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bone cancerA popular lay term for a malignancy of bone, which is usually secondary—i.e., metastatic from primary tumours of prostate, breast, kidneys, etc. Primary bone cancers include osteosarcoma and chondrosarcoma.
Intense, gnawing pain.
History, physical examination, X-rays, biopsy.
Increased alkaline phosphatase.
Depends on type and mitotic activity, location, size, extent of tumour.
Depends on histologic type, extent of disease at presentation, location of tumour, as well as on the age and health of the patient.
bone cancerOncology Any malignancy of bone, which is usually 2º to, ie metastatic from primary tumors of prostate, breast, kidneys, etc; 1º BCs include osteosarcoma, chondrosarcoma Clinical Intense–“gnawing”–bone pain Diagnosis Hx, PE, x-rays, Bx Lab ↑ Alk phos Treatment Depends on type and mitotic activity, location, size, extent of tumor
bone cancerPrimary bone cancers are called osteogenic sarcomas and are comparatively rare. Secondary bone cancer, occurring as a remote spread (metastasis) from a primary cancer elsewhere, are much more common. See also OSTEOSARCOMA.
|Mean LOS:||5.4 days|
|Description:||MEDICAL: Pathological Fractures and Musculoskeletal and Connective Tissue Malignancy With CC|
Bone cancers are sarcomas—that is, cancers of connective tissue. It is estimated that there were 3,010 new cases of bone cancer diagnosed in 2013. Primary bone cancers are relatively uncommon, constituting less than 0.2% of all cancers. Most (60% to 65%) tumors of the bone are secondary, or metastatic, ones from other primary tumors. Cancers originating in the osseous, cartilaginous (chrondrogenic), or membrane tissue are classified as bone cancer. Cancers originating from the bone marrow are usually classified as hematologic cancers. The most common type of primary bone cancer is osteosarcoma (Table 1). Osteosarcoma and chondrosarcoma are the most common sarcomas of the bone; they compose 70% of all bone cancers. The remaining 30% of bone cancers are Ewing’s sarcoma, chordomas, and malignant histiocytoma and fibrosarcomas.
|Type||Ages of Peak Occurrence (Years)||Major Locations in the Body||Average Number of New Cases per Year||Treatment in Order of Importance|
|Osteogenic sarcoma or osteosarcoma (35% of all cases)||10–30||Bone of leg, arm, pelvis||520; occurs in males more than females||Surgery, radiation, chemotherapy|
|Chondrosarcoma (26% of all cases)||Peaks at 50–60 but occurs in ages 25–75||Cartilage of leg, hip, rib||428||Surgery, chemotherapy|
|Ewing’s sarcoma (16% of all cases)||10–20; rare in adults > 30 years||Long bones of legs and arms; pelvis||234||Radiation, chemotherapy|
|Fibrosarcoma (6% of all cases)||30–40||Bone of leg, arm, jaw||66||Surgery, radiation, chemotherapy|
|Chordoma (8% of all cases)||55–65||Spinal column or skull||56||Surgery, radiation|
|Parosteal osteosarcoma||30–40||Bone of arm or leg||26||Surgery, chemotherapy|
An osteosarcoma arises from osteoblasts (bone-forming cells) and osteoclasts (bone-digesting cells) in the interior of the bone; it occurs most commonly in the femur but also in the tibia and humerus. A chondrosarcoma arises from cartilage, and Ewing’s sarcoma tumors usually occur in bone but also arise from soft tissue such as muscle, fat, or other supporting tissue.
Evidence links the development of bone cancer with exposure to therapeutic radiation or treatment with some chemotherapeutic agents. A higher incidence has not occurred, however, in populations exposed to other forms of radiation, such as survivors of the atomic bomb. There have been reports of siblings with bone cancer, suggesting genetic influences. Osteogenic sarcoma is most common after puberty, which suggests that hormonal fluctuations and spurts of growth may be involved. Bone cancers tend to be more common in adults who are affected by Paget’s disease, hyperparathyroidism, and chronic osteomyelitis. The development of bone cancer has also been linked to trauma and sites of old bone infarcts or fractures, multiple exostoses (overgrowth of bone tissue), multiple osteochondromas (benign bone tumor), and bone marrow transplantation.
Several factors can increase the risk of bone cancer. Families with retinoblastoma (an eye cancer often caused by mutations in RB1) have an increased risk for osteosarcoma, as do those with familial cancer syndromes, such as Li-Fraumeni syndrome (from TP53 and CHEK2 mutations). The genetic condition of multiple hereditary exostosis (abnormal bone overgrowths) also increases the likelihood of bone cancer, which may be caused by a loss of heterozygosity of a tumor suppressor at 18q21–q22.
Gender, ethnic/racial, and life span considerations
Children seem particularly susceptible to bone cancer related to exposure to therapeutic radiation or chemotherapeutic agents. Primary cancers of the bone are more common in males and tend to occur in the late teen years or after age 60. Osteogenic sarcoma, or osteosarcoma, the most common kind of bone cancer, occurs mainly in teenagers. Metastatic bone cancer usually appears later in life because it accompanies other cancers, especially lung, breast, prostate, and thyroid cancer. Incidence of osteosarcoma is slightly higher in blacks/African Americans than in whites.
Global health considerations
The overall incidence of bone cancer globally is slightly higher in males than in females and approximately three times higher in developed nations compared with developing nations.
The focus of the assessment should be on gathering data that differentiate bone cancer from arthritic or traumatic pain. The patient usually reports the gradual onset of pain described as a dull ache. The patient often notices a swelling or the inability to move a joint as before. A distinctive trait of bone cancer pain is its tendency to be worse at night. Generally, it is a localized, aching pain, but it may also be referred from the hip or spine. The sudden onset of pain does not rule out bone cancer, however, because a pathological fracture may be present. If the cancer has spread, the patient may report weight loss and fatigue.
The most common symptom is pain with activity. Inspect for any unusual swellings or dilated surface vessels. The patient may walk with a limp or have weakness of the affected limb. If the tumor has progressed, you may note weight loss or cachexia, fever, and decreased mobility. Perform gentle range-of-motion exercises of all the extremities and document any limitations in joint movement. Note any firm, nontender enlargements in the affected area when it is palpated. Consider, however, that bone tumors are not always visible or palpable. The tumor site may also be tender.
Although some cancers can be cured with treatments that leave no visible signs, primary bone cancer often requires extensive surgical reconstruction or amputation of the affected limb as part of the treatment. Determine the patient’s view of his or her body image and assess whether the impact of the treatment may lead to a body image disturbance.
|Test||Normal Result||Abnormality With Condition||Explanation|
|Serum alkaline phosphatase||4.5–13 units/dL||Elevated||Elevations occur with formation of new bone by increasing osteoblastic activity|
|X-rays and computed tomography (CT); Magnetic resonance imaging (MRI)||No lesions||Visualization of lesions; malignant lesions often have poor margination, irregular new bone growth||Each tumor type has its own characteristic pattern; CT shows extent of soft tissue damage; MRI of primary lesion assesses extent of disease|
Other Tests: In Ewing’s sarcoma and metastatic bone lesions, increases occur in erythrocyte sedimentation rate as well as in leukocytosis and normocytic anemia. Other tests include bone biopsy, bone scan, serum calcium, MRI, complete blood count, liver function tests, serum electrolytes, renal function tests, and urinalysis.
Primary nursing diagnosis
DiagnosisImpaired physical mobility related to weakness, loss of limb, or pain
OutcomesAmbulation: Walking; Joint movement: Active; Mobility level; Self-care: Activities of daily living; Transfer performance; Balance; Muscle function; Pain level
InterventionsExercise therapy: Ambulation and joint mobility; Positioning; Energy management; Exercise promotion; Self-care assistance; Teaching: Prescribed activity/exercise; Environmental management; Medication management; Pain management
Planning and implementation
medical.Radiation has variable effectiveness in bone cancer. It is quite effective with Ewing’s sarcoma, moderately effective with osteosarcoma, and relatively ineffective in chondrosarcoma. Even when a cure is not possible, radiation is often used to decrease pain and slow the disease process. External beam radiation therapy, where the radiation is delivered from outside of the body, is the type most often used to treat bone cancer.
surgical.Surgery may range from simple curettage (removal of necrotic tissue or tumor with a curet) when primary bone cancer is confined to amputation or extensive resection such as a leg amputation with hemipelvectomy. Ongoing data suggest that for many bone cancers, limb-sparing treatment (surgical removal of only the tumor with chemotherapy and/or radiation) may provide the same cure rate as amputation. Pain is usually managed with narcotic analgesia in the immediate postoperative period. As the patient recovers, prosthetic devices are often fitted after amputations. The patient may have a prosthesis fitted immediately or a more traditional delayed fitting. Usually, a physical therapist works with the patient to help her or him learn ways to maintain mobility and the appropriate use of appliances and adjuncts.
|Medication or Drug Class||Dosage||Description||Rationale|
|Chemotherapy||Varies by drug||Doxorubicin, cisplatin, methotrexate with calcium leucovorin, ifosfamide, etoposide||Chemotherapy is often used preoperatively to reduce the size of the tumor or postoperatively to help eliminate the risk of micrometastasis|
Other Drugs: Immunotherapy, primarily interferon or tumor-specific transfer factor, remains investigational with bone cancer; analgesia. Zometa is used for the treatment of bone metastases and is superior to the other bisphosphonates in the treatment of pain and skeletal-related events.
Presurgical preparation is essential. Encourage the patient to eat foods high in protein and vitamins to foster wound healing. Begin teaching the exercises that, after surgery, prevent contractures and strengthen limbs to accept the adjustments in posturing and movement. With extensive resection, the patient is exposed to anesthesia for a longer period of time. Preparation for pulmonary toileting and methods to prevent venous stasis become even more important in those patients. When radiation or chemotherapy is used as well, begin preoperative teaching.
Start exercises within 24 hours after surgery to maintain muscle tone and prevent edema, joint contractures, and muscle atrophy. If a prosthesis is to be fitted after healing, take care to wrap the stump to promote proper shrinking and shaping without compromising the patient’s circulation.
Whether the treatment is amputation, resection, chemotherapy, or radiation, the changes in the patient’s body create severe emotional stress. Listen to the patient’s concerns and support efforts to maintain grooming and hygiene. Provide opportunities for the patient to make treatment decisions and to maintain as much control over his or her environment as possible. If the patient develops a body image disturbance or ineffective coping, provide referrals for counseling or a support group when required. Acquaint the patient and family with the supports available through the American Cancer Society or hospice.
Evidence-Based Practice and Health Policy
Smorti, M. (2012). Adolescents’ struggle against bone cancer: An explorative study on optimistic expectations of the future, resiliency, and coping strategies. European Journal of Cancer Care, 21(2), 251–258.
- The period immediately following successful treatment for bone cancer is an important time for supporting the establishment of future expectations and resilience related to cancer experiences, especially among adolescents.
- Investigators of one study compared 32 adolescents ages 11 to 30 who were successfully treated for osteosarcoma or Ewing’s sarcoma within 1 month of participating in the study to a normative sample of 48 gender- and age-matched, randomly selected adolescents.
- The adolescents with a bone cancer diagnosis had more optimistic expectations of the future (mean of 41.15 versus 35.23, F = 10.5, p < 0.005) and greater impulse control (mean of 21.69 versus 16.02, F = 30.48, p < 0.001) than the normative sample.
- However, these adolescents also reported lower resilience (mean of 26.94 versus 31.13, F = 18.48, p < 0.001), less positive engagement with the world (mean of 10.41 versus 13.92, F = 20.96, p < 0.001), and greater use of avoidance-type coping strategies (mean F = 92.11, p < 0.001) than the normative sample.
- Appearance of the surgical incision site: Presence of inflammation, infection, or signs of healing
- Response to chemotherapy or radiation treatments
- Comprehension of treatment plan, including care of surgical site, purpose, and potential side effects of medical treatments
- Reaction to the loss or disfigurement and prognosis
- Readiness to adapt to a prosthetic device
- Presence of complications: Infection, bleeding, poor wound healing, ineffective coping by the patient or significant others
Discharge and home healthcare guidelines
preparation for prosthetic.Teach the patient how to promote healing at the surgical site by keeping the incision clean, dry, and covered. Explain that the stump needs to be wrapped to promote shrinkage and proper shaping for the prosthesis. Teach exercises to maintain strength and range of motion and to prevent contractures. Explain the roles of the interdisciplinary team members in the patient’s rehabilitation.
continuing treatment.If the patient receives outpatient chemotherapy or radiation, teach the patient the purpose, duration, and potential complications of those treatments.
Patient discussion about bone cancer
Q. Is a bone tumor cancer? My son is 10 years old and his Doctor found a tumor on his bone in an x-ray he did to him. Is this cancer?
Q. is there such thing bone cancer? if so what does it cause? i am asking because bone isn't a cell platform and cancer is cells that are multiplying by the dozen !!! is so also in bone , if there is such thing ...