BONE TUMOR

A. NITHYA 1ST YEAR M.SC (NURSING)

INTRODUCTION:

Neoplasms of the musculoskeletal system are of various types,

including osteogenic, chondrogenic, fibrogenic, muscle
(rhabdomyogenic), and marrow (reticulum) cell tumors as well as nerve,
vascular, and fatty cell tumors. They may be primary tumors or
metastatic tumors from primary cancers elsewhere in the body (eg,
breast, lung, prostate, kidney). Metastatic bone tumors are more common
than primary bone tumors.
INCIDENCE:

 Out of the total 1203 bone tumor cases, 15% (n = 181) were

benign.
 66% (n = 794) were malignant,
 19% (n = 228) were lesions of nonneoplastic (NNP).
 Majority of the cases were from the state of Maharashtra in
Western India.
RISK FACTORS:

 Genetics. Children with familial retinoblastoma, which is a type of

eye cancer, have an increased risk of developing osteosarcoma. ...
 Previous radiation therapy. ...
 Chemotherapy for another cancer. ...
 Benign tumors or other bone conditions.
BENIGN BONE TUMORS

 Benign bone tumors are more common than primary malignant

tumors.
 The main types of benign bone tumors are osteochondroma,
osteoclastoma, and endochroma .
 These types of tumors are often removed by surgery.
 OSTEOCLASTOM
ENDOCHROMA A
 TYPES OF PRIMARY BONE TUMORS

Types Descriptions:

Osteochondroma • Most common benign bone tumor

• Frequently located in metaphyseal portion of long bones,
particularly leg, pelvis, or scapula
• Occurs most often in persons ages 10-25
• Malignant transformation may occur (chondrosarcoma)

Osteoclastoma (giant cell tumor) • Arises in cancellous ends of arm and leg bones.
• About 10% are locally aggressive and may spread to
lungs.
• High rate of local recurrence after surgery and
chemotherapy.

Endochroma • Intramedullary cartilage tumor usually found in cavity of

a single hand or foot bone .
• Rare malignant transformation can occur.
• If tumor becomes painful, a surgical resection is done.
• Peak incidence in persons ages 10-20
Osteochondroma:

 Osteochondroma is the most common primary benign bone

tumor.

 It is characterized by an over growth of cartilage and bone near

the end of the bone at the growth plate.
 It is more commonly found in the long bones of the leg, pelvis, or
scapula.
Clinical manifestations:

 painless,
 Hard
 immobile mass
 lower-than-normal height for age
 soreness of muscles in close proximity to the tumor
 one leg or arm longer than the other
 pressure or irritation with exercise.
 Patients may also be asymptomatic.
Diagnostic Evaluation:

CT MRI
 x-ray, OSTEOCHONDRPMA OSTEOCHONDROMA
 CT scan
 MRI.
Treatment:

 No treatment is necessary for asymptomatic osteochondroma.

 If the tumor is causing pain or neurologic symptoms because of
compression, surgical resection is usually done.
 Patients should have regular screening examinations for early
detection of malignant transformation.
 MALIGNANT BONE TUMORS

TYPES DESCRIPTIONS
Osteosarcoma Most common primary bone cancer.
• Occurs mostly in young males between ages 10 and 25 .
• Most often in bones of arms, legs, or pelvis.

Chondrosarcoma • Occurs in cartilage most commonly in arm, leg, and pelvic

bones of older adults ages 50-70.
• Can also arise from benign bone tumors
(osteochondromas).
• Wide surgical resection is mostly done, since tumor rarely
responds to radiation and chemotherapy .
• Survival rate depends on stage, size, and grade of tumor.

Ewing’s sarcoma Develops in medullary cavity of long bones, especially femur,

humerous, pelvis, and tibia.
• Usually occurs in children and teenagers.
• Use of wide surgical resection, radiation, and chemotherapy
has greatly improved the 5-yr survival rate to 60% .
Metastatic Bone Cancer:

 Common sites for the primary tumor include breast, prostate, lungs,
kidney, and thyroid.
 Metastatic cancer cells travel from the primary tumor to the bone via
the lymph and blood supply.
 The metastatic bone lesions are commonly found in vertebrae,
pelvis, femur, humerous, or ribs.
 Pathologic fractures at the site of metastasis are common because of
a weakening of the involved bone.
 High serum calcium levels result as calcium is released from
damaged bones.
MALIGNANT BONE TUMORS:

 A sarcoma is a malignant tumor that can develop in bone, muscle, fat,

nerve, or cartilage.
 The most common types of malignant bone tumors are
osteosarcoma, chondrosarcoma, and Ewing’s sarcoma.
 Primary malignant tumors occur most often during childhood and
young adulthood.
 They are characterized by their rapid metastasis and bone destruction.
TNM CLASSIFICATION

1. Skeleton, trunk, skull, and facial bones:

 TX: The primary tumor cannot be evaluated.
 T0 (T plus zero): There is no evidence of a primary tumor.
 T1: The tumor is 8 centimeters (cm) or smaller.
 T2: The tumor is larger than 8 cm.
 T3: There are more than 1 separate tumors in the primary bone
site.
Spine:

 TX: The primary tumor cannot be evaluated.

 T0 (T plus zero): There is no evidence of a primary tumor.
 T1: The tumor is found only on 1 part of the vertebrae, called the vertebral segment, or
on 2 adjacent parts of the vertebrae.
 T2: The tumor is found only on 3 adjacent parts of the vertebrae.
 T3: The tumor is found on 4 or more adjacent parts of the vertebrae, or it is found on
parts of the vertebrae that are not next to each other.
 T4: The tumor has grown into the spinal canal or great vessels.
 T4a: The tumor has grown into the spinal canal.
 T4b: The tumor has grown into the great vessels or affects blood flow.
Pelvis:

 TX: The primary tumor cannot be evaluated.

 T0 (T plus zero): There is no evidence of a primary tumor with no extraosseous
extension.
 T1: The tumor is located only on 1 part of the pelvis.
 T1a: The tumor is 8 cm or smaller.
 T1b: The tumor is larger than 8 cm.
 T2: The tumor is located only on 1 part of the pelvis with extraosseous extension or on 2
parts of the pelvis without extraosseous extension.
 T2a: The tumor is 8 cm or smaller.
 T2b: The tumor is larger than 8 cm.
CONT:

 T3: The tumor is found on 2 parts of the pelvis with extraosseous extension.

 T3a: The tumor is 8 cm or smaller.
 T3b: The tumor is larger than 8 cm.
 T4: The tumor is found on 3 parts of the pelvis or it has crossed the sacroiliac joint,
which connects the bottom of the spine with the pelvis.
 T4a: The tumor involves the sacroiliac joint and has grown to the sacral neuroforamen.
 T4b: The tumor has grown around blood vessels or affects blood flow.
NODE: (N)

 NX: The regional lymph nodes cannot be evaluated.

 N0 (N plus zero): The cancer has not spread to the regional lymph nodes.
 N1: The cancer has spread to the regional lymph nodes. This is rare for primary bone
cancer.
Metastasis (M)

 The “M” in the TNM system describes whether the cancer has spread to other parts of the
body, called distant metastasis.

 M0 (M plus zero): The cancer has not metastasized.

 M1: The cancer has metastasized to another part of the body.
 M1a: The cancer has metastasized to a lung.
 M1b: The cancer has metastasized to other bones or another organ.
1. Osteosarcoma

 Osteosarcoma is a primary malignant bone tumor that is extremely

aggressive and rapidly metastasizes to distant sites.
 It usually occurs in the metaphyseal region of the long bones of
extremities, particularly in the regions of the distal femur, proximal
tibia, and proximal humerous, as well as the pelvis.
 Osteosarcoma is the most common malignant bone tumor affecting
children and young adults.
 It can also occur, but not as commonly, in older adults.
 It is most often associated with Paget’s disease and prior radiation.
OSTEOSARCOMA CHONDROSARCOMA
 PATHOPHYSIOLOGY:

A tumor in the bone

osteolytic response (bone destruction)

weakens the bone, resulting in bone fractures.

Malignant bone tumors invade and destroy adjacent bone tissue.

 Benign bone tumors, in contrast, have a symmetric, controlled growth pattern and place pressure on
adjacent bone tissue.
 Malignant invading bone tumors weaken the structure of the bone until it can no longer withstand the
stress of ordinary use; pathologic fracture commonly results.
CLINICAL MANIFESTATIONS:

 The gradual onset of pain and swelling, especially around the

knee.
 A minor injury does not cause the neoplasm but may bring the
preexisting condition to medical attention.
 Metastasis is present in 10% to 20% of individuals.
CONT:

 Weight loss, malaise,

 fever may be present.
 Spinal cord compression may occur.
 It can progress rapidly or slowly. Neurologic deficits (eg,
progressive pain, weakness, gait abnormality, paresthesia,
paraplegia, urinary retention, loss of bowel or bladder control)
must be identified early and treated with decompressive
laminectomy to prevent permanent spinal cord injury.
CONT:

 Symptoms of hypercalcemia include

Muscle weakness,
Fatigue,
Anorexia,
Nausea,
vomiting,
polyuria,
cardiac dysrhythmias,
seizures, and coma.
DIAGNOSTIC EVALUATION:

 History
 Physical examination,
 Myelography
 Arteriography,
 Biochemical assays of the blood and urine.
 Serum alkaline phosphatase levels are frequently elevated with osteogenic sarcoma.
 With metastatic carcinoma of the prostate, serum acid phosphatase levels are elevated.
 Hypercalcemia is present with breast, lung, or kidney cancer bone metastases.
DIAGNOSTIC EVALUATION:

o Tissue biopsy
o Elevation of serum alkaline phosphatase and calcium levels
o X-ray
o Computed tomography (CT)
o Positron emission tomography (PET) scans
o Magnetic resonance imaging (MRI).
MANAGEMENT:

 Surgical excision (ranging from local excision to amputation and

disarticulation).
 Limb- salvage ( Sparing). Limb-salvage (limb-sparing) surgery:
removing the cancer and some surrounding normal tissue but
leaving the limb basically intact. 
 Radiation therapy (if the tumor is radiosensitive, and
chemotherapy). External beam radiation to involved metastasis sites
may be used.
TREATMENT:

 Preoperative (neoadjuvant) chemotherapy may be used in the treatment

of osteosarcoma to decrease tumor size before surgery.

 Limb salvage procedures are usually considered when there is a clear

(no cancer present) 6- to 7-cm margin surrounding the lesion.

 Limb salvage( Sparing) is usually contraindicated if there is major

neurovascular involvement, pathologic fracture, infection, or extensive
muscle involvement.
LIMB SALVAGE PROCEDURE
 CONT:

 The use of adjunct chemotherapy after amputation or limb salvage has

increased the 5-year survival rate to 70% in people without metastasis.

 Chemotherapy includes
 methotrexate
 doxorubicin (Adriamycin)
 cisplatin (Platinol)
 cyclophosphamide (Cytoxan)
CONT:

 dactinomycin (Cosmegen)
 ifosfamide (Ifex)
 etoposide (VePesid)
 bleomycin (Blenoxane)
NURSING MANAGEMENT:

 Assess the patient with bone cancer for the location and severity of
pain.(managed with adequate and appropriate opioid, nonopioid, and
nonpharmaceutical interventions. )
 Note weakness caused by anemia and decreased mobility.
 Monitor the site of the tumor for swelling; changes in circulation; and
decreased movement, sensation, or joint function.
 Treatment for hypercalcemia may need to be initiated.
 The patient is often reluctant to participate in exercise or therapeutic
activities because of weakness from the disease and the treatment, fear
of falling and fracturing a bone, and fear of pain.
 Provide regular rest periods between activities.
CONT:

 Hypercalcemia results from breakdown of bone. It needs to be

recognized promptly. Treatment includes hydration with IV
administration of normal saline solution, diuresis, mobilization, and
medications such as bisphosphonates, pamidronate, and calcitonin.
 Because inactivity leads to loss of bone mass and increased calcium in
the blood.
 The nurse assists the patient to increase activity and ambulation.
 Hematopoiesis is frequently disrupted by tumor invasion of the bone
marrow or by treatment (chemotherapy or radiation). Blood product
transfusions restore hematologic factors.
CONT:

 Carefully monitor the patient’s pain and ensure that he or she has
adequate pain medication.
 Sometimes radiation therapy is used as a palliative therapy to shrink
the tumor and decrease the pain.
 Assist the patient and caregiver in accepting the poor prognosis
associated with bone malignancies.
 Special attention is necessary for the problems of pain and disability,
side effects of chemotherapy, and postoperative care after surgery such
as spinal cord decompression or amputation.
 Stress the importance of follow-up examinations.
NURSING DIAGNOSIS:

1. Acute pain related to compression or destruction of nerve tissues.

2. Altered Nutrition : Less than body requirement related to anorexia
, nausea and vomiting after chemotherapy.
3. Risk for fluid volume deficit related to excessive vomiting .
4. Risk for infection related to low immunity in the body.
5. Risk for impaired skin integrity related to radiation.
6. Risk for constipation or diarrhea related to chemotherapy
treatment.
7. Anticipatory grieving related to sudden changes in health
changes.
8. Situational low self esteem related to disease condition.
ASSESSMENT NURSING EXPECTED INTERVENTION RATIONALE
DIAGNOSIS OUTCOME

Subjective data: Acute pain related to The pain will be reduce Ask the patient about indicating need for
compression or through the the effect of drugs for higher dose or shorter
destruction of nerve intervention. the pain. dose interval.
tissues.
Objective data: May decrease
Provide cutaneous inflammation, muscle
On observation of the stimulation (heat or spasms, reducing
patient or having the cold, massage). associated pain.
conservation. By using
the pain scale maximum pain control
assessment. with minimum
Provide daily minimal interference with ADLs.
active and passive
exercise. May provide reduction
or relief of pain without
drug-related side
effects.
Provide additional
alternative or
complementary
therapies (acupuncture
and acupressure).
ASSESSMENT NURSING EXPECTED INTERVENTION RATIONALE
DIAGNOSIS OUTCOME

Provide diversional Helps to divert the

therapy like watching concentration on pain
TV, reading news paper, and also it helps for
Hearing music therapy mind relaxation.
or any entertainment
activity.

Acetaminophen
(Tylenol); and nonstero Effective for localized
idal anti-inflammatory and generalized
drugs ( NSAID) moderate to severe pain,
including aspirin with long-acting.
ibuprofen (Motrin,
Advil).
May be effective in
Corticosteroids: controlling pain
Dexamethazone (Decad associated with
ron) inflammatory process.
ASSESSMENT NURSING EXPECTED INTERVENTION RATIONALE
DIAGNOSIS OUTCOME
Administer narcotics. To reduce the
Eg. Morphin, chronic pain.
Fentanyl.

Apply patches on the

skin.eg. To control the pain.
Buprenorphine and
fentanyl patches
requires 24-72hrs.

Provide good rest

and sleep.
Helps for regain the
energy level.
ASSESSMENT NURSING EXPECTED INTERVENTION RATIONALE
DIAGNOSIS OUTCOMES
Subjective Data: Altered Nutrition : Less The patients body Encourage patient to eat Helps to increase the
than body requirement weight will be increase. high-calorie, nutrient- nutrients level.
related to anorexia , rich diet, with adequate
nausea and vomiting fluid intake.
after chemotherapy.
Objective Data:
On Observation and Encourage use of
physical examination, supplements and Supplements can play
BMI of the patient. frequent or smaller an important role in
meals spaced maintaining adequate
throughout the day. caloric and protein
( Ensure powder). intake.

Create pleasant dining

atmosphere; encourage
patient to share meals Makes mealtime more
with family and friends. enjoyable, which may
enhance intake.
Encourage open
communication
regarding anorexia.
To elevate the
Emotional distress.
Assessment NURSING EXPECTED INTERVENTION RATIONALE
DIAGNOSIS OUTCOME
Give liquids 1 hr before Avoiding fluids during
or 1 hr after meals. meals minimizes
becoming “full” too
quickly.

Control environmental Can trigger nausea and

factors (strong or vomiting response.
noxious odors or noise).
Avoid overly sweet,
fatty, or spicy foods.

Administer antiemetics, Nausea and vomiting

eg. emeset are frequently the most
disabling and
psychologically
stressful side effects of
Insert and maintain NG chemotherapy.
or feeding tube for
enteric feedings, or To improve the nutrition
central line for  to ill health patient.
total parenteral nutrition
 (TPN) if indicated.
COMPLICATION:

 Infection,
 Loosening or dislocation of the prosthesis,
 Allograft nonunion,
 Fracture,
 Devitalization of the skin and soft tissues,
 Joint fibrosis, and recurrence of the tumor.
BIBLIOGRAPHY

 Brunner and suddarths. Text book of medical surgical nursing .

12thedition.volume1.lippincott publication.
 Lewis 2014 . medical surgical nursing.2ndedition. volume1. elsevier publication.

 https://nurses labs.com

 www.google.com
 www.mediplus.com