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Skeletal System Tumours

What are the indicators of bone tumours?

Depending on the type of the tumour, swelling and pain are the most common indicators. While this is especially noticeable in malign tumours - or sarcomas - most of the time benign tumours can stay without showing any indicators for a long time.


How many types of bone tumours are there?

Bone tumours are divided in two as primary (or originating from the bone) or secondary, or originating from another organ and spreading to bone with the way of metastasis. Tumours originating from the bone itself are further divided as benign and malign tumours. Malign tumours are also called sarcomas.


What is sarcoma?

Sarcomas are malign tumours or cancers of tissues forming up muscoloskeletal system. The most important difference between malign and benign tumour is the ability to spread (metastasis) and therefore threaten life.


Which organs do malign tumours spread (metastasis) to?

While most metastasis are to lung and other bones, other internal organ metastasis can rarely be observed.


Which methods can be used to diagnose malign tumours?

First of all the complaints, examination of the patient, imaging methods and laboratory investigations are responsible for their diagnosis.


Which imaging methods are used for diagnosis?

Roentgen examinations, drugged (with contrast) computerised tomography and MRI (Magnetic Resonance Imaging), scintigraphy, and rarely PET (positron emission tomography) are the used methods.

Also lung films for investigating metastasis and more reliable lung tomography are needed.

Even with all these advanced methods, roentgen films are still the most beneficial investigation method for bone tumours. Especially computerised tomography for bone tumours and MRI for soft tissue tumours and both investigation methods for tumours holding bone and soft tissue together are required.


What is scintigraphy and why is it used?

Bone scintigraphy is and examination where the count of a radioactive agent that is help up by bone cells with a special camera following the injection. It allows for whole skeletal system to be monitored at the same time and therefore is very beneficial to see if there are more than one tumour foci or if there are cancers which metastasis to bone.


Can bone tumours be reliably diagnosed with these methods?

Especially for the patients who are thought to have malign tumours, if whether the tumour is malign or benign cannot be made the diagnosis needs to be defined with biopsy.


What is biopsy, how is it performed?

Biopsy is taken a piece of tumour tissue and evaluation of this part under microscope after special inks, immunological methods and sometimes genetic investigations. This process usually requires a few days following the biopsy.

While biopsy can be made with open method, in other words with small incisions of 2-3 cm, it can also be performed by taking parts from the tumour tissue with special needles without surgery. Open biopsy is a surgical operation while needle biopsy can be made standing.


In that case, wouldn’t it be better for all patients to go through need biopsy?

Since the part that can be taken with needle biopsy is very small, it might not be enough for definite diagnosis. Especially for malign bone tumours and some soft tissue tumours, open biopsy is a more suitable method. Again, if the part taken with the needle is taken from the healthy tissue or if the dead (necrotic) part of the tumour, it may give wrong results.


Isn’t there the same risk in open biopsy?

During the open biopsy “frozen section” is applied routinely, allowing for taken parts from the correct tissue and correct region of the tumour, while the pathologist who observes the tissue during this process can decide whether the amount taken will be enough or not.


What is “frozen section”?

Frozen section is the microscopic evaluation by freezing the part during the open biopsy while the patient is under anaesthesia (narcosis) and taking very thin slices and painting them. This process is usually enough to make benign - malign separation. Bu it is not enough to distinguish malign tumours from each other.


Are there many and various malign bone and soft tissue tumours?

Yes. Generally a few types are encountered frequently. But with the rarely encountered tumours, there are hundreds of different types of bone and soft tissue tumours that were identified.


What are the commonly encountered malign bone tumours?

In order of frequency osteosarcoma, Ewing Sarcoma, chondrosarcoma, and fibrosarcoma can be count amongst them.


What is Osteosarcoma?

It is the most common malign primary tumour of bone that is usually encountered between ages of 10-30 but can occur at any age. In about 90% of cases they are formed of “High Grade” bone cells. We also rarely encounter “Low Grade” osteosarcomas.


What is Tumour Grade?

The more the cells forming up a tumour is differentiated from the originals in the body and the more quickly and uncontrolled they multiply, they are that “High Grade”. This is a specification determined by the pathologist and it is the most important finding that determined the prognosis of the tumour. According to this, while high grade tumours are the ones with the most growth and spreading potential, and the ones with the earliest and most frequent metastasis tendency, these risks lower as the “Grade” of the tumour lowers.


What is Ewing sarcoma?

This tumour is an “High Grade” tumour that is encountered on younger ages than osteosarcom (usually 5-15 years of age) but can be encountered in young and middle aged people too.


What is chondrosarcoma?

Chondrosarcoma is a tumour that is encountered in more advanced ages (50 and upper) and originates from cartilage cells.


Why is it important to determine which tissue the tumour is originated from, apart from it being malign?

Treatment on malign tumours need to be performed according to type of the tumour. While the treatment for osteosarcoma is chemotherapy and surgical removal of the tumour tissue while in ewing sarcoma radiotherapy can be added to these two, and in chondrosarcoma, since chemotherapy and radiotherapy are inefficient, only surgical removal is performed.


How often are malign bone tumours encountered?

These tumours are very rarely encountered tumours. The most common osteosarcoma encounter ratio is about 3-4 in a million. Because of this, the most rare tumour’s diagnosis and treatment should be performed by a team that is formed of onco-orthopaedist, radiologist, pathologist, medical and radiation oncologists. Otherwise diagnosis and treatment mistakes can result in ways that is not possible to revert and the patient can lose their limb or in fact their life.


How are surgeries performed for bone cancers?

There are two base methods. Removing the cancerous limb from the body by cutting from a healthy area, or amputation in other words, or preserving the limb and only removing the tumour and tumorous area, or limb protective surgery in other words.


Is is possible to preserve the limb and remove the cancerous area in all patients?

Unfortunately, no. But in about 85-90% of the patients this method can be used. In very big tumours, tumours that hold main veins and nerves, if the metastasis of tumour with bad biopsies is possible, if there is inflammation along with the tumour, amputation - or removal of the limb - might be necessary.


How do the empty spaces after the tumour is removed fill in bones and soft tissue?

If it is a bone where there would be no important functional loss after the removal of the tumour, such as fibula, or collarbone, it can be left as is without doing anything. But if the tumour held on to an important part of an important bone, following the removal of the tumour;

  • Prosthesis that hold the bone and joint,
  • Bone transfer from the body,
  • Bone transfer from cadaver,
  • Bone lengthening and shifting methods,
  • Artificial filling materials,
  • Bone cement or calcium compounds,

can be used to preserve the functionality.


What is chemotherapy and how is it applied?

Chemotherapy is killing of cancerous cells with drugs. It is especially applied in high grade osteosarcomas and Ewing sarcoma. Usually a few drugs are given together to target for highest tumorous cell death. In these tumours, chemotherapy is started before the surgery. It continues following the surgery.


What side effects do chemotherapy have?

Currently it is possible to lower the effect of chemotherapy on healthy tissues is possible with the help of drugs. At the same time, there can be many different side effects from complaints like hair loss, nausea to significant reduction of blood cells. Generally, patients who are young and without any other diseases, with high body resistance can tolerate chemotherapy well and side effects are gone after the treatment stops.


Why is chemotherapy applied before the surgery too?

If the response from the chemotherapy, in other words the tumour death, is above 90% it is regarded as a good response and it contributes significantly to the patient’s survival. But if this response cannot be achieved, drug changes will be need. The way to determine this method is to start chemotherapy before the surgery and again pathologically examining tumorous tissue removed in the surgery to determine the tumour death ratio.

Again, receiving chemotherapy before the surgery shrinks the tumour and makes the surgery easier and increase surety.


What are the side effects of radiotherapy?

Radiotherapy is performed with high dose radiation. This causes death in tumorous tissue, as well as healthy tissue and there for function loss in soft tissues and hardening in joints can occur.

In long term, there is the risk of other cancers occurring in the area radiotherapy is applied to. While not common, this is a serious issue. Again the damage due to radiation in growth areas of the bones can cause shortness in arm or leg. Because of this, especially for children, radiotherapy is seen as an alternative on the cases where not good enough response with chemotherapy is received after the surgery or if surgical removal of the tumour is insufficient or impossible.


What is the success ratio in bone cancers with all these treatments?

Of the patients who had 90% or higher tumour necrosis with chemotherapy and, if applied, radiotherapy, about 60% of them can be cured of the disease with a successful surgical operation.

But, if there is metastasis when the patients first applied or if it develops during the treatment, success rate is lowered. Again, for patients with metastasis, success can be achieved with removal of metastasis and chemotherapy.

As in all cancers, success depends on diagnosis and treatment being performed by experienced doctors and centres in a timely manner.


What are the indicators of benign bone tumours?

Pain is the most common indicator. Usually it occurs during nights. Depending on the type of the tumour, it can vary between very severe pain to mild pain. It responds to painkillers initially. If the tumour is local aggressive, the pain increases gradually, becomes continuous and does not respond to regular painkillers.


What does local aggressive mean?

Some benign bone tumours can cause serious damage in the bone they are located in and the soft tissue around it, disrupting the structure of the bone structure and spread in the area they are in or even, as it is the case in giant celled bone tumour, they can do lung metastasis with 5% ratio. When these tumours are not treated properly, they carry the potential to relapse frequently.


What are the other findings of benign bone tumours apart from the pain?

Swelling, movement loss due to pain, thinning in arms or legs are other findings. But a significant majority does not show any indicators. In these cases, tumour is either observed by chance from a roentgen of the patient due to another reason, or shows itself with a pathological fracture.


What is pathological fracture?

In the case of a situation where the bone gets weaker - such conditions as osteoporosis or bone loss, benign and malign bone tumours, bone inflammations - a simple sprain, tripping or even turning in the bed and such small traumas that would not normally cause fracture would cause fracture and these are called pathological fractures.


If a benign or malign tumour is detected by chance, how should it be treated?

Once again the important thing here is the tumour’s type. While some tumours are monitored every few months with imaging methods, especially local aggressive tumours or tumours that carry the risk of pathological fractures should be treated.


How are benign tumours treated?

Generally they are treated by removal of the tumorous tissue and filling the resulting area with organic or inorganic filler materials. Additional agents (chemical agents like alcohol, phenol, hydrogen peroxide, cauterisation or burning, scrapping with high rpm scalpels, freezing with liquid nitrogen etc.) should be used to prevent the relapsing of the tumour in local aggressive tumours.

For tumours that weaken the bone excessively or fractures that occurred with the tumour, the bone should be supported with materials such as nails or plates. On basic bone cysts and some similar tumours a surgery with small incisions of 1-2cm is possible and these patients can return to their daily life quickly.