Bone Cancer

What is Bone Cancer?

Bone is the framework that supports the body. Most bones are hollow. Bone marrow is the soft tissue inside hollow bones. The bone itself is very hard and strong. At each end of the bone is a softer bone-like tissue called cartilage that acts as a cushion between bones. The outside of the bone is covered with a layer of fibrous tissue.

The bone itself is made up of 2 kinds of cells. Osteoblasts are cells that form the bone. Osteoclasts are cells that dissolve bone. Although we think that bone does not change, the truth is that it is very active. New bone is always forming and old bone dissolving.

The marrow of some bones is made up only of fatty tissue. In other bones the marrow is a mixture of fat cells and blood-forming cells. These blood-forming cells make red blood cells, white blood cells, and platelets.

Cells from any of these parts of the bone can develop into cancer.

Types of bone cancers

Most of the time when someone is told they have cancer in their bones, the doctor is talking about a cancer that started somewhere else and then spread to the bone. This is called metastatic cancer. This can happen to people with advanced breast cancer, prostate cancer, lung cancer, and many other cancers, too. Under a microscope, theses cancer cells in the bone look like the cancer cells that they came from. If someone has lung cancer that has spread to the bone, the cells there will look and act like lung cancer cells and they will be treated the same way.

To learn more about metastatic bone cancer, please see the American Cancer Society document Bone Metastasis, as well as the document on the specific place where the cancer started (Breast Cancer, Lung Cancer, Prostate Cancer, etc.).

Other kinds of cancers that are sometimes called "bone cancers" start in the bone marrow—in the blood-forming cells--not the bone itself. The most common of these is multiple myeloma. Certain lymphomas (which more often start in lymph nodes) and all leukemias start in bone marrow. Call us for more information about any of these types of cancer.

The main types of bone cancers that really start in the bone are called sarcomas. A sarcoma is a cancer that starts bone, muscle, tendons, ligaments, fat tissue, or some other tissues in the body.

Primary bone tumors

There are different types of bone tumors. Their names are based on the bone or tissue that is involved and the kind of cells that make up the tumor. Some are cancer (malignant). Others are not cancer (benign). Most bone cancers are called sarcomas.

Benign bone tumors do not spread to other tissues and organs. They can usually be cured by surgery. The information here does not cover benign bone tumors.

Bone tumors that are cancer

Osteosarcoma: Osteosarcoma, also called osteogenic sarcoma, is the most common cancer that starts in the bone itself. It most often occurs in young people between the ages of 10 and 30. But about 10% of cases are people in their 60s and 70s. This cancer is rare during middle age. More males than females get this cancer. These tumors start most often in bones of the arms, legs, or pelvis. For more information see the ACS document Osteosarcoma.

Chondrosarcoma: This is cancer of the cartilage cells. It is the second most common true bone cancer. Chondrosarcoma is rare in people younger than 20. After age 20, the risk of this cancer keeps on rising until about age 75. It occurs in men and women at about the same rate.

Cartilage is softer than bone but more firm than most other tissues. Ears are mainly cartilage. Cartilage is actually the tissue from which most bones form. It is mainly found at the end of long bones and at the place in the chest where the ribs meet the breastbone. Chondrosarcoma most often starts in cartilage of the pelvis, leg, or arm, but it can start in many other places, too.

Chondrosarcomas are given a grade, which measures how fast they grow. The lower the grade, the slower the cancer grows. When a cancer is slow growing, the chance that it will spread is lower and the outlook is better. There are also other differences among chondrosarcomas that can be seen under a microscope which help to predict the response to treatment and outlook for survival.

Ewing tumor: This cancer is also called Ewing sarcoma. It is named after Dr. James Ewing, the doctor who first described it in 1921. It is the third most common bone cancer. Most Ewing tumors start in bones, but they can start in other tissues and organs. This cancer is most common in children and teenagers. It is rare in adults over age 30. For more information see the ACS document Ewing Family of Tumors.

Fibrosarcoma and malignant fibrous histiocytoma: These cancers usually start in the soft tissues around bones (such as ligaments, tendons, fat, and muscle) rather than the bone itself. They usually occur in older and middle-aged adults. These cancers most often affect bones of the legs, arms, or jaw.

Giant cell tumor of bone: This type of bone tumor has both benign and malignant forms. The benign (not cancer) form is most common. These don't often spread to distant sites, but they tend to come back where they started after surgery. When they come back after surgery they are more likely to spread to other parts of the body. These tumors often affect the arm or leg bones of young and middle-aged adults.

Chordoma: This tumor usually occurs in the base of the skull and bones of the spine. It is found most often in adults older than 30 years. It is about twice as common in men than in women. Chordomas tend to grow slowly and usually do not spread to other parts of the body. But they often come back in the same place if they are not removed completely. When they do spread, the lymph nodes, lungs, and liver are the most common places.

Other types: Two other types of cancer can start in bone but they are covered in separate documents. Please see the ACS documents Non-Hodgkin Lymphoma and Multiple Myeloma to learn more about these cancers.

How Is Bone Cancer Found?

For some types of cancer there are tests that can find the cancer early, before it causes any symptoms. But right now, there are no special tests to find bone cancer early. The best thing to do is report any symptoms to a doctor right away.

Signs and symptoms of bone cancer

Pain: Pain in a bone is the most common symptom of bone cancer. At first, the pain is not constant. It may be worse at night or when the bone is used. As the cancer grows, the pain will be there all the time.

Swelling: Swelling in the area of the pain may not happen until weeks later. Depending on the where the tumor is, you may be able to feel a lump.

Breaks (fractures): The cancer may weaken the bone it grows in, but most of the time the bone does not break.

Other symptoms: Problems such as weight loss and tiredness (fatigue) may mean that the cancer has spread. If it has spread to organs inside the body, there may be other symptoms as well. For example, if the cancer spreads to the lung, the person may have trouble breathing.

Bone pain and swelling are usually caused by other problems, like an injury or arthritis. Most people with these symptoms do not have cancer. Still, if these problems go on for a long time without a known reason, you should see your doctor.

Tests to find bone cancer

There are many things doctors can do to look for bone cancer. Symptoms, a physical exam, imaging tests, and blood tests may all suggest bone cancer. But in most cases, a biopsy is needed to make sure since other diseases can cause the same symptoms.

X-rays: Most of the time, bone cancer will show up on x-rays of the bone. The radiologist (a doctor who is trained to read x-rays) can often tell whether or not a tumor is cancer by the way it looks on the x-ray. But a biopsy is the only way to know for sure. A chest x-ray may be done to see whether the bone cancer has spread to the lungs.

CT scans (computed tomography): In this test, many x-rays of the body are taken from different angles. These images are combined by a computer to make cross-section pictures of your insides. Before the x-rays are taken, a harmless dye may be given into a vein. The dye helps better outline details. Some people have a reaction to the dye (hives, flushing, trouble breathing). Be sure to tell the doctor if you have ever had problems with contrast dye. CT scans can also be used to guide a biopsy needle into a tumor or mass.

CT scans take longer than regular x-rays. You will need to lie still on a table as the part of your body being scanned is placed within the scanner, a doughnut-shaped machine that completely surrounds the table. The test is painless, but you may find it hard to hold still for minutes at a time. This is less of a problem with modern scanners, which are much faster.

CT scans are helpful in staging cancer. They help tell if your bone cancer has spread into your lungs, liver, or other organs. These scans also show the lymph nodes and distant organs where there might be cancer.

MRI (magnetic resonance imaging): MRI scans use radio waves and strong magnets instead of x-rays to make detailed pictures of parts of the body. Sometimes a contrast dye might be used, just as with CT scans.

MRI scans are often the best test for outlining a bone tumor. They are also useful for looking at the brain and spinal cord.

MRI scans take longer than CT scans, often up to an hour. And you have to be placed inside a tube, which can upset some people. The machine makes a thumping noise but many places will give you headphones with music to block this out.

Radionuclide bone scan: A bone scan helps show whether cancer has spread to other bones. It can also show how much the cancer has damaged the bone. In this test, a radioactive material is put into a vein in your arm. (The radioactivity is very low and causes no long-term effects.) The material is attracted to diseased bone cells throughout the body. A special camera then takes a picture. The picture shows the diseased bone as dense, gray to black areas, called "hot spots." These areas may be cancer. But arthritis, infection, and other bone diseases can look much the same. The doctor may use other tests or biopsies to find out for sure what is causing the hot spots.

PET scan (positron emission tomography): PET scans use a radioactive glucose (a type of sugar), which can be seen by a special camera. The radioactive material is put into a vein in your arm. Cancer cells then take in large amounts of the sugar because they are very active. A PET scan can be more helpful than many x-rays because it scans the whole body. It can sometimes help tell whether or not a tumor is cancer. It is being combined with CT scans to better pinpoint some kinds of cancer.

Biopsy

For a biopsy a tiny piece of the tumor is removed and looked at it under a microscope. Doctors study the piece to see whether it is cancer. The biopsy can also help tell if the cancer started in the bone or started somewhere else and spread to the bone (metastasis). The surgeon doing the biopsy needs to have experience diagnosing and treating bone tumors. Mistakes at this point can lead to removing too much tissue, which can limit options for saving an arm or leg. (This is called limb-sparing surgery. It is discussed later in the section "How is bone cancer treated?")

There are 2 different types of biopsies: the needle biopsy and the surgical bone biopsy.

Needle biopsy: This can be done with a thin (fine) or a thick (core) needle. For both types, a drug is first used to numb the area for the biopsy. The fine needle biopsy removes a small amount of fluid and tissue fragments. The doctor aims the needle by feeling the area. If the tumor is deep inside the body, the needle can be guided by a CT scan. A core needle biopsy uses a bigger needle. With a core biopsy, the doctor takes out a small cylinder of tissue.

Surgical bone biopsy: For this biopsy, the doctor cuts through the skin to reach the tumor and take out a small piece of it. This is often done using drug to numb the skin and tissue around the tumor. It can also be done under general anesthesia (when drugs are used to put the patient into a deep sleep). If this type of biopsy is needed, it is important that the surgeon who will later remove the cancer be the one to do the biopsy.

How Is Bone Cancer Treated?

This information represents the views of the doctors and nurses serving on the American Cancer Society's Cancer Information Database Editorial Board. These views are based on their interpretation of studies published in medical journals, as well as their own professional experience.

The treatment information in this document is not official policy of the Society and is not intended as medical advice to replace the expertise and judgment of your cancer care team. It is intended to help you and your family make informed decisions, together with your doctor.

Your doctor may have reasons for suggesting a treatment plan different from these general treatment options. Don't hesitate to ask him or her questions about your treatment options.

There has been great progress in the treatment of bone cancer during the last 30 years. In the 1960s the only treatment available was cutting off the limb (amputation). Now, because of new methods, amputation isn't needed most of the time

Surgery

Surgery is the main treatment for most bone cancers. Surgery includes the biopsy done to find the cancer and the surgery done to remove it. It is very important that the biopsy and surgical treatment be planned together. If possible, the same surgeon should do both the biopsy and the main surgery.

The goal of surgery is to remove all of the cancer and some of the normal-looking tissue around it. This is called a wide-excision. After surgery, an expert will look at the tissue that was removed under the microscope to see if the outer edges (margins) have cancer cells. If so, it could mean that some cancer was left behind. When no cancer is seen at the edges of the tissue, the margins are said to be "negative," "clean," or "clear." A wide-excision with clean margins gives the lowest chance that the cancer will grow back where it started.

Tumors in the arms or legs

There are 2 types of surgery for tumors in the arms or legs:

• Amputation removes the cancer and all or part of an arm or leg.
• Limb-salvage (also called limb-sparing) surgery removes the cancer without amputation.

Both surgeries have the same overall survival rates. And no matter which type of surgery is done, rehabilitation will be needed afterwards. This can be the hardest part of treatment. If possible, the patient should meet with a rehab specialist before surgery, in order to understand what will be involved.

Amputation: Amputation may be the only option for some patients. If there is a large tumor that extends into the nerves and/or the blood vessels, it may not be possible to save the limb. Surgery is planned so that muscles and the skin will form a cuff around the end of the arm or leg. This cuff will fit into the end of an artificial limb (called a prosthesis). With proper physical therapy the person is often walking again 3 to 6 months after leg amputation.

Sometimes if the leg must be removed at mid-thigh, the lower leg and foot are turned and attached to the thigh bone. The ankle then serves as a knee joint. This type of surgery is called rotationplasty. Of course, the person will need an artificial limb to make the new leg as long as the other (healthy) leg..

If the bone tumor is located in the upper arm, the tumor may be removed and then the lower arm attached again. This leaves the patient with an arm that works but is much shorter.

Limb-salvage surgery: This is a very complex surgery. The goal is to remove all of the cancer and still leave the patient with a working leg or arm. The surgeons who do it must have special skills and experience. The bone that is removed is replaced with a bone graft from donors or with a rod made of metal or other materials. This rod is called an endoprosthesis (meaning internal prosthesis).

Nine out of 10 patients with bone cancer in a limb are able to have their limbs spared. Ask the surgeon to explain the best way to remove the cancer and keep as much use of the arm or leg as possible. Because the rods or grafts are often used in growing children, they are designed to grow with the child. They can be made longer without any extra surgery. Some have tiny devices in them that can lengthen the implant when needed to make room for growth.

Problems with this approach can include infection and grafts or rods that become loose or broken. Patients may also need more surgery during the next 5 years, and some may need an amputation after all. On average, it takes a year for patients to learn to walk again after such surgery on a leg. Rehabilitating the patient is more intense than after amputation. If the patient does not take part in the rehab program, the salvaged arm or leg may become useless.

Tumors in other places

Bone cancer in the pelvis is treated with a wide-excision, when possible. If needed, bone grafts can be used to rebuild the pelvic bones.

For a tumor in the lower jaw bone, the whole lower half of the jaw may be removed and later replaced with bones from other parts of the body.

For tumors in places like the spine or the skull, it may not be possible to safely do a wide-excision. Cancers in these bones may need a number of different treatments like cutterage, cryosurgery, and radiation.

Curettage: This treatment involves cutting out the tumor from the bone. This leaves a hole in the bone. In some cases, after most of the tumor has been removed, the surgeon will treat the nearby bone tissue to kill any cancer cells that may have been left behind. One way to do this is with cryosurgery. For this treatment, liquid nitrogen is poured into the hole that is left in the bone. This kills cancer cells by freezing them. Then the hole can be filled by bone grafts or by a type of bone cement called PMMA. PMMA starts out as a liquid and gets hard over time. As it hardens, it gives off a lot of heat. The heat also helps kill any remaining tumor cells. PMMA may be used without cryosurgery for some types of bone tumors.

Surgery for cancer that has spread: In order to be able to cure a bone cancer, it must be completely removed with surgery, even in any places where it has spread. The lungs are the most common place for bone cancer to spread. Surgery to remove bone cancer that has spread to the lungs must be planned very carefully. Before the operation, the surgeon takes into account the number of tumors, where they are (one lung or both lungs), their size, and the general condition of the patient.

A chest CT scan may not show all the lung tumors. The surgeon must have a plan in case more tumors are found during the operation than can be seen in the chest CT scan.

Removing all the lung metastases likely gives the patient the only chance for cure. But some tumors are too big or are too close to important structures in the chest (such as large blood vessels) to be removed safely. And patients whose general health is not good may not be able to withstand the stress of anesthesia and surgery to remove metastases. Then other treatments are needed.

Radiation therapy

Radiation therapy uses high-energy radiation to kill cancer cells. External beam radiation uses radiation delivered from outside the body. The beam is focused on the cancer. This is the type of radiation that has been tried as a treatment for bone cancer. But bone cancers are not easily killed by radiation. Radiation does not play a major role in the treatment of most types of bone tumors. It may be useful, though, in some cases where the tumor cannot be completely removed by surgery. It is also helpful in controlling symptoms like pain and swelling if the cancer has come back or if surgery is not possible.

Chemotherapy

Chemotherapy (often called "chemo") refers to the use of drugs to kill cancer cells. The drugs are often given into a vein or by mouth. Once the drugs enter the bloodstream, they go throughout the body. This treatment is useful for cancer that has spread to other organs. Except for Ewing sarcoma and osteosarcoma, chemo is seldom used for bone cancer unless it has spread.

Before giving chemo, your doctor will check your lab test results to be sure your liver, kidney, and bone marrow (which produces your blood cells) are working well.

Chemo kills cancer cells, but it will also damage some normal cells. This can cause some side effects. These will depend on the type of drugs given, the amount taken, and how long treatment lasts. These side effects could include the following:

• nausea and vomiting
• loss of appetite
• hair loss (the hair grows back after treatment ends)
• mouth sores
• increased chance of infection (from a shortage of white blood cells)
• bleeding or bruising after small cuts or injuries (from a shortage of platelets)
• tiredness or shortness of breath (from low red blood cell counts)

Most side effects go away once treatment stops. There are also treatments for many of the chemo side effects. For example, certain drugs can help with nausea and vomiting.