Bone Tumors

A tumor is a mass or swelling that arises from the uncontrolled division of body cells, resulting in growth within the affected tissue and/or organ. The cause of most bone tumors is unknown. As the tumor grows, it gradually spreads to healthy tissues, causing them to be replaced by abnormal tissues and weakening the bone, which can lead to pathological fractures. If necessary precautions are not taken, aggressive tumors can cause functional deficiencies within the organ system they develop in and may even threaten life by affecting the entire body's metabolism.

Most bone tumors are benign. Some can be malignant. Rarely, infections, stress fractures, and other non-tumor conditions may exhibit tumor-like behavior.

Benign tumors do not pose a threat to life. Malignant tumors can spread throughout the body and cause metastasis. The spread of cancer cells beyond the tissue where they originated, either directly or through blood/lymph, is referred to as metastasis.

Cancer that begins in the bone (primary) is different from cancer that originates in another part of the body and then settles in the bone (secondary). The development of the tumor and its destruction depend on the biological behavior of the tumor cells. While some bone tumors may be discovered incidentally, others can lead to many symptoms that significantly discomfort the patient.

Types of Bone Tumors

Malignant Tumors

Metastatic Bone Tumors: These are malignant tumors that spread to the bones from other organs. Patients often present with complaints of persistent pain that does not improve with rest or pathological fractures. The cancers that most commonly metastasize to the bones are prostate, lung, and breast cancers.

Multiple Myeloma: Multiple myeloma is the most common primary bone cancer. It is a malignant tumor of the bone marrow. It can cause the death of 20 people per million each year. It can affect any bone and is typically seen in patients aged 50 to 70.

Osteosarcoma: Osteosarcoma is the second most common bone cancer. Frequently occurring during adolescence, it usually manifests in the knee area and is seen in 2-3 people per million each year. Although less common, it can also occur in the hip and shoulder regions.

Ewing Sarcoma: Ewing sarcoma is commonly seen in individuals aged 5 to 20; it forms a large soft tissue mass along with bone destruction. It is most frequently observed in the upper and lower extremities, pelvis, and rib bones.

Chondrosarcoma: Chondrosarcoma is a type of bone tumor that typically presents as a mass in the hip area, pelvis, and shoulder in individuals aged 40 to 70.

Benign Tumors

Most Common Types:

• Non-osseifying fibroma
• Simple bone cyst
• Osteochondroma
• Giant cell tumor
• Enchondroma
• Fibrous dysplasia

What Are the Symptoms of Bone Tumors?

The pain observed in most patients with tumors is typically dull and constant (it persists even at rest); it is not related to activity and often worsens at night.

The pain is not due to trauma, but it may increase after an injury. Pathological fractures occur in weakened bones, which also contributes to increased pain. Some tumors can cause fever and night sweats. Occasionally, they may present as a painless mass. In cases of ankle trauma, certain tumors may be incidentally discovered on X-rays.

How Is Bone Tumor Diagnosis Made?

If you think you have some of the symptoms and/or complaints mentioned above, it is advisable to consult a physician. Medical examination and assessments will be helpful in this regard.

Medical History
The physician you consult will first take a detailed medical history. This history will encompass every detail related to your medical background, including medications you are taking and any past illnesses.

Physical Examination
Your doctor will conduct a thorough physical examination. During the examination, if there is a tumor or a suspicion of a tumor, the physician will assess the size, mobility, and whether the mass is adhered to surrounding tissues, as well as its relationship with joints, and will perform additional examinations of other systems if necessary.

Imaging
Your doctor will request a simple imaging film known as a "direct" X-ray to evaluate the body area in question. Various types of bone pathologies, including bone tumors, will present different images on direct X-rays. Some may show excessive calcification (bone formation), while others may indicate bone resorption. Sometimes, these two conditions may appear mixed together. These X-rays will be evaluated along with a report prepared by the radiology department, the results of your physician’s examination, and any laboratory test results requested if needed.

In some cases, direct X-rays may not be sufficient to clarify the problem, and physicians may utilize advanced imaging techniques such as computed tomography, MRI, bone scintigraphy, PET scans, and lung tomography. Tomography is used to visualize bone details, while MRI is utilized to see soft tissue spread, tumor extension within the bone, or metastasis to distant sites. Bone scintigraphy provides information about whether metastasis is present or about tumor activity.

Tests
Complete blood tests and/or urinalysis may be required. A biopsy is another sampling method that should be performed by an orthopedic oncologist specializing in this area at the center where the surgical intervention will take place. The biopsy options may include needle biopsy or open biopsy, depending on the targeted tissue. It is crucial for the pathologist to have experience in this field as well as the biopsy chosen. The collected sample will be sent to the pathology department for cellular level examination and necessary staining tests.

How Are Bone Tumors Treated?

Treatment of Benign Bone Tumors

The treatment of benign bone tumors varies depending on the type of tumor and the patient's age; however, in most cases, observation is sufficient. In some cases, medical treatment can relieve pain. Some tumors may also spontaneously disappear over time (especially in children).

Close clinical observation may be necessary to investigate whether certain benign bone tumors are undergoing changes in characteristics (such as becoming malignant, progressing, or spreading to other tissues). In some situations, the doctor may recommend the excision of the tumor, which can prevent possible pathological fractures. However, in some types of tumors, recurrence can occur even if the mass is removed (this is referred to as recurrence). Giant cell tumors are among those benign tumors that can become increasingly aggressive over time. In cases of multiple osteochondromas, there may be a risk of malignant transformation or cancer development.

To monitor whether the different clinical courses mentioned above develop over time, it is advisable to remain under the supervision of a physician.

Treatment of Malignant Bone Tumors

If you are faced with a malignant bone tumor, you may always want to seek an evaluation from another physician and/or healthcare unit. The treatment of bone cancers is carried out through the collaborative work of a healthcare team. This team typically includes orthopedic oncologists, medical oncologists, radiologists, radiation oncologists, and pathologists. In such cases, the entire team's goal is to defeat the cancer and preserve the affected organ and/or limb. After assessing the patient’s condition, the physicians may use several treatment options together (for example; medication therapy (chemotherapy), radiation therapy (radiotherapy), and surgery). The decision-making in treatment approaches plays a significant role based on the tumor’s biological behavior (type) and stage (presence of metastasis, which is known as the spread of the tumor beyond its original location).

Limb-Sparing Surgery
If your physician believes that you would benefit from a surgical approach, this treatment may involve merely draining the tumor focus, or it may involve the removal of the tumor tissue along with a narrow or wide margin of healthy tissue (wide en-bloc resection). The aim here is to make the limb functional after providing the oncological treatment. Advanced techniques referred to as "reconstruction" are utilized during this process. Nowadays, prostheses, bone grafts (allografts, which are transplants of healthy tissue from the patient’s own body), and biological reconstruction methods are frequently used.

Radiotherapy
Some malignant bone tumors are sensitive to radiation therapy. It can be used alone or in combination with other treatments.

Chemotherapy
Medication treatment can be therapeutic at varying levels depending on the biological behavior of the disease. It is generally administered before or after surgery.

How Should Post-Treatment Follow-Up Be Conducted?

One of the most important aspects is the follow-up of the patient, which must be conducted first at short intervals and then throughout the following years. This way, any recurrence of the disease or spread to other organs can be detected early, allowing for the necessary treatment to be planned. During this period, psychological support should also be provided to the patient to help them return to their social life.

In addition to primary malignant tumors of the bone, tumors can arise through metastasis from cancers of the lungs, breast, thyroid, and prostate in men. In older adults, particularly those with a malignant tumor in any organ, any resulting bone pain must be carefully investigated.