Primary Bone Cancer

The four most common types of primary bone cancer are:

• Multiple myeloma. Multiple myeloma is the most common primary bone cancer. It is a malignant tumor of bone marrow, the soft tissue in the center of many bones that produces blood cells. Any bone can be affected by this cancer.
  Multiple myeloma affects approximately seven people per 100,000 each year. According to the National Cancer Institute, more than 130,000 people are living with the disease each year. Most cases are seen in patients between the ages of 50 and 70. Multiple myeloma is typically treated with chemotherapy, radiation, and, occasionally, surgery. Surgery for people with multiple myeloma is usually used to treat complications of the cancer: for example, to stabilize weakened or broken bones.
• Osteosarcoma. Osteosarcoma is the second most common primary bone cancer. It occurs in two to five people per million each year, with most cases in teenagers and children. The average age of someone with osteosarcoma is 15 years. However, there is a smaller group of people who develop osteosarcoma in their 60s to 80s. Often, this is the result of a pre-existing condition (e.g., Paget's disease of bone). Most tumors develop around the knee in either the femur (thighbone) or tibia (shinbone). Other common locations include the hip and shoulder. Osteosarcoma is typically treated with chemotherapy and surgery.
• Ewing sarcoma. Ewing sarcoma usually occurs in patients between the ages of 5 and 20. The most common locations affected are the upper and lower leg, pelvis, upper arm, and ribs. Ewing sarcoma is typically treated with chemotherapy and either surgery or radiation therapy.
• Chondrosarcoma. Chondrosarcoma is a malignant tumor made up of cartilage-producing cells. It is most often seen in patients between the ages of 40 and 70. Most cases occur around the hip, pelvis, or shoulder area. Often, surgery is the only treatment used for chondrosarcoma.

Benign Bone Tumors

There are many types of benign bone tumors, as well as some diseases and conditions that resemble bone tumors. Although these conditions are not truly bone tumors, in many cases they require the same treatment.

Some common types of benign bone tumors — and conditions that are commonly grouped with tumors — include:

• Nonossifying fibroma
• Unicameral (simple) bone cyst
• Osteochondroma
• Giant cell tumor
• Enchondroma
• Fibrous dysplasia
• Chondroblastoma
• Aneurysmal bone cyst
• Osteoid osteoma

Medical History

As part of the examination, your doctor will take a complete medical history. They will ask about your general health, medications you take, and your current symptoms. Your doctor will also want to know if you or any family member has a history of any tumor or cancer.

Physical Examination

Your doctor will perform a thorough physical examination, focusing on the tumor mass. They will look for:

• Swelling or tenderness in the area of the tumor
• Changes in the overlying skin
• The presence of a mass
• Any effect the tumor might have on nearby joints

In some cases, your doctor will examine other parts of your body to rule out cancers that can spread to bone.

Tests

X-rays. X-rays provide images of bone. In most cases, your doctor will order an X-ray to help diagnose a bone tumor. Different types of tumors may look different on X-ray. Some dissolve bone or make a hole in the bone. Others cause additional bone to form. Some may do both.

Femur (thighbone) tumor. This X-ray shows a tumor that caused a saucer-like erosion in the end of the thighbone. The insert shows the same tumor using a cross-sectional magnetic resonance image (MRI) scan.

Other imaging tests. If necessary, your doctor will order a magnetic resonance imaging (MRI) scan, computerized tomography (CT) scan, or bone scan to help further evaluate your tumor. If the doctor is worried that a bone tumor is related to cancer in another part of your body, they may order CT scans or a positron emission tomography (PET) scan of other parts of your body to look for other tumors.

A PET scan is a nuclear medicine test. It is often used to detect cancer and to see if cancer has spread. It uses a small, safe amount of radioactive tracer to find cancer cells in the organs and soft tissues. The cancer cells show up as bright spots on PET scans. 

Blood or urine tests. While there are blood tests to look for cancers in other parts of your body (e.g., breast cancer, prostate cancer), there are no blood tests to look for or help diagnose benign bone tumors or primary bone cancers. 

However, your doctor may order blood and/or urine tests to help exclude other conditions. For example, blood tests can be used if your doctor is trying to determine, based on your symptoms and your imaging, whether you have an infection or a tumor. In addition, blood and urine tests are useful in making the diagnosis of multiple myeloma, if your doctor is concerned about that diagnosis.

Femur (thighbone) tumor. This X-ray shows a tumor in the middle of the thighbone. The tumor is also seen using magnetic resonance imaging (MRI) scan. The insert at top shows a coronal MRI. The insert at bottom shows a cross-sectional MRI. The arrows on all images show the location of the tumor.

Humerus (upper arm) tumor and fracture. This X-ray shows a fracture through a tumor in the middle of the bone of the upper arm.

Biopsy. Some benign tumors can be identified by how they look on X-rays and/or MRI scans. A biopsy may be needed if the diagnosis is not clear, especially for tumors that are causing pain or if the doctor is concerned about a bone cancer.

In a biopsy, a sample of tissue is taken from the tumor. This sample is examined under a microscope and analyzed by a pathologist (a doctor who identifies diseases by studying abnormal cells).

There are two basic methods of performing a biopsy:

• Needle biopsy.  In this procedure, a needle is inserted into the tumor to remove some tissue. You will first be given a local anesthetic. A needle biopsy of a bone tumor is most often done by a radiologist. An imaging study, such as an X-ray, CT scan, or MRI scan, will be used to help direct the needle.

In a needle biopsy, the doctor inserts a needle into the tumor to remove some tissue.

• Open biopsy. An open biopsy is performed in an operating room by a surgeon. After you are given general anesthesia to put you to sleep, the surgeon will make a small incision and remove some tissue.

In an open biopsy, the doctor surgically removes tissue. This is usually done in an operating room.

Neither type of biopsy will cause your tumor to spread.

Benign Tumors

If your tumor is benign, your doctor may recommend just monitoring it closely to see if it changes. This is especially true of the tumor is not causing any symptoms and is not weakening the bone.

During this time, you may need periodic follow-up X-rays or other tests. However, there are some benign tumors (for example, giant cell tumor) that will continue to grow, causing increasing damage to bone.

Some benign tumors can be treated effectively with medication. Some will disappear or fill in with bone over time without surgery. 

Malignant Tumors

If you have bone cancer, treatment will include a team of doctors from different medical specialties working together to provide care. Some of these specialists will be oncologists — doctors who specialize in cancer treatment. Your team may include an orthopaedic oncologist, medical oncologist, radiation oncologist, radiologist, and pathologist.

The goal of treatment is to cure the cancer while maintaining function, as best as possible, in the part of the body affected by the tumor.

Treatment depends on several factors, including the stage and location of the cancer. If the cancer is localized (has not spread), it means cancer cells are contained to the tumor and the immediate surrounding area. When the cancer has reached a metastatic stage, it has spread elsewhere in the body and may be more serious and harder to cure.

Doctors often combine several methods to treat malignant bone tumors:

• Radiation therapy. Radiation therapy uses high-dose X-rays to kill cancer cells and shrink tumors. This only treats the cancer in the area of the beam. It does not treat cancer elsewhere in the body. Only a few primary bone sarcomas (e.g., Ewing sarcoma) respond to radiation therapy. For other types of primary bone cancers, radiation therapy can be used if the tumor cannot be safely or completely removed with surgery. Your doctor will determine if radiation therapy is the best choice of treatment in your situation.
• Chemotherapy (systemic, or whole body, treatment). Chemotherapy is often used to kill tumor cells when they have spread into the bloodstream but may or may not yet be detected on tests and scans. It is generally used when cancerous tumors have a very high chance of spreading. Chemotherapy is usually given intravenously (injection into a vein) or in a pill or capsule that is swallowed.

Generally, primary malignant bone tumors are removed with surgery. For some primary bone cancers, chemotherapy is used in combination with surgery. For metastatic bone cancers or myeloma, treatment focuses on chemotherapy and sometimes radiation therapy, with surgery used only to treat bones that have broken or are at risk of breaking.

Benign Tumors

In some cases, your doctor may recommend removing the tumor (excision) or another technique to reduce your pain.

Some benign tumors can be aggressive, destroying large amounts of bone and increasing your risk of fracture. These tumors are often treated with surgery.

Some tumors may come back, even repeatedly, after appropriate treatment. Rarely, certain benign tumors can spread (metastasize).

Malignant Tumors

Limb salvage surgery. This surgery removes the cancerous section of bone and any nearby muscles or tendons that are involved with the tumor. The surgeon will take out the tumor and a portion of healthy tissue around it. They will try to keep any nerves and blood vessels intact where possible. The bone that is removed is then replaced with a metallic implant (prosthesis), bone from elsewhere in your body, or bone from a donor.

Amputation. Amputation is surgery to remove all or part of an arm or leg. It is usually used:

• When nerves and blood vessels are involved.
• If the tumor is large and so much muscle around the bone is involved with the tumor that removing the tumor would make the arm or leg not functional.

A prosthetic limb can aid function after amputation.

Recovery

The length and complexity of your recovery depend on the type of tumor as well as which type of procedure and other treatments you had.

After treatment, you will continue to see your doctor for regular follow-up visits and tests every few months. Even though the tumor has disappeared, it is important to monitor your body for signs of recurrence. Tumors that come back may pose serious problems, so it is important to detect them early.

Even if no other areas of tumor were seen on imaging right after treatment, they can show up later on.  This does not mean that your cancer was not completely removed. It often means there were areas of tumor that were too small to see on CT or PET scans but that started to grow later, after treatment.