Bone cancer is a group of rare tumors. Primary malignant tumors are 50% osteosarcoma. The development of chondrosarcoma is more typical for the pelvic bones. In most cases, diseases of this group are diagnosed in children and young people under 30 years of age. About a tenth of the cases are elderly people, in whom the development of cancer can be triggered by other diseases of the musculoskeletal system.
- Causes and risk factors for developing pelvic bone cancer
- Stages of the disease
- Types of disease
- Clinical picture of osteosarcoma
- How does chondrosarcoma manifest?
- Metastasis of chondrosarcoma
- Diagnosis of the disease
- Therapy methods
- Complications
- Forecast
- Prevention
Causes and risk factors for developing pelvic bone cancer
Factors that predispose to the development of the disease are some disembryonic disorders, as well as radiation and chemical effects on the body. As a result of an experiment on animals, the occurrence of bone cancer was revealed after the effect of radioactive strontium on the body. Precancerous conditions are considered to be osteochondral exostoses and deforming ostosis (Paget's disease).
Osteosarcoma most often develops during periods of increased bone growth. Therefore, adolescents, especially young men, are more at risk of developing this tumor.
Stages of the disease
The basis for staging bone cancer is the international TNM system. It includes determining the primary tumor site, local spread of the tumor, and the presence of distant metastases.
Thus, there are 4 stages of bone tumors:
- Stage I. The malignant tumor does not extend beyond the bone or involves the cortical layer, and has a high or moderate level of differentiation. There is no damage to lymph nodes or distant metastases.
- Stage II. The tumor does not extend beyond the bone or beyond the cortex, but has a low degree of differentiation or is undifferentiated.
- Stage III. A neoplasm of any degree of differentiation without boundaries in the affected bone.
- Stage IV. Tumor of any size and any differentiation with metastases.
This cancer staging system is the basis for assessing a patient's survival prognosis. It also helps in selecting treatment tactics and the type of surgical intervention.
How does sarcoma develop?
Genetic changes lead to a chaotic division of connective tissue structures. The tumor grows, invades nearby structures, and destroys them. Typically, the lower the degree of differentiation of structures, the more malignant the disease. With the development of formation, atypical elements are distributed in the body with the blood or lymph flow, collecting far from the location of the primary formation, forming secondary areas of metastasis. Therefore, even with radical treatment, relapse processes are not uncommon.
As the tumor progresses, it grows into other tissues, disrupting their functions; in addition, pain syndrome develops (due to ingrowth into nerve trunks), the swallowing process is disrupted (if the esophagus is affected), and breathing failures are present (when the trachea is affected). Most often, at the site of the incision, the sarcoma tissue is soft, elastic, white-pink in consistency (like fish meat), in addition, they do not have clear boundaries - the tissue gradually turns into normal tissue. Due to the fact that sarcomas exist in many variations, it should be noted that some of them progress very slowly (for example, parosteal bone sarcoma), others have a very rapid progression (rhabdomyosarcoma), while liposarcoma is distinguished by simultaneous or sequential formation in several locations.
Types of disease
There are several types of primary cancer that can cause damage to the pelvic bones. These include: osteosarcoma, chondrosarcoma and Ewing's sarcoma.
Osteosarcoma
Osteogenic sarcoma is the most common type of bone cancer. Most often, the disease occurs in children and young people under 20 years of age, but older people aged 60-70 years are also affected. The favorite localization of osteosarcoma is the femur and tibia. This tumor rarely affects the pelvic bones.
Chondrosarcoma
This type of cancer occurs primarily in people over 40 years of age. Chondrosarcoma consists of cartilage tissue cells. It is for this type of cancer that the most common location is the pelvic bones.
List of sources
- Clinical guidelines for bone sarcomas, 2021, 51 p.
- Practical recommendations for the treatment of primary malignant bone tumors (osteosarcoma, Ewing's sarcoma) / Malignant tumors. Russian Society of Clinical Oncology. 2021, pp. 283-295.
- Clinical guidelines for the diagnosis and treatment of patients with primary malignant bone tumors. 2014, 25 p.
- Clinical protocol for diagnosis and treatment. Bone sarcoma, 2015, 19 p.
- Belokon O.V., Nechval V.N. Surgical treatment of children with osteogenic sarcoma with metastases to the lungs/Health of Ukraine, 2012, pp. 34-35.
Clinical picture of osteosarcoma
The disease manifests itself as a progressive increase in the volume of the affected part of the body. The main symptoms of osteogenic sarcoma of the pelvic bones:
- “Deep” increasing pain over several weeks or months.
- The skin over the tumor may become hyperemic and swollen. A pronounced venous pattern is often identified in this area.
- With a large volume of damage, movements in the hip joint may be limited; in some cases, effusion in the joint cavity is detected.
In the area of tumor growth, a painful, dense formation can be felt, which is fused to the bone. A local increase in skin temperature may also be observed.
How does chondrosarcoma manifest?
The severity of clinical manifestations of chondrosarcoma depends on its morphological structure. Well-differentiated tumors are characterized by long-term slow growth (over 4-5 years) with low severity of symptoms. Such formations can reach significant sizes. With anaplastic chondrosarcomas, which often affect young people, symptoms develop faster, on average within 3 months.
The main symptoms of the disease are pain in the area of tumor growth. The pain is constant, characterized by a progressive increase in intensity. Other local manifestations (increased venous pattern, local increase in temperature, dysfunction of a nearby joint) are less common than with osteosarcoma and are less pronounced.
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The first manifestations of sarcoma
It should be noted that the clinical manifestations of sarcomas depend primarily on their location and the biological characteristics of the original structures. For most sarcomas, the initial manifestation of the disease is the formation of an expanding tumor. A clear sign that distinguishes sarcoma from benign tumors or non-tumor diseases is the limitation of its level of mobility (it can vary from subtle fixation to absolute fusion with the underlying tissue). This is explained by the fact that the sarcoma covers nearby structures.
With bone sarcomas, the disease is first indicated by pain in the area of the affected bone at night; then swelling in this place and dysfunction are connected to them. Due to the growth of the tumor and the inclusion of nearby anatomical formations in the process, symptoms are added (the network of veins expands, there are conductive pains in the area of the affected nerves). In the future, employees of a famous Israeli clinic note, fatigue, loss of appetite, weight, and increase in temperature may occur.
If the base of the skull is affected, the functions of the cranial nerves are disrupted, and this, for example, can manifest itself in double vision or facial nerve paralysis.
Retroperitoneal tumors are characterized by weight loss and pain of unknown localization. Bleeding is the most common sign of such pathologies of the gastrointestinal tract and female genital organs. A number of varieties of such tumors (parosteal bone sarcomas) are characterized by almost asymptomatic development and unhurried growth over several years. Other sarcomas (poorly differentiated formations with high proliferative activity, for example, rhabdomyosarcomas) are characterized by extensive local spread, surgical progression, and early hematogenous metastases.
As a rule, a person's arm, shoulder, hip, or leg first becomes very swollen. Later, unusual areas of compaction are noticeable and they gradually harden. The pathological process does not always complement the pain syndrome, but the lump grows in size. In a number of situations, people seeking cancer treatment abroad complain of pain in the extremities. With bone sarcoma, significant pain is felt even at rest, seemingly without any reason for the formation of a pain syndrome.
Certain sarcomas (for example, liposarcomas) have a primary multiple nature; they arise simultaneously or sequentially in different places of the body, which often complicates the solution of issues of their metastasis.
Prognostic factors for sarcomas are their level of malignancy, scale, depth of invasion, possibility of surgery, etc. This is an aggressive type of tumor, most effectively cured in the initial phases. Every person with an enlarging tumor; If you experience prolonged “unreasonable” bone pain, you should immediately seek the services of a specialist. Prices for treatment in Israel will also be lower if treatment is started early.
Before starting treatment abroad, the patient is usually prescribed an MRI or CT scan, due to which the formation becomes visible on the image. Soft tissue sarcoma does not cause pain. Most people go to the doctor with a lump that is gradually growing. As a result, a sarcoma is discovered. If the tumor is localized in the abdominal cavity, its initial sign is usually a large formation. Sometimes it is discovered by a therapist during a simple physical examination; in other situations, the tumor is identified by CT image.
Diagnosis of the disease
Based on complaints and examination of the patient, a specialist may suspect pelvic bone cancer, but an accurate diagnosis can be made using the following instrumental research methods:
- X-ray diagnostics. Taking an image in two projections is mandatory if bone cancer is suspected. The main radiological symptoms of malignant bone tumors are foci of destruction of a plastic, lytic or mixed nature. The lesions do not have clear boundaries. A common symptom is periostitis with a needle or bulbous pattern.
- Osteoscintigraphy. The severity of the malignant process in the bone is characterized by the intensity of accumulation of the radiopharmaceutical. This study is used both to identify hidden lesions inside and outside the bone, and for the purpose of differential diagnosis with bone metastases.
- Computed tomography allows you to clarify the boundaries of tumor formation. Using CT, you can also determine the nature of the location of the primary lesion in relation to the surrounding soft tissues.
- A histological examination is mandatory to establish a diagnosis of bone cancer.
Sometimes it becomes necessary to perform phlebography or angiography. These studies help to clarify the location of the vessels near the tumor before performing surgery.
Oncological endoprostheses
Implants used in orthopedic oncology are usually much larger. This is necessary to replace removed bone tissue. It is logical that megaprostheses disrupt the biomechanics of the joint, which leads to instability of the implant. For tumors of the lower extremity, patients can have not only joints replaced, but also bones. The type of implant depends on the location and size of the malignant neoplasm.
Types of oncological prostheses of the lower limb:
- replacing the hip joint and part of the femur;
- replacing the knee joint and part of the femur or tibia;
- completely replacing the femur;
- spacers – closed knee joint endoprostheses;
- partially replacing and lengthening the femur.
The main difference between oncological implants is their massiveness and complexity of design.
Several companies are involved in the production of oncological prostheses: Stryker, ImplantCast, Biomet. Companies produce modular endoprostheses that can be fixed with cement or cementless methods.
A special feature of modular prostheses is the ability to assemble them during surgery. This makes it possible to reconstruct bone defects of any size. The use of modular endoprostheses makes it possible to avoid the manufacture of an individual implant.
Unexpected intraoperative findings in oncology are not uncommon. They force doctors to remove more bone tissue than planned. The use of modular prostheses allows us to cope with this problem with minimal harm to the patient. To replace the defect, you just need to expand the endoprosthesis to the desired size.
Curious! In oncologic orthopedics, endoprostheses with silver coating are becoming increasingly popular. The silver ions it contains have an antibacterial effect and reduce the risk of infection.
Therapy methods
The goal of treatment is to remove the tumor along with part of the healthy bone and surrounding tissue (taking into account zonation), as well as to prevent recurrence and metastasis. Most often, combination cancer treatment is used using chemotherapy and/or radiation methods in combination with surgery.
Surgery
The extent of the operation is determined based on the results of histological examination, tumor size, and general condition of the patient. Often, along with the tumor, it is necessary to remove the muscular-fascial sheath (sheath principle). If the fascial border is technically difficult to access, then the layer of muscles that surrounds it is removed (zonal principle). These features must be taken into account when planning the operation.
The gold standard of surgical treatment is organ-conserving surgery. Such an intervention for cancer of the pelvic bones is interiliac-abdominal resection.
If the tumor affects the hip joint, then endoprosthetics can be performed simultaneously. The use of an endoprosthesis allows one to quickly improve the patient’s quality of life while fully restoring limb function.
Radiation therapy
The method of radiation therapy is selected taking into account the morphological type of cancer and its radiosensitivity. This treatment is used together with chemotherapy, as well as in the process of preoperative preparation.
Chemotherapy
Most often, several drugs are used that mutually potentiate each other's effects. If there is a solitary (single) lesion in the pelvic bones and subsequent surgical intervention, chemotherapy is carried out locally. The antitumor drug is delivered directly to the pathological focus using an arterial catheter. This method is highly effective because it helps to achieve an increased concentration of the drug in the tumor. For a generalized process, systemic chemotherapy is used.
Contraindications to surgery
Before performing surgery, doctors examine the patient and determine the extent of the operation. They “give a verdict” based on the results of biopsy, radiography, CT, MRI, skeletal scintigraphy and other research methods. The final decision still remains with the person himself; he has the right to refuse removal of the lower limb.
Total femur replacement surgery with knee implant.
There are a number of situations when leg amputation is necessary. Sometimes refusal of organ-preserving surgery saves a person’s life, but an attempt to save the lower limb leads to his quick death.
Absolute indications for amputation:
- disintegration of a malignant neoplasm;
- dissemination (spread) of tumor cells due to poorly performed biopsy;
- damage to the main vessels or nerves of the limb.
Doctors often recommend amputation for patients with pathological fractures, complications of chemotherapy and severe damage to vital organs, accompanied by decompensation of their functions. In these cases, removing a lower limb gives the person a much better chance.
A contraindication is the inability to form a muscular case for the implant. This jeopardizes the implantation of the prosthesis and poses a risk of developing infectious complications.
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Complications
Malignant bone tumors, especially osteosarcoma, are characterized by hematogenous metastasis. The most common localization of metastases is lung and brain tissue.
It is also common for bone cancer to recur even after complete treatment. 95% of local relapses occur within 2 years after surgery. In this regard, radiography is recommended every 3 months during the first year after tumor removal, once every six months in the second year and subsequently - once a year.