Let’s discuss bone tumor treatments, symptoms and achievable outcomes from surgery. Bone tumors fall into several categories, benign, osteosarcoma, soft tissue and may be metastatic. The tumor type informs the treatment used to remove and treat the tumors. The information on this page defines the types of tumors, their causes and the various ways that we use to treat our patients with bone tumors.
Bowleg Quick Links: Benign Vs. Malignant | Osteosarcoma | Soft Tissue Sarcoma | Metastic Bone Disease | Benign Bone Tumors
Bone Tumor Videos:
Cyborg for Life Podcast Interviews Dr. Reif
Doctor: Dr. Taylor J. Reif, MD
Bone Tumors
Doctor: Dr. Taylor J. Reif, MD
Limb Reconstruction – Malignant Bone Tumor
Doctor: Dr. S. Robert Rozbruch, MD
Management of Bone Defects
Doctor: Dr. Austin Fragomen, MD
Limb Lengthening on Instagram: #BoneTumor Stories
My latest scientific work explains the convergence of benign bone tumors and limb deformity, #openaccess so check it out! Link in bio 🦴 🤓
@limblengthening @limbdeformity
#limbdeformity #benignbonetumor #bonetumor #limblengthdiscrepancy
My latest scientific work explains the convergence of benign bone tumors and limb deformity, #openaccess so check it out! Link in bio 🦴 🤓
@limblengthening @limbdeformity
#limbdeformity #benignbonetumor #bonetumor #limblengthdiscrepancy
Benign Versus Malignant Lesions
What does benign versus malignant mean?
Benign lesions form in a bone and can grow locally but do not spread to other organs to cause harm. Malignant lesions, more commonly referred to as cancer, may form and develop in the bone but have the capacity to spread to other areas of the body and continue to grow. For bone cancers this most commonly occurs to the lungs, where growth can lead to difficulty breathing and ultimately prove fatal. A tumor is an abnormal growth of cells and may be either benign or malignant, since both benign and malignant lesions form tumors in the bone.
Who gets benign versus malignant bone tumors?
Benign bone lesions can be due to genetic causes, growth disturbances, or changes in a small population of cells behavior. We often don’t know why a lesion forms in a specific area of bone in a specific person, but over time physicians have developed an understanding how the lesions behave regardless of why they formed. Benign tumors usually develop during growth and development so we frequently diagnose them in children and young adults, but asymptomatic lesions can be identified well into adulthood.
Malignant bone lesions, or bone cancer, occur when a cell in the bone multiplies without restraint and evades the body’s defenses to destroy abnormal tissue. Mutations in a person’s DNA which can be genetic, spontaneous, or induced by environmental factors, usually cause bone cancer in patients. Bone cancer affects all age groups, but certain subtypes, like osteosarcoma and Ewing sarcoma occur more often in children, while chondrosarcoma more frequently affects adults.
How is a benign versus malignant lesion diagnosed?
Lesions in the bone are usually identified on XR images but are also evident on CT and MRI scans. The images often help lead to a diagnosis, and sometimes make a particular diagnosis nearly certain. However, many lesions look quite similar and no diagnosis can be immediately made. For lesions that look concerning for cancer or caused damage to the bone, a biopsy is performed to make a specific diagnosis. This diagnosis then guides further treatment. For lesions that do not appear cancerous or destructive, We can obtain serial images over time and compared them to look for changes, making biopsy often unnecessary.
How are benign bone lesions treated?
Many benign lesions are stable in the bone and require no treatment. Some benign lesions or tumors act locally aggressive and require surgical treatment to eradicate the process and prevent further damage. Malignant lesions always require treatment. Malignant lesions are usually treated with surgery to remove the tumor, but may require other forms of bone tumor treatment like chemotherapy or radiation therapy as well.
Osteosarcoma
What is osteosarcoma?
Osteosarcoma is a form of cancer that originates from within a bone. Unlike most “bone cancer” which actually originates from another cancerous organ from the breast, prostate or lung and spreads to bone, osteosarcoma is a malignancy of the bone itself. Osteosarcoma cancer cells produce an immature, non-functional form of bone which aids in making the diagnosis.
Who gets osteosarcoma?
Classic osteosarcoma is diagnosed in children, adolescents and teenagers; however older individuals can develop a form of the disease as well. When older individuals are diagnosed with osteosarcoma it is often associated with other medical conditions like Paget’s disease or the area has been treated previously with radiation therapy.
How is osteosarcoma diagnosed?
Typically, patients with osteosarcoma report pain near a joint, most commonly the knee, that does not remit with rest or pain medications. The pain usually increases with time and is aggravated by impact activity or merely putting weight on the extremity. An X-ray is the first step in making a diagnosis. Once we suspect an osteosarcoma, we recommend a referral to a physician who specializes in orthopedic oncology.
We then perform further imaging of the suspicious area of the bone with an MRI. These advanced images will guide the physician in performing a biopsy of the lesion.A biopsy is a surgical procedure that obtains a sample or core of the bone tumor for further examination under a microscope by a pathologist. Once the diagnosis is made, further imaging studies are performed to determine if the cancer has spread elsewhere in the body.
How is osteosarcoma treated?
The treatment of osteosarcoma is conducted by a team of doctors primarily lead by an oncologist and an orthopedic surgeon. The oncologist directs the chemotherapy treatment of the disease which is indicated in most forms of osteosarcoma. The orthopedic surgeon performs the excision of the bone tumor and the reconstruction of the limb. There are many options for surgical treatment, so patient and family input is essential. New techniques to reconstruct the affected bone with the patient’s own live bone are possible in many circumstances, even during chemotherapy.
After the initial chemotherapy and surgical procedures, the treatment team follows the patient over time to monitor for disease recurrence. Although any diagnosis of cancer is life altering for a patient and their family, osteosarcoma is treatable and many patients are cured of the disease.
Soft Tissue Sarcoma
What is soft tissue sarcoma?
Soft tissue sarcoma is the generic name given to types of cancer that affect the muscle, nerves, vessels and fat in our bodies. They can develop anywhere in the body but are often diagnosed in the extremities. “Soft” simply implies they are not from the bone. The designation includes many forms of cancer that are treated similarly and often studied together.
Who gets soft tissue sarcoma?
The spectrum of soft tissue sarcoma includes some forms which occur more commonly in children, like rhadomyosarcoma, and some forms that predominate in older individuals, like undifferentiated pleomorphic sarcoma. There are certain medical conditions which also predispose an individual to certain forms of soft tissue sarcoma. For example, patients with neurofibromatosis are more likely to develop a malignant peripheral nerve sheath tumor. Overall, these rare cancers, represent less than 1% of adult malignancies.
How is soft tissue sarcoma diagnosed?
Regardless of the specific diagnosis, patients usually notice an enlarging mass or lump in the arm or leg. There may sense a feeling of fullness compared with the opposite extremity. Many people ignore this usually painless mass until it reaches substantial size. X-rays are usually negative. Any suspicious mass should be referred to an oncologic surgeon, as even small masses can represent cancer and need to be managed appropriately. Patients should obtain an MRI of any growing mass to assess its character and true size. A biopsy is then needed to make a diagnosis.
The biopsy can safely be performed in an office setting (using a needle) or in the operating room depending on the size and location of the mass. A pathologist evaluates the biopsy to determine if cancer is present since many masses, even ones with slow growth over time, may be benign. If cancer is present, additional imaging studies are performed to assess for cancer in other parts of the body.
How is soft tissue sarcoma treated?
Treatment specifics depend on the diagnosis obtained during the biopsy. However, in general, an essential part of treatment includes surgical excision of the mass performed by an orthopedic oncologist. Many forms of soft tissue sarcoma are treated with radiation therapy as well, thus a radiation oncologist usually participates in treatment. Some forms of soft tissue sarcoma also respond to traditional chemotherapy or new emerging therapies (like immunotherapy), so a medical oncologist may also guide treatment. This team of physicians will determine and coordinate the initial treatment.
Once completed, the team closely follows patients over time to assess for any signs of recurrent cancer or side effects from the treatment. Soft tissue sarcoma is most effectively treated early so we encourage patients to seek medical attention for any concerning mass or lump.
Metastatic Bone Disease
What is metastatic bone disease?
Metastatic bone disease occurs when one form of cancer, like breast or prostate, migrates through the body to a new site in the bone and begins to grow there as well. The initial growth usually goes unnoticed since the bone continues to function normally. Once the cancer grows to sufficient size to weaken the stability of the bone, pain usually develops with weight bearing or activity.
Who gets metastatic bone disease?
Patients with a history of cancer are at risk for metastatic bone disease. Cancers of the breast, prostate, lung, thyroid and kidney are the most common types of cancer to affect the bone. However most forms of cancer can metastasize to bone, so any new bone or joint pain in a patient with a history of cancer should be evaluated.
Bone lesions/bone tumors may be discovered at the time of diagnosis of the primary cancer, or they may develop years later despite thorough and appropriate treatment. We evaluate patients with a history of cancer and new abnormalities with a higher level of suspicion on XR as a result. In some cases, the pain from a metastatic bone lesion may lead to a previously unknown diagnosis of cancer elsewhere in the body.
How we diagnose metastatic bone disease
XR, CT, or MRI scans help identify suspicions lesions in the bone. If we discover new lesions in a patient with a history of cancer, we refer the patient to an orthopedic oncologist for further evaluation. Additional imaging to evaluate the entire skeleton may be warranted. The bone tumor is then biopsied to make the diagnosis of metastatic bone disease. A pathologist can compare the cells from the biopsy to the primary cancer to determine if there is a match.
Treating metastatic bone disease
Patients diagnosed with cancer often need the care of an orthopedic surgeon because the most common cancer types—breast, prostate, lung—all have a tendency to spread to bone. Most other forms of cancer can metastasize there as well. While fighting cancer is certainly difficult enough, additional pain and limited function of the arms and legs only adds to the burden. Therefore we aim treatment of additional sites of cancer at maximizing pain relief and return to function as efficiently as possible.
Cancerous bone tumor treatment requires a team approach
The orthopedic surgeon will closely communicate with the treating oncologist to ensure prior therapies can continue with as little interruption as possible. Choosing an orthopedic surgeon with specific knowledge and training with cancer is important because many bone metastasis behave uniquely based on the organ they originate from. The team aims to perform as few operations as possible to meet each patient’s goals and get them back to living. It is also important to evaluate for other sites of disease that may not be symptomatic yet—if treated early larger procedures can often be avoided.
Much like the initial treatment of a cancer, we treat metastasis with a team approach. We perform surgery as soon as possible to stabilize the diseased bone so the recovery and rehabilitation process can begin. We then follow up treatment with some combination of radiation therapy, chemotherapy, or bone building medications to continue the fight against the new site of disease.
The surgical options available include plates and screws, rods or nails, and partial or full joint replacement. After a thorough discussion with the patient and involved family members an individualized choice of treatment is made. For example, a common site of metastasis is around the hip joint. This can lead to pain and difficulty ambulating or even a fracture. Some bone tumors will require medications and radiation only. Others must be scraped from the bone and stabilized with a plate or a nail. Still others may be large enough to require a joint replacement. Regardless, minimizing time in the hospital yet thoroughly treating the new site of disease remains the objective.
Benign Bone Tumors
What are benign bone tumors?
Benign bone tumors are abnormal lesions in the bone which affect the architecture of the bone and are identifiable on XR or other images. While they are tumors, which means an abnormal growth of tissue, they are not cancer because they do not have the capacity to grow and cause damage in other parts of the body.
Common benign bone tumors include non-ossifying fibroma, osteoid osteoma, fibrous dysplasia, bone cysts, ganglion cysts, osteochondroma, and enchondroma.
Who gets benign bone tumors?
Most benign bone tumors develop during growth so most commonly show up in children and adolescents. We do not know how many people are affected because many people never seek treatment for asymptomatic lesions. Some benign tumors are inherited through families, like multiple osteochondromatosis, but the majority are spontaneous growths and it is usually unknown why one person develops one and another does not.
Diagnosing benign bone tumors
We initially discover a benign bone tumor on an XR, which may have been obtained for a completely separate reason, but nonetheless identifies a bone lesion. Many benign bone tumors exhibit a particular appearance on XR, so require no further studies to make a predictive diagnosis. Some benign tumors further require a CT or MRI scan, both to aid in the diagnosis and to plan treatment. The final step in making a definitive diagnosis is with a biopsy. While the majority of benign bone tumors do not require a biopsy, some look similar enough to a malignant cancerous tumor to require this procedure. However, once a benign diagnosis is made, treatment can often proceed during the same operation.
How are benign bone tumors treated?
There is a wide spectrum of treatment for benign bone tumors, depending on the specific diagnosis. Tumors known as indolent or quiescent are stable in the bone and unlikely to cause problems. They can be followed over time but do not require surgery. Other tumors are more active and require surgical removal of the abnormal tissue to stop their growth and allow normal bone to fill the space previously occupied by the tumor. Occasionally, benign tumors are aggressive and may have already destroyed a substantial amount of bone prior to treatment. These require a longer surgery to both remove the tumor as well as stabilize the remaining healthy bone with an orthopedic implant (plate, screws, nail, etc). Some tumors, despite being benign, recur in the same area, so close follow up with your surgeon over time is important.
For more information on bone tumors, visit the sections below:
Patient Stories
Case Histories & Presentations
Publications
Limb Length Discrepancy and Angular Deformity due to Benign Bone Tumors and Tumor-like Lesions, Journal of the American Academy of Orthopaedic Surgeons, March 2021, Taylor J. Reif, MD, Julia Matthias, Austin T. Fragomen, MD, and S. Robert Rozbruch, MD.