb.
	For metastatic osteosarcoma, one of the following options may be entertained:
		Chemotherapy followed by surgery, followed by adjuvant chemotherapy.
		Surgery followed by adjuvant chemotherapy.
	This may include surgery to remove the lungs or remove the metastasis which has occurred to the lung. This surgery is called a metastatectomy. For recurrent osteosarcomas, one of the following treatment options may be entertained:
		Depending on whatever treatment has been given before, an alternative must be found.
		If the cancer has come back only in the lungs, then the surgery may be to remove the cancer in the lungs.
		Metastatectomy with or without chemotherapy.
		If cancer has come back in places other than the lungs the treatment would be combination chemotherapy.

	What are the side effects of treatment for osteosarcoma?

	Unfortunately treatment for cancer does cause damage to the healthy tissues. Please ask the clinician about any possible side effects before any form of treatment commences. Amputated patients have a mountain to climb. Besides all the medical challenges they have to face, they have social problems, economic problems, and definite mental and psychological problems. Some patients find this emotional burden too heavy a load to carry. These emotional problems dominate over the physical and practical aspects of their disease. Tragically, many clinicians and family members never really have time to pay attention to what the patient is going through mentally. It is very important that the entire health care system including the surgical oncologist, the patient's general physician, the nursing staff, the family members, all get together to form an emotional support team and help improve the quality of the lives of such hapless patients by making them feel less alone. There are cancer support groups in certain parts of the country, but the distribution is not very uniform. So the onus really falls back on the group mentioned before. The effects of radiation depend upon the dose of radiation, the size of the area radiated, and the number and size of each fraction. The commonest side effect is extreme fatigue. Although bed rest is good, most radiotherapists advise the patient to be as mobile as possible. Another common problem is that of radiation dermatitis in which the skin covering the radiated area becomes red, dry, itchy, and may show signs of scaling off. This will slowly settle down after radiation ceases, but there may be a permanent 'bronzing' of the skin. It is important to note here that this skin problem is associated only with teletherapy or external radiation therapy. Radiation also may cause nausea and vomiting, diarrhea, urinary discomfort. There may also be a fall in the white blood cells, which are needed by humans to fight infection. Usually the radiotherapist can suggest the drugs and diet necessary to alleviate such problems. The various drugs in chemotherapy cause a varied spectrum of side effects. The severity and variability of these symptoms are very individualistic, changing from patient to patient. Some of the common side effects are:
		Skin rashes.
		Loss of hair.
		Diarrhea.
		Vomiting.
		Tingling and numbness in the fingers and toes.
		Hearing loss.
	Most are temporary and recede after therapy is over. Hair growth gradually starts after cessation of chemotherapy. The medical oncologist will usually be able to reduce the severity and spectrum of these side effects. The psychology of the patient is very important during therapy. Better psychologically prepared the patient is, better are his chances of having decreased side effects. The patient should drink large quantities of water while the therapy is in progress, and preferably avoid uncooked or raw food. Water should be filtered or boiled. Any relative or person who has any sort of infection such as common cold should be asked to desist from coming close to the patient.

	What is the importance of follow up?

The importance of followup cannot be overemphasized. It is a fatal fallacy to assume on the patient's part that once the primary or the first phase of treatment is over, then he or she is cured. It must be stressed here that cancer has a notorious proclivity of coming back again and again. The only way to fight this is to pick up any problem when it is still early, so that it can be nipped in the bud. And the only way to do this is to follow up when the doctor calls you for the next visit. Each such visit will include a detailed history, a physical examination (including an internal i.e. a rectal or vaginal examination), a chest x-ray, an ultrasonography or a CT scan, and various other blood studies as indicated.