Bone

Common types of bone cancer include1 ||
 * **Epidemiolgy:** || Primary bone tumors are very rare1
 * Osteosarcoma
 * Ewing's sarcoma
 * Chondrosarcoma
 * Malignant fibrous histiocytoma (MFH)
 * Fibrosarcoma
 * Chordoma
 * Giant cell tumor
 * **Etiology:** || These tumors are most common during the years of major bone growth, usually between the ages of 10 and 20.1

The survival of radiation treatments as a young child with doses higher than 60Gy or the use of alkylating agents in the treatment of retinoblastoma. || General Radiologic Studies  Optional Chondrosarcomas2 Fibrosarcomas2 Malignant fibrous histocytomas2 Giant cell tumors of the bone2 Ewing’s2 Plasma cells2
 * **Signs & Symptoms:** || Most common symptoms at time of presentation are local swelling and pain, joint effusion and pathological fractures can happen but are not common at presentation.1 ||
 * **Diagnostic Procedures:** || Diagnostic workup for bone tumors1
 * History
 * Physical Examination
 * Special Studies
 * Open biopsy, avoiding incision over area not to be irradiated
 * Bone marrow aspiration and biopsy (for Ewing’s)
 * Standard
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Plain radiography of bone and chest
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">CT of affected bone, surrounding soft tissue, and lungs
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Radionuclide bone scan
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">MR imaging of affected bone and surrounding soft tissue
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Angiography
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Laboratory Studies
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Complete blood cell count on admission
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Blood chemistry profile
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Urinalysis
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Erythrocyte sedimentation rate ||
 * **Histology:** || <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Osteosarcomas2
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Osteoblastic, chondroblastic, fibroblastic or mixed chondroblastic
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Low Grade: clear cell and juxtacortical
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">High Grade: mesenchymal
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Low Grade: myxofibrosarcoma, fibromyxoid sarcoma, hyalinizing spindle cell tumor with giant collagen rosettes, and sclerosing epithelioid fibrosarcoma
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Undifferentiated pleomorphic sarcoma with histiocytic and fibroblastic differentiation
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Round or spindle shaped mononuclear cells uniformly incorporated in with multinucleated giant celss
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Small, blue, round cells with high nuclear to cytoplasmic ratio
 * <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">B-cell lymphocytes, developed from stem cells ||
 * **Lymph node drainage:** || <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Bone tumors rarely spread to the lymphatics2 More common if the primary tumor is in the trunk of the body ||
 * **Metastatic spread:** || For most sarcomas the trend is to metastasize hematologically to the lungs (especially the periphery of the lung). Sometimes, Osteosarcoma, MFH, and chondrosarcoma will metastasize to other sites (bone, liver, and brain). Low grade tumors are locally invasive and do not have tendency to metastasize easily. Local recurrence is common with low grade tumors. Skip metastasis are another pattern of spread with osteosarcomas. 3 ||
 * **Grading:** || There is no universally accepted staging system for primary bone sarcomas. The Enneking system classifies tumors according to grade, local extent, and presence or absence or distant metastases.3
 * G1- Low Grade **
 * Parosteal osteosarcoma
 * Endosteal osteosarcoma
 * Secondary chondrosarcoma
 * Fibrosarcoma, low grade
 * Atypical malignant fibrous histiocytoma
 * Giant cell tumor

G1- Low grade
 * G2- High grade **
 * Classic osteosarcoma
 * Radiation-induced sarcoma
 * Paget's sarcoma
 * Primary chondrosarcoma
 * Fibrosarcoma, high grade
 * Malignant fibrous histiocytoma
 * Giant cell sarcoma ||
 * **Staging:** || There is no universally accepted staging system for primary bone sarcomas. The Enneking system classifies tumors according to grade, local extent, and presence or absence or distant metastases.3
 * Grade (G) **
 * Parosteal osteosarcoma
 * Endosteal osteosarcoma
 * Secondary chondrosarcoma
 * Fibrosarcoma, low grade
 * Atypical malignant fibrous histiocytoma
 * Giant cell tumor

G2 High grade
 * Classic osteosarcoma
 * Radiation-induced sarcoma
 * Paget's sarcoma
 * Primary chondrosarcoma
 * Fibrosarcoma, high grade
 * Malignant fibrous histiocytoma
 * Giant cell sarcoma

T1- Intracompartmental
 * Local Extent (T) **
 * Intraosseous
 * Paraosseous

T2- Extracompartmental
 * Soft tissue expansion
 * Extrafascial or deep fascial extension


 * Metastases (M) **
 * M0 - No distant metastases
 * M1 - Distant metastases exists


 * Staging Grouping **

IA G1 T1 M0 IB G1 T2 M0  IIA G2 T1 M0  IIB G2 T2 M0  III G1 or G2 T1 or T2 M1 ||
 * **Radiation side effects:** || Radiation side effect vary on location, but typical side effects to bone include stunted bone growth in children, and death of healthy bone cells. 4 ||
 * **Prognosis:** || ** Prognostic Factors ** 4

Osteosarcoma Condrosracoma Fibrosarcoma Chordoma
 * Metastasis at presentation
 * Response to chemotherapy
 * Grade
 * Size
 * Cell type
 * Location
 * Stage at presentation
 * Age
 * Local aggressiveness
 * Pain at presentation
 * Metastasis at presentation
 * Site or origin
 * Local extension ||
 * **Treatments:** || **Treatments** 4

Osteosarcoma Chondrosarcojma Chordoma Giant Cell Tumor Aneurysmal Bone Cyst Bone Metastases
 * Surgery
 * IMRT or conformal techniques for unresctable osteosarcoma
 * 75 Gy without chemotherapy, and less with adjuvant chemotherapy
 * Surgery
 * Protons or IMRT for targets in spine and skull base
 * 50 Gy to subclinical disease, 70 Gy to micsroscopic disease, 77 Gy to gross disease
 * Surgery followed by radiation therapy, or radiation therapy alone
 * Protons or IMRT
 * 72 Gy or higher
 * Surgery or radiation therapy
 * 40 – 50 Gy
 * Surgery followed by radiation therapy for resistant lesions
 * Conformal or IMRT
 * 20 – 30 Gy
 * Radiation therapy for bone pain and the prevention of fractures ||
 * **TD 5/5:** || [[image:Normal tissue tolerance to therapeutic irradiation.jpeg width="800" height="664"]] ||
 * **References:** || # <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Chao KS, Perez CA, Brady LW. Radiation Oncology Management Decisions. 3rd edition. Philadelphia, PA: Lippincott Williams & Wilkins. 692.
 * 1) <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Bartenhagen L, Koth J. Principles and Practice of Radiation Therap. 3rd Edition. St. Louis, Missouri: Mosby.2011:599.
 * 2) <span style="color: #ff0000; font-family: Arial,Helvetica,sans-serif;">Chao KS, Perez CA, Brady LW. //Radiation Oncology Management Decisions//. 3rd edition. Philadelphia, PA: Lippincott Williams & Wilkins. 692.
 * 3) Perez CA, Brady LA, Halpern EC, Schmidt-Ullrich RK. Principles and Practice of Radiation Oncology. 4th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2004.
 * 4) <span style="background-color: #ffffff; color: #800080; font-family: Arial,Helvetica,sans-serif;">Hoppe RT, Phillips TL, Mack III M. Leibel and Phillips Textbook of Radiation Oncology. 3rd ed. Philadelphia Pa: Elsevier Saunders; 2010. ||

Back to Week 7