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Bone Cancer

Orthopaedics

Bone cancer can be divided into primary and metastatic, which refers to cancer that has spread from other parts of the body to the bone tissue. The majority of cases fall under metastatic bone cancer. As for primary bone cancer, it originates in the bone cells and is relatively rare.

According to data from the American Cancer Society, primary bone cancer cases account for less than 0.2%. The common types of primary bone cancer are as follows:

  • Osteosarcoma
    The most common type of bone cancer, usually occurring in the upper arms or knees. It primarily affects patients who are children or adolescents, as it tends to develop in growing bone tissues.
     
  • Chondrosarcoma
    Derived from cartilage, this type most commonly appears in the hip and pelvic areas but can also occur in any other body part. It predominantly affects adults.
     
  • Chordoma
    Often occurs at the skull base or the end of the spine, primarily affecting adults.
     
  • Ewing Tumours
    Derived from immature cells in the bone marrow, these tumours can occur in any part of the body but are most commonly found in the thigh bone, pelvis, or chest wall. They predominantly affect children or adolescents.

Symptoms

Due to the rare occurrence of primary bone cancer and the lack of public awareness, combined with inconspicuous early symptoms, it is one of the most challenging cancers to prevent and detect. However, this does not mean there are no signs to be aware of. The following are symptoms of primary bone cancer:

  • Bone pain near the tumour - Early-stage bone cancer patients may experience pain, especially at night or during activities such as walking. Leg pain while walking is an example. As the cancer progresses and activities intensify, the pain becomes more noticeable and persistent.
     
  • Back pain - Early-stage bone cancer patients may have persistent and unexplained back pain.
     
  • Joint swelling and stiffness - If the tumour grows near a joint, the joint may become swollen and stiff, reducing the patient's mobility and causing pain during movement.
     
  • Compression symptoms - Due to the bone tumour compressing nerves and blood vessels, early-stage bone cancer patients may experience numbness in the extremities.
     
  • Weakening of bones - The bones become fragile, and fractures may occur.
     
  • Other - Patients may exhibit atypical bone cancer symptoms, including extreme fatigue, fever, and weight loss.

Currently, the exact causes of primary bone cancer are not fully understood, but research suggests that it may be associated with the following factors:

  • Genetic Inheritance: Individuals with a family history of bone cancer may face a higher risk.
  • Radiation Exposure: Previous exposure to high doses of radiation may increase the risk of developing primary bone cancer.
  • Genetic Mutations: Abnormal variations in specific genes may be associated with bone cancer. For example, Li-Fraumeni Syndrome, a rare hereditary condition, increases the risk of various tumours, including bone cancer. Patients with Hereditary Retinoblastoma also have an elevated risk of developing bone cancer.
  • Bone Diseases: Some hereditary or acquired diseases related to the bones, such as multiple osteochondromas (multiple hereditary exostoses), may be linked to an increased risk of bone cancer.
  • Radiation Therapy: Individuals who have undergone radiation therapy may develop primary bone cancer several years or decades after treatment.
  • Other Diseases: Certain rare diseases, such as Paget's Disease of bone, may increase the risk of developing primary bone cancer.

When doctors suspect a patient may have bone cancer, they first conduct preliminary and straightforward examinations, such as checking for pain, deformities, or noticeable lumps in the body. If these tests indicate a likelihood of bone cancer, further assessments will be conducted for a more accurate diagnosis, primarily using the following methods:

Blood TestsBlood tests may include checking alkaline phosphatase (ALK-P) levels. Since alkaline phosphatase is abundant in organs such as the liver and bones, it is often used in clinical evaluations of liver and bone-related diseases. If bone cancer is present, ALK-P levels may increase.
X-rayX-ray examinations are essential for diagnosing bone cancer. They provide initial insights into the location and extent of the tumour, such as irregularities in the affected bone, making it appear less solid. Although X-rays can reveal the presence of cancer, they cannot determine the malignancy of the tumour. The malignancy of the tumour requires a biopsy for histopathological examination.
Bone ScanA bone scan further examines the entire skeletal system for other lesions and metastasis to other bones and evaluates the activity of bone tumours.
CT ScanCT scan is used to examine the entire skeletal system further for other lesions and metastasis to other bones and assess the activity of bone tumours.
MRIMRI with contrast imaging precisely locates the extent of bone sarcoma invasion and helps understand whether the tumour erodes nearby fat, muscles, other organs, blood vessels, and nerves.
PET CTPET CT is highly sensitive to cellular metabolism and is particularly suitable for identifying early cancer cell changes. It can also differentiate whether there are signs of tumour spread and determine the cancer stage.

Staging

After the diagnosis through the methods above, if the doctor discovers that the patient has bone cancer, further tests may be conducted to determine the stage of cancer accurately. Factors determining the early or advanced stage of cancer include the tumour's size, whether it has spread, and if it has spread to more distant body tissues. The subdivisions of the stages are as follows:

Stage IIA: Tumour diameter is no more than 8 centimetres and has not spread to nearby lymph nodes.
IB: The tumour's diameter is over 8 centimetres and has not spread to nearby lymph nodes. Tumour growth is in more than one location in the bone.
Stage IIIIA: Tumour diameter is over 8 cm, and it has not spread to nearby lymph nodes—/Tumour growth in more than one location in the bone.
IIB: Tumour diameter is no more than 8 cm, and it has not spread to nearby lymph nodes or distant locations. Cancer is of a high grade.
Stage IIITumour growth in multiple locations on the same bone has not spread to nearby lymph nodes or distant locations.
Stage IVIVA: Tumour of any size, possibly growing in more than one location in the bone. Although it has not spread to nearby lymph nodes, it has spread to the lungs.
IVB: Tumour of any size, possibly growing in more than one location in the bone. It has spread to nearby lymph nodes and may have spread (or not spread) to the lungs or other bones.

Treatments

After diagnosis, doctors will choose the most appropriate treatment for patients confirmed with bone cancer. The treatment methods for bone cancer depend on its type, extent of spread, the patient's age, and overall health. The main treatment methods include:

Surgical TreatmentSurgery is crucial for treating bone cancer, with the primary goal being the removal of the localized tumour. Limb-sparing surgery, where cancerous tissue is removed along with some surrounding normal tissue, is now preferred over amputation. Advances in surgical techniques, combined with postoperative chemotherapy and radiation therapy, make it possible to preserve limbs more easily.
ChemotherapyChemotherapy involves a variety of drugs, typically administered through intravenous injections and sometimes in the form of oral tablets. Since chemotherapy uses drugs to kill cancer cells, it can cause side effects such as fatigue, nausea, chest discomfort, or hair loss. Chemotherapy is commonly used for osteosarcoma and Ewing tumours but less frequently for chondrosarcoma. Doctors often administer chemotherapy before and after surgery to aid tumour removal and prevent a recurrence.
Radiation TherapyRadiation therapy kills cancer cells by directing radiation beams at the cancer cells, causing them to shrink. However, most cancer cells are not easily destroyed by radiation, so high doses are often needed. Yet, high doses can damage nearby healthy tissues, nerves, and blood vessels. Radiation therapy is typically used when surgery cannot altogether remove cancer cells.

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