Bone tumors, primary malignant
Bone tumors, primary malignant: Excerpt from Handbook of Diseases
A rare type of bone cancer, primary malignant bone tumors (sarcomas of the bone) constitute less than 1% of all malignant tumors. Most malignant 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 patients between ages 35 and 60.
The tumors 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 (chondroblatic), 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 (fibroblastic), and chordoma. Osteogenic and Ewing’s sarcomas are the most common bone tumors in childhood. (See Types of primary malignant bone tumors, pages 108 to 109.)
Causes
Although some cases of osteosarcoma are associated with genetic abnormalities (retinoblastoma, Rothmund Thomson syndrome) or exposure to carcinogens (such as ingested radium in watch dial painters), most cases have no immediately apparent cause. Ewing’s sarcoma cells demonstrate a characteristic translocation of genetic material from chromosome 22 to chromosome 11. Additional theories point to heredity, trauma, and excessive radiation therapy.
Signs and symptoms
age alert Limb pain and refusal to walk with limited range of motion are common findings in children with bone tumors.
Bone pain is the most common indication of a primary malignant bone tumor. It’s usually more intense at night and isn’t usually associated with mobility. The pain is dull and usually localized, although it may be referred from the hip or spine, which result in weakness or a limp. Another common sign is the presence of a mass or tumor.
The tumor site may be tender and swell; the tumor itself is often palpable. Pathologic fractures are common. In late stages, the patient may be cachectic, with fever and impaired mobility.
Diagnosis
A biopsy (by incision or by aspiration) is essential for confirming a primary malignant bone tumor. Bone X-rays and radioisotope bone and computed tomography (CT) scans show tumor size. Serum alkaline phosphatase levels are usually elevated in patients with sarcoma.
Clinical tip Bone X-rays, CT scans, and magnetic resonance imaging are all useful in assessing tumor size. Bone scans and CT scans of the lungs are important in checking for metastatic disease.
Treatment
❑ Excision of the tumor along with a 3"(7.6 cm) margin is the treatment of choice. It may be combined with preoperative chemotherapy.
❑ In some patients, radical surgery (such as hemipelvectomy or interscapulothoracic amputation) is necessary. However, surgical resection of the tumor (often with preoperative and postoperative chemotherapy) has saved limbs from amputation.
❑ Intensive chemotherapy includes administration of doxorubicin, ifosfamide, cisplatin, and high doses of methotrexate, alone or in various combinations for osteosarcomas. Additionally, vincristine, etoposide, and dactinomycin may be added if the patient has Ewing’s sarcoma. 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 into 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 and circulation to the extremities every 15 minutes for the first hour, every 30 minutes for the next 2 hours, every hour for the next 4 hours, every 2 hours for the next 4 hours, and then every 4 hours once the patient’s condition 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 an analgesic for pain before morning care. If necessary, brace him with pillows, keeping the affected part at rest.
❑ Urge the patient to eat foods high in protein and vitamins and to get plenty of rest and sleep to promote recovery.
Clinical tip If the patient is receiving methotrexate, dietary folate should be avoided.
❑ Encourage some physical exercise. Administer a stool softener, if necessary, to maintain proper elimination.
❑ Encourage the patient to drink plenty of fluids to prevent dehydration. Accurately record intake and output. After a hemipelvectomy, insert a nasogastric tube to prevent abdominal distention. Continue low gastric suction for 2 days after surgery or until bowel sounds return and the patient can tolerate a liquid diet. Administer an antibiotic to prevent infection. Give a transfusion, 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 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 amputees as follows:
❑ Start physical therapy 24 hours postoperatively. Pain usually isn’t 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; rest an above-the-knee stump on the crutch handle; or abduct an above-the-knee stump.
❑ Wash the stump, massage it gently, and keep it dry until it heals. Make sure the bandage is firm and 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 any neurosensory problems. Generally, children need relatively simple devices, whereas older adults may need prostheses that provide more stability. Consider finances, too. Children outgrow prostheses, so advise parents to plan accordingly.
❑ The same points are applicable for an interscapulothoracic amputee, 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.
age alert Refer older patients to community health services, if necessary. Suggest tutoring for children to help them keep up with schoolwork.
❑ Urge patients to immediately report any new pain or masses.
❑ Patients with large bone grafts or prosthetic implants require antibiotic prophylaxis when undergoing dental procedures.
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Book Source Details
- Book Title: Handbook of Diseases
- Author(s): Springhouse
- Year of Publication: 2003
- Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.
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More About This Book:
Title: Handbook of Diseases
Authors: Springhouse
Publisher: Lippincott Williams & Wilkins
Copyright: 2003
ISBN: 1-58255-266-5
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