Bone cancer treatment

Introduction

The treatment options for your bone cancer are based on the type of cancer you have, the stage of cancer, your overall health and your preferences. Different bone cancers respond to different treatments, and your doctors can help guide you in what is best for your cancer. Primary bone cancers are not common. Because of this, not a lot of doctors have extensive experience with them. Treating these cancers can be complex, so they are often best treated by a team of doctors. Your treatment should be managed by a specialist centre with experience in treating bone cancer, where you’ll be cared for by a team of different healthcare professionals known as a multidisciplinary team (MDT). Doctors on the treatment team might include:

  • An orthopedic surgeon: a doctor who uses surgery to treat bone and joint problems. Often this is an orthopedic oncologist, an orthopedic surgeon who specializes in treating cancer of the bones and joints.
  • A radiation oncologist: a doctor who uses radiation to treat cancer
  • A medical oncologist: a doctor who uses chemotherapy and other medicines to treat cancer
  • A physiatrist: a doctor specializing in rehabilitation and physical therapy

There are several approaches to treating bone cancer:                                                                  

Surgery                                                                                                 

Surgery aims to remove the tumour and some of the bone tissue that surrounds it. It is the most common treatment for bone cancer. If a surgeon leaves some cancer, it may continue to grow and eventually spread. The surgeon replaces the lost bone with some bone from another area of your body, with material from a bone bank or with a replacement made of metal and hard plastic. Limb sparing surgery, or limb salvage surgery, means that surgical intervention occurs without having to amputate the limb. However, for a person to use the limb again, they may need reconstructive surgery. Bone cancers that are very large or located in a complicated point on the bone may require surgery to remove all or part of a limb (amputation). As other treatments have been developed, amputation is becoming less common.

Limb-sparing surgery- It’s possible to avoid completely removing an affected body part using limb-sparing surgery. Limb-sparing surgery is usually possible when cancer has not spread beyond the bone, and the bone can be reconstructed. The most common type of limb-sparing surgery involves removing the section of affected bone and some of the surrounding tissue. The removed section of bone may then be replaced with a metal implant called a prosthesis or a piece of bone from elsewhere in your body (bone graft). If the cancer is near a joint, such as the knee, it may be possible to remove the joint and replace it with an artificial one.

Amputation- Amputation may be necessary if limb-sparing surgery is not possible or has not worked well. It may be necessary if:

  • he cancer has spread beyond the bone into major blood vessels or nerves
  • you developed an infection after limb-sparing surgery and the prosthesis or bone graft had to be removed
  • the cancer has developed in a part of the body where limb-sparing surgery is not technically possible, such as the ankle

After an amputation, most people use an artificial limb to replace the removed limb.

These limbs are now very advanced and convenient to use. For example, people with an artificial leg are often able to walk, run and play sport, and have an excellent quality of life.

Chemotherapy

Chemotherapy involves using medications to destroy cancer cells, usually delivered through a vein (intravenously). There are 4 ways chemotherapy can be used to treat bone cancer:

  • before surgery – to shrink the tumour and make surgery easier
  • in combination with radiotherapy before surgery (chemoradiation) – this approach works particularly well in the treatment of Ewing sarcoma. after surgery, to prevent the cancer returning
  • to control symptoms in cases where a cure is not possible (known as palliative chemotherapy)

Chemo is often an important part of treatment for Ewing sarcoma, osteosarcoma, and undifferentiated pleomorphic sarcoma (UPS). But it’s used less often for most other types of bone cancer, like giant cell tumours and most types of chordomas and chondrosarcomas. These types aren’t very sensitive to chemo, so other medicines might be tried first instead.

Some of the chemo drugs that can be used to treat bone cancer include: 

  • Doxorubicin (Adriamycin)
  • Cisplatin
  • Etoposide (VP-16)
  • Ifosfamide
  • Cyclophosphamide
  • Methotrexate
  • Vincristine

A doctor may also recommend a combination of chemotherapy and radiation therapy.

Side effects of chemotherapy – Chemo can damage the bone marrow, where new blood cells are made. This can lead to low blood cell counts, which can result in: 

  • Increased chance of infection 
  • Easy bleeding or bruising after minor cuts or injuries 
  • Fatigue or shortness of breath 

Common side effects of chemotherapy include:

  • Nausea and vomiting
  • Loss of appetite
  • Hair loss
  • Mouth sores
  • Diarrhea
  • Mouth ulcer
  • tiredness

Radiation therapy 

Radiation therapy uses high-powered beams of energy, such as X-rays, to kill cancer cells. During radiation therapy, you lie on a table while a special machine moves around you and aims the energy beams at precise points on your body. As with chemotherapy, radiotherapy can be used before and after surgery to treat bone cancer or be used to control the symptoms and slow the spread of cancer when a cure is not possible. A person may receive radiation therapy alongside surgery. People who do not need surgery for bone cancer might also be candidates for radiation therapy. It is a standard treatment for Ewing sarcoma and a regular part of combination treatment for other bone cancers. Combination therapy is radiation therapy combined with another type of treatment. This may be more effective in some cases. This is normally given in daily sessions, 5 days a week, with each session lasting a few minutes. The whole course of treatment will usually last a few weeks.                                                                                                        

   External beam radiation therapy is radiation delivered from outside the body that’s focused on cancer. This is the type of radiation therapy used most often to treat bone cancer. Before treatment starts, the radiation team takes careful measurements of the area to be treated with imaging tests such as MRI scans to determine the correct angles for aiming the radiation beams and the proper dose of radiation. This planning session is called simulation.

Types of radiation therapy-

1.Intensity-modulated radiation therapy (IMRT)- With IMRT, a computer program is used to shape and aim radiation beams at the tumour from several different angles, as well as to adjust the strength (intensity) of the beams. This makes it possible to reduce radiation damage to nearby normal tissues while increasing the radiation dose to cancer.

2.Stereotactic radiosurgery (SRS)- This technique lets doctors give a large dose of radiation to a small tumour area, usually in one session. Once imaging tests have been done to show the exact location of the tumour, a very thin beam of radiation is focused on the area from many different angles. This is typically done with a radiation source on the end of a computer-controlled robotic arm, which rotates around the person as they lie on a table. 

3.Proton-beam radiation therapy- Proton-beam radiation therapy uses protons to kill cancer cells, instead of x-rays or other types of radiation. This type of treatment can be helpful in treating tumours in small, intricate areas, where it’s very important to limit the radiation that reaches nearby structures. Proton beam radiation requires highly specialized equipment, and there are only a limited number of them in the United States at this time. 

Side effects of radiation therapy: 

  • reddening and irritation of the skin (this can feel much like sunburn)
  • joint pain in the part of the body that is being treated
  • feeling sick
  • hair loss in the body part being treated
  • tiredness

Target therapy

This treatment uses a drug that scientists have designed to interact specifically with a molecule that causes cancer cells to grow. The targeted drugs used to treat some types of bone cancers are known as kinase inhibitors. Kinases are proteins in the cell that normally relay signals. Blocking certain kinases can help stop or slow the growth of some tumours. These drugs are used most often to treat chordomas that have spread or have come back after treatment. Some of these drugs might also be used to treat advanced chondrosarcomas. Denosumab prevents osteoclasts, which are a type of blood cell, from destroying bone tissue. Denosumab is a monoclonal antibody that doctors use in targeted therapy. The U.S. Food and Drug Administration (FDA) has approved it for use in adults and adolescents with fully developed skeletons. Examples of kinase inhibitors include Imatinib, Dasatinib, Sunitinib, Erlotinib, Lapatinib, Sorafenib, Regorafenib and Pazopanib.

The side effects of these drugs can vary, based on which one is being used, and can include things like diarrhoea, nausea, muscle pain, and fatigue. Some of these drugs can cause itchy skin rashes or fluid build-up around the eyes, feet, or belly. 

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