Primary malignant bone tumors

Primary malignant bone tumors: Excerpt from Professional Guide to Diseases (Eighth Edition)

Primary malignant bone tumors (also called sarcomas of the bone and bone cancer) are rare, constituting less than 1% of all malignant tumors. Most bone tumors are secondary, caused by seeding from a primary site. Primary malignant bone tumors are more common in males, especially in children and adolescents, although some types do occur in people between ages 35 and 60. They may originate in osseous or nonosseous tissue. Osseous bone tumors arise from the bony structure itself and include osteogenic sarcoma (the most common), parosteal osteogenic sarcoma, chondrosarcoma, and malignant giant cell tumor. Together they make up 60% of all malignant bone tumors. Nonosseous tumors arise from hematopoietic, vascular, and neural tissues and include Ewing's sarcoma, fibrosarcoma, and chordoma. Osteogenic and Ewing's sarcomas are the most common bone tumors in childhood. (See Comparing primary malignant bone tumors.)

Causes and incidence

Causes of primary malignant bone tumors are unknown. Some researchers suggest that primary malignant bone tumors arise in areas of rapid growth because children and young adults with such tumors seem to be much taller than average. Additional theories point to heredity, trauma, and excessive radiotherapy.

For incidence information, see Comparing primary malignant bone tumors.

Signs and symptoms

Bone pain is the most common indication of primary malignant bone tumors. It's generally more intense at night and isn't usually associated with mobility. The pain is dull and is usually localized, although it may be referred from the hip or spine and result in weakness or a limp. Another common sign is the presence of a mass or tumor. The tumor site may be tender and may swell; the tumor itself is in many cases palpable. Pathologic fractures are common. In late stages, the patient may be cachectic, with fever and impaired mobility.

Diagnosis

CONFIRMING DIAGNOSIS A biopsy (by incision or by aspiration) is essential to confirm primary malignant bone tumors. Bone X-rays and radioisotope bone and computed tomography scans show tumor size. Serum alkaline phosphatase level is usually elevated in patients with sarcoma.

Treatment

Excision of the tumor with a 3"(7.6 cm) margin is the treatment of choice. It may be combined with preoperative chemo-therapy.

In some patients, radical surgery (such as hemipelvectomy or amputation) is necessary; however, surgical resection of the tumor (commonly with preoperative and postoperative chemotherapy) has saved limbs from amputation.

Intensive chemotherapy includes administration of doxorubicin, vincristine, cyclophosphamide, cisplatin, dacarbazine, and etoposide in various combinations. Chemotherapy may be infused intra-arterially into the long bones of the legs.

Special considerations

❑Be sensitive to the emotional strain caused by the threat of amputation. Encourage communication and help the patient set realistic goals. If the surgery will affect the patient's lower extremities, have a physical therapist teach him how to use assistive devices (such as a walker) preoperatively.

❑Teach the patient how to readjust his body weight so that he can get in and out of the bed and wheelchair.

❑Before surgery, start I.V. infusions to maintain fluid and electrolyte balance and to have an open vein available if blood or plasma is needed during surgery.

❑After surgery, check vital signs every hour for the first 4 hours, every 2 hours for the next 4 hours, and then every 4 hours if the patient is stable. Check the dressing periodically for oozing. Elevate the foot of the bed or place the stump on a pillow for the first 24 hours. (Be careful not to leave the stump elevated for more than 48 hours because this may lead to contractures.)

❑To ease the patient's anxiety, administer analgesics for pain before morning care. If necessary, brace the patient with pillows, keeping the affected part at rest.

❑Urge the patient to eat foods high in protein, vitamins, and folic acid and to get plenty of rest and sleep to promote recovery. Encourage some exercise. Administer laxatives, if necessary, to maintain proper elimination.

❑Encourage fluids to prevent dehydration. Record intake and output accurately. After a hemipelvectomy, insert a nasogastric tube to prevent abdominal distention. Continue low gastric suction for 2 days after surgery or until the patient can tolerate a liquid diet. Administer antibiotics to prevent infection. Give transfusions, if necessary, and administer medication to control pain. Keep drains in place to facilitate wound drainage and prevent infection. Use an indwelling urinary catheter until the patient can void voluntarily.

❑Keep in mind that rehabilitation programs after limb salvage surgery will vary, depending on the patient, the body part affected, and the type of surgery performed. For example, one patient may have a surgically implanted prosthesis (for example, after joint surgery), whereas another may have reconstructive surgery requiring an allograft (such as bone from a bone bank) or an autograft (bone from the patient's own body).

Encourage early rehabilitation for patients with amputated limbs as follows:

❑Start physical therapy 24 hours postoperatively. Pain is usually not severe after amputation. If it is, watch for a wound complication, such as hematoma, excessive stump edema, or infection.

❑Be aware of the “phantom limb” syndrome, in which the patient “feels” an itch or tingling in an amputated extremity. This can last for several hours or persist for years. Explain that this sensation is normal and usually subsides.

❑To avoid contractures and ensure the best conditions for wound healing, warn the patient not to hang the stump over the edge of the bed; sit in a wheelchair with the stump flexed; place a pillow under his hip, knee, or back or between his thighs; lie with knees flexed; or rest an above-the-knee stump on the crutch handle or abduct it.

❑Wash the stump, massage it gently, and keep it dry until it heals. Make sure the bandage is firm and is worn day and night. Know how to reapply the bandage to shape the stump for a prosthesis.

❑To help the patient select a prosthesis, consider his needs and the types of prostheses available. The rehabilitation staff will help him make the final decision, but because most patients are uninformed about choosing a prosthesis, give some guidelines. Keep in mind the patient's age and possible vision problems.

PEDIATRIC TIP Generally, children need relatively simple devices. Children also outgrow prostheses, so advise parents to plan accordingly.

ELDER TIP Elderly patients may need prostheses that provide more stability. Consider finances, too.

❑The same points are applicable for a patient with an arm amputation, but losing an arm causes a greater cosmetic problem. Consult an occupational therapist, who can teach the patient how to perform daily activities with one arm.

❑Try to instill a positive attitude toward recovery. Urge the patient to resume an independent lifestyle. Refer elderly patients to community health services if necessary. Suggest tutoring for children to help them keep up with schoolwork.

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Book Source Details

• Book Title: Professional Guide to Diseases (Eighth Edition)
• Author(s): Springhouse
• Year of Publication: 2005
• Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.

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More About This Book: Title: Professional Guide to Diseases (Eighth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2005 ISBN: 1-58255-370-X

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