Bone cancer

Bone cancer can be either primary or secondary.

• Primary bone cancer starts in the cells of the bone.
• Secondary bone cancer. This is cancer while starts in another organ of your body but has spread to the bones. This cancer behaves like the original cancer that it spread from and not like bone cancer.

This factsheet is about primary bone cancers.

There are many types of primary bone cancer. The main ones are listed below.

• Osteosarcoma. This is the most common type of bone cancer. Children and young people between the ages of 10 and 20 are more commonly affected, but it can occur at any age. It is slightly more common in males than females.
• Ewing's sarcoma. This cancer also tends to develop between the ages of 10 and 20. Like osteosarcoma, it is slightly more common among males than females. This cancer can also occur in soft tissues in the body such as muscle.
• Chondrosarcoma. This is the second most common type of bone cancer. It is more common in adults between the ages of 40 and 60. It starts in the cartilage cells in joints.
• Spindle cell sarcoma. There are four types of bone cancer: undifferentiated sarcoma of the bone, malignant fibrous histiocytoma, fibrosarcoma and leiomyosarcoma. They all behave like osteosarcoma but are more common in adults.

The symptoms of bone cancer vary depending on where it develops and how severe it is. Different types of bone cancer tend to form in different areas. For example:

• Osteosarcoma is most common in the lower thigh, shins and arms.
• Ewing's sarcoma most commonly occurs in the pelvis, thigh and shins.
• Chondrosarcoma is most common in the thigh, pelvis, ribs, upper arm and shoulder bone.
• Spindle cell sarcoma most commonly develops in the lower thigh, shins and arms.

Bone cancer often causes pain and tenderness in the affected area. This is often worse at night. As the cancer grows it can also cause swelling in the affected area. If it is near a joint it may make movement in that area difficult.

Less common symptoms of bone cancer include:

• tiredness
• fever
• weight loss

It's important to remember that these symptoms can be caused by many problems other than bone cancer. So although not necessarily a result of bone cancer, if you have these symptoms you should visit your GP.

No one knows exactly what causes bone cancer, but research is ongoing. But there are some things that increase your chances of getting bone cancer.

• Previous treatment with radiotherapy. If you have had a lot of radiotherapy for cancer in the past, you have a slightly increased risk of getting bone cancer in that area.
• Paget's disease. This bone disease gradually deforms your bones, causing pain and fractures. Having Paget's disease for a long time increases your risk of developing bone cancer
• Having a previous benign bone tumour. If you have had a benign (non-spreading) type of bone cancer, you are more likely to develop chondrosarcoma.
• Retinoblastoma. Inheriting the gene that causes this rare type of eye cancer also makes you more likely to develop osteosarcoma.
• Having certain other rare inherited conditions, such as Li-Fraumeni syndrome, can increase your risk of developing bone cancer.

Bone cancer can be diagnosed by many different tests.

X-ray

Doctors are often able to diagnose bone cancer from an X-ray image of the affected area. X-rays can sometimes be useful for finding out the type of bone cancer it is.

Bone scan

For having a bone scan a small amount of harmless radioactive dye is injected into a vein. This collects in areas of the bone that may have cancer, and is picked up by the scan.

Bone scans are better than X-ray images at showing up a bone cancer. But other diseases, such as arthritis, can also cause a positive result. So if you have a positive bone scan, you may need further tests to make sure you have bone cancer.

MRI scan

Magnetic resonance imaging (MRI) scans use magnets and radio waves to produce images of the inside of your body. Tumours growing inside bones can be seen with MRI scans.

Biopsy

Often your doctor will want to take a biopsy to check if a tumour is non-cancerous. A biopsy is a small sample of tissue. This will be sent to a laboratory for testing.

The biopsy is usually done using a long needle, under local anaesthesia. The procedure is called a core needle biopsy. Sometimes doctors do an operation called a surgical biopsy. This can be done under local or general anaesthetic.

Further tests

If you are diagnosed with bone cancer, you will have more tests to check if the cancer has spread. This is called staging. You are likely to have a chest X-ray, to see if it has spread to your lungs, or a computerised tomography (CT) scan to look for signs of cancer elsewhere in your body.

How bone cancer is treated depends on the type of bone cancer you have, how far it has spread, your age and your general health. The treatment for these rare tumours is carried out in expert centres where cancer specialists (oncologists) and surgeons are familiar with the special treatments required. There are three main types of treatment for bone cancer.

Surgery

The type of surgery you have depends on how far the cancer has spread.

• Limb salvage surgery involves removing the area of bone where the tumour is. Because of the recent advances in surgery, this method of treating bone cancer is becoming more common. The area of bone removed is replaced with either a metal prosthesis (an artifical replacement part) or a piece of healthy bone taken from another part of your body (a bone graft).
• Despite ongoing improvements in surgical technique, sometimes a limb salvaging operation isn't possible. If the cancer has spread into surrounding tissues, amputating the limb may be the only way to get rid of the cancer. Support from the medical staff looking after you can help you come to terms with this news. Advances in prosthetics (artificial limbs) mean that you can often have a fully active life after this surgery. A specialist in artificial limbs will visit you at hospital to arrange one for you. A physiotherapist will be able to teach you how to adapt to and best use it.

Non-surgical treatments

Chemotherapy

Chemotherapy uses medicines to destroy cancer cells. However, they can also have side effects such as making you feel tired or ill, or causing nausea or hair loss. Chemotherapy is particularly good at treating Ewing's sarcoma, but it can also treat other types of bone cancer such as osteosarcoma.

There are lots of different types of chemotherapy drugs. They are usually injected into a vein but sometimes tablets are used.

Chemotherapy is often given before and after surgery to make it easier to remove the tumour and to prevent it coming back.

Radiotherapy

Radiotherapy uses radiation to kill cancer cells. A beam of radiation is targeted on the cancerous cells, which shrinks the tumour.

Radiotherapy is especially useful for Ewing's sarcoma but it's sometimes used for osteosarcoma. It can be used before surgery to make it easier to remove the tumour, or afterwards to prevent it coming back.

After your treatment

If you have had an operation you may need physiotherapy and other support to help get you back to functioning well. You will also be seen regularly by a specialist to make sure the cancer hasn't returned.

1. How is limb sparing surgery going to affect me in my day-to-day life?

Surgery usually works well and many people recover almost full use of their limb. Rehabilitation can help you to make as full a recovery as possible though there may be some issues, such as limited movement, which may affect your day-to-day life.

Around eight out of 10 people who have bone cancer in an arm or a leg have limb-sparing surgery to remove the cancer from the bone.

You will need lots of physiotherapy to help get back as much power and flexibility in your arm or leg as possible. An occupational therapist can also help you become independent.

Certain issues may affect your life.

• You may have a slight limp if you had surgery to your leg. Trying to compensate for the limp can sometimes cause pain in other areas. Speak to your doctor if this happens.
• You may need further surgery in the future to replace loosened or worn artificial joints.
• If you are treated in childhood, you may need operations to extend (lengthen) the bone as your body grows. Some artificial bones are designed to expand and can be lengthened using a strong magnet without an operation.
• You may not be able to take part in contact sports like football as it may damage or loosen the artificial bone or joint.
• If you had your shoulder joint replaced, you may not be able to lift your arm above your shoulder.
• You will have surgical scars and you may feel self-conscious. You may want to talk to your family or a counsellor about your feelings.
• Rarely, surgery and radiotherapy can cause a build up of fluid causing swelling in your arm or leg (lymphoedema). This can be well controlled if treated early.

2. What will life be like after an amputation?

Amputation of a limb is a major life change and affects people in different ways. Many go onto lead full and active lives and are able to work, drive and play sport.

Life after amputation is different for everyone. The kind of amputation you have and how much of your limb is removed will affect your recovery and how much you are able to do.

Recovery from amputation isn't easy and you will need to be committed and determined. A team of health professionals will help you make as full a recovery as possible.

A few days after your operation, the physiotherapist will start to help you to strengthen the muscles around the site of your operation. Once your wound has healed, you can be measured for your artificial limb. Your limb will be made specifically for you to make sure it fits as well as possible. New technology and materials now mean that artificial limbs are very effective.

Rehabilitation can be frustrating. You may need to learn how to walk and balance again or how to write, eat and get dressed. An occupational therapist can help make changes to your home and workplace. He or she can also give you aids to make life easier.

It commonly takes about a year for you to get back to your usual lifestyle and to wear your artificial limb regularly.

Problems can include the following.

• Phantom limb pain - about six in 10 people who have a leg or arm amputated will have phantom limb pain at some time (pain in the amputated arm or leg). This feeling usually disappears gradually over a few months. Massage, elevating the existing limb, rest and distraction can all help to reduce phantom limb pain. Your doctor may prescribe painkillers or mild antidepressants to relieve phantom limb pain. Always ask your doctor for advice and read the patient information leaflet that comes with your medicine.
• Feelings of anger, frustration or shock. It can be difficult to deal with the change in the way you look. Support groups and talking to your family, friends and health professionals can help overcome these feelings.

3. Will I still need to see my doctor after my treatment finishes?

You will need to visit your doctor regularly after your treatment finishes to check for any signs that the cancer has come back or spread, and to see how well you are recovering. It's important to go to your appointments to make sure you have the best chance of getting early treatment and making a good recovery if the cancer returns.

After you have finished your treatment, you will have follow-up appointments with your doctor. How often these are depends on your individual circumstances. For the first two years after your treatment finishes, you will probably see your doctor every three months. If everything goes well, these appointments will then be less frequent - every six months and then once a year. The gaps between your appointments get longer as time goes on because the chance of the cancer coming back gets less as time passes. If you notice any new symptoms or you are worried that the cancer has come back in between these appointments, arrange to see your doctor straight away.

You will have regular follow-up appointments with your doctor for several reasons.

• To spot any early signs that the cancer has come back - this means you can have any further treatment quickly so you have the best chance of a good recovery.
• To check for any complications of your treatment and see how you are progressing.
• To give you an opportunity to ask questions or talk about your worries.

At every appointment, your doctor will examine you. He or she may also ask you to have blood tests and X-rays, including chest X-rays. This is because some types of cancer can spread to the lungs. If the cancer does spread to your lungs, it can be successfully treated if it's spotted early.

For many people with bone cancer, treatment is very successful. However, for some people, the cancer does come back or spread to other areas, which is why follow-up appointments are so important.