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Overview |
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Definition |
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Bone malignancies broadly encompass multiple myeloma, bone sarcomas, and
tumors metastatic to the bone. Multiple myeloma (MM) is the most common
malignant tumor of the bone. It accounts for only 1% of all malignant diseases.
The two most common bone sarcomas are osteosarcoma (45%) and chondrosarcoma (20%
to 25%). These tumors are rare, accounting for only 0.2 % of new malignancies.
Tumors metastatic to the bone are more common than primary bone tumors, largely
arising from carcinomas of the prostate, breast, and lung. |
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Etiology |
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Multiple myeloma:
- Unknown—possibly multistep process
(mutation-induced genetic abnormalities, chromosomal translocations, viral
triggers)
- Neoplastic disease with proliferation of a single clone of
immunoglobulin-secreting plasma cells from B cell series of
immunocytes
- Monoclonal (M) component—two heavy
polypeptide chains (immunoglobulin [Ig] G, IgA, IgD, IgE, IgM) and two light
polypeptide chains (kappa, lambda)
Osteosarcoma:
- Unknown etiology
- After radiation exposure
- Arising from benign lesions (malignant
degeneration)
Chondrosarcoma:
- Unknown etiology
- Arising as transformation of enchondromas or
osteochondromas
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Risk Factors |
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Multiple myeloma:
- Radiation exposure—20-year latency
- Possibly, through exposure to petroleum products, benzene, herbicides,
insecticides
- Genetic
- > 68 years of age
- Males slightly > females
- Blacks > whites (twice)
Osteosarcoma:
- Enchondromas, osteochondromas, Paget's disease, fibrous
dysplasia
- Radiation exposure
- Genetic (especially p53 gene)
- Childhood, adolescents
- Males > females
Chondrosarcoma:
- Age 40 to 60
- Enchondromas, osteochondromas, Paget's disease, fibrous
dysplasia
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Signs and Symptoms |
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Multiple myeloma:
- Bone pain, tenderness (especially back, ribs; made worse by movement),
fracture
- Bone lesions—skull, ribs, pelvis, femur,
humerus, sternum, spinal cord compression and possible collapse
- Weakness, fatigue
- Hypercalcemia—nausea, anorexia, weakness,
confusion
- Renal failure—25% of patients (secondary
amyloidosis)
- Cold sensitivities
- Chronic infections
- Anemia
- Hyperviscosity—headache, fatigue, visual
problems, retinopathy
- Bleeding
- Neurologic complications—from nerve
compression as bones collapse; includes carpal tunnel
syndrome
Osteosarcoma:
- Affects the long bones (distal femur, proximal tibia, proximal
humerus)
- Pain (especially with weight bearing), swelling
- Fractures
- "Cannonball metastasis" to the lungs
Chondrosarcoma:
- Affects the flat bones (shoulder, pelvis, femur) and diaphyseal
portions of long bones
- Pain, progressive swelling
- Possible metastasis to the
lungs
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Differential
Diagnosis |
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Multiple myeloma:
- Benign monocolonal gammopathies
- Monocolonal gammopathies of uncertain significance
(MGUS)—M components < 30 g/L; 25% develop
myeloma
- Leukemia
- Non-Hodgkin's lymphoma
- Metastatic carcinoma
- Sarcoma
- Lymphoma
Bone sarcomas:
- Myeloma
- Lymphoma
- Osteomyelitis
- Benign tumor
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Diagnosis |
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Physical Examination |
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Multiple myeloma:
- Bony lesions; possibly palpable
- Pallor, bone pain, weakness, fatigue
Bone sarcomas:
- Complaints of pain
- Fractures; possibly palpable
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Laboratory Tests |
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Multiple myeloma:
- Bone marrow plasmacytosis > 10%—diagnostic
in conjunction with other evidence
- Protein electrophoresis, serum immunoglobulins,
immunoelectrophoresis—identify M component type, level
(3 g/dL—diagnostic), and type of light chain (secretion
> 1 g/d indicates a neoplasm)
- Salmon calcitonin stimulation test—indicates
bone destruction; rules out MGUS
- Complete blood count—detects anemia; revels
elevated serum calcium, urea nitrogen, creatinine, uric acid, interleukin (IL)
6, and erythrocyte sedimentation rate. Most patients will present with anemia,
and all will develop anemia as the disease progresses.
- Serum beta2-microglobulin—prognostically
important
- Consider testing for heavy metals and
pesticides.
Bone sarcomas:
- Laboratory findings generally not helpful
- Elevated alkaline phosphatase—not diagnostic
alone
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Pathology/Pathophysiology |
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Multiple myeloma:
- Elevated serum M component—IgG (53%), IgA
(25%), IgD (1%)
- Kappa/lambda 2:1
- Cytogenic abnormalities—overexpression of
ras and myc genes; p53 and Rb-1 mutations
- IL-6—aids myeloma cell
proliferation
- Tumor usually remains within bone marrow, invades adjacent
bone
- Chronic antigen exposure involved in transformation of B cell
clone
- Bone—lytic bone lesions are diagnostic; tumor
cell production of osteoclast activating factor causes osteoclast proliferation,
destroying bone
- Renal failure—large waxy laminated casts in
the tubules; hypercalcemia, hyperuricemia, glomerular amyloid deposits; tubular
damage from excretion of light-chain proteins; dehydration
- Infection— increased hypogammaglobulinemia
and other factors impairs immune system; Streptococcus pneumoniae,
Staphylococcus aureus in lungs; Escherichia coli and gram-negative
bacteria in urinary tract
- Anemia—from erythropoiesis
- Bleeding—from thrombocytopenia or coating of
platelets with M component
- Secondary amyloidosis
Osteosarcoma:
- Atypical spindle cell neoplasm, abundantly producing osteoid (50%) or
cartilage (25%)
- Elevated alkaline phosphatase
- Hypervascular
Chondrosarcoma:
- Malignant spindle-cell tumor that does not produce osteoid
substance
- Hyperploid (abnormally increased DNA) lesions more
aggressive
- Five types: central, peripheral, mesenchymal, differentiated, clear
cell
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Imaging |
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Multiple myeloma:
- Radiographs reveal lytic lesions in the diaphysis of long
bones
- "Punched out" appearance of skull (raindrop skull)
- Vertebral compression fractures (thoracic and lumbar spine)
- MRI helps to distinguish lesions from benign compression
fractures
Osteosarcoma:
- Radiograph shows moth-eaten or sclerotic appearing lesion with a cuff
(Codman's cuff) of periosteal new bone
- CT shows bone destruction and calcification, lung metastases
("cannonball")
- MRI reveals soft tissue involvement
- Bone scan reveals bone metastasis
Chondrosarcoma:
- Radiograph shows lytic lesion with mottled, punctate, or annular
calcifications
- Endosteal scalloping
- Cannot distinguish low-grade lesions from
benign
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Other Diagnostic
Procedures |
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Bone sarcomas:
- Core-needle or open biopsy must not compromise later limb-sparing
resection
- Angiography assesses response to preoperative
chemotherapy
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Treatment Options |
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Treatment Strategy |
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Multiple myeloma:
- Systemic chemotherapy treatment not indicated for asymptomatic
patients; begins when M component rises to 50 g/L or with progressive bone
lesions
- Chemotherapy—controls progression; combined
with radiation and/or bone marrow transplant
- Treat symptoms promptly
- Spinal cord involvement requires immediate
stabilization
Osteosarcoma:
- Preoperative chemotherapy with limb-sparing surgery, followed by
postoperative chemotherapy
Chondrosarcoma:
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Drug Therapies |
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Multiple myeloma:
- Chemotherapy—alkylating agent (e.g., oral
regimen of melphalan 0.15 mg/kg/day) plus prednisone (20 mg/tid), for seven days
every six weeks; 50% to 60% response rate; adjusted to marrow tolerance; reduces
bone pain, anemia, infections, and hypercalcemia; M component takes about five
weeks to fall; regimens containing alkylating agents should not be administered
to patients being considered for combination and high-dose therapy
- Alpha-2b interferon and
dexametasone—potentiates alkylating agents
- Analgesics—for pain
- Bone lesions—osteoclast production stopped by
glucocorticoids and interferon-gamma; biphosphonates (e.g., pamidronate 90
mg/month) reduces osteoclast reabsorption
- Bone plasmocytomas—treated with radiation (40
Gy)
- Hypercalcemia—glucocorticoids (25 mg qid
prednisone), hydration (isotonic saline), diphosphonates or gallium
nitrate
- Renal failure—allopurinol with chemotherapy;
plasmapheresis
- Infection—vaccines may not illicit antibody
response; new intravenous gamma globulin—prophylactic;
prophylactic antibiotics unwarranted
- Radiation—for localized tumor, prompt
palliative effects
- Anemia—iron, folate, cobalamin,
androgens
- Hyperviscosity—plasmapheresis
Osteosarcoma:
- Doxorubicin, ifosfamide, cisplatin, high-dose methotrexate with
leucovorin rescue
- Radiation ineffectual, except for palliation and lung
metastasis
Chondrosarcoma:
- Resistant to chemotherapy except mesenchymal
chondrosarcoma
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Surgical Procedures |
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Multiple myeloma:
- Allogenic bone marrow transplant—25% to 44%
transplant mortality rate, relapse common, advantage of graft containing no
tumor cells
- Autologous bone marrow transplant—bone marrow
likely to be contaminated; median survival 24 to 36 months, possibly higher with
high-dose chemoradiotherapy
Osteosarcoma:
- Limb-sparing surgery, if possible (80%), replaces
amputation
Chondrosarcoma:
- Resection
- Cryosurgery—liquid nitrogen after curettage
kills remaining cells
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Complementary and Alternative
Therapies |
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Nutrients and herbs may be helpful in enhancing conventional treatments,
optimizing detoxification, and supporting immune function. |
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Nutrition |
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- Avoid foods that may compromise immune function, such as refined
foods, sugar, alcohol, caffeine, and saturated fats (e.g., animal products).
Eliminate organ meats and processed meats.
- Use only organically-raised foods. Include foods that support
detoxification, immunity, and are high in antioxidants, such as beets, carrots,
artichokes, yams, onions, garlic, yellow and orange vegetables, shiitake
mushrooms, sea vegetables, green tea, and filtered water. Include liberal
amounts of dark leafy greens and whole grains. Green tea may potentiate the
effects of doxorubicin.
- Vitamin C (1,000 mg qid), vitamin E (400 IU bid), beta carotene
(50,000 IU once to twice daily), coenzyme Q10 (100 mg tid), and zinc (30 mg/day)
provide antioxidant protection and immune support. Coenzyme Q10 and L-carnitine
(600 mg tid) may reduce cardiac toxicity from doxorubicin.
- Selenium (200 mcg bid) and glutathione (500 mg bid) support
detoxification.
- Magnesium (200 mg bid to tid), vitamin D (400 IU/day), vitamin K (5
mg/day), and boron (3 to 5 mg/day) may be helpful in reducing hypercalcemia and
enhancing normal bone growth.
- Bromelain (250 to 500 mg between meals) is a proteolytic enzyme that
has anticancer activities and may enhance chemotherapy.
- Glutamine (3 to 10 g/day) to support lymphocyte recovery after bone
marrow transplant.
- N-acetylcysteine (200 mg tid), a precursor to glutathione, enhances
detoxification and is protective of lung tissue.
- Consider commercial protein supplements, such as Seacure, to provide
easily assimilated protein and
calories.
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Herbs |
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Herbs may be used as dried extracts (pills, capsules, or tablets), teas, or
tinctures (alcohol extraction, unless otherwise noted). Dose is 1 heaping tsp.
herb/cup water steeped for 10 minutes (roots need 20 minutes).
- Turmeric (Curcuma longa): 500 mg qid potentiates the effects of
bromelain and has antitumor activities. May enhance the effectiveness of
cisplatin.
- Ginkgo (Ginkgo biloba): 120 mg standardized extract bid may
reduce nephrotoxic side effects of cisplatin.
Include one or more of the following formulas for tumor inhibition,
detoxification, and immune support.
- Scudder's Alterative Compound: combine equal parts of corydalis tubers
(Dicentra Canadensis), black tag alder (Alnus serrulata), mayapple
root (Podophyllum peltatum), figwort (Scrophularia nodosa), and
yellowdock (Rumex crispus). Take 30 to 40 drops tincture tid to qid for
six months.
- Commercial herbal mixes in the form of teas or formulas containing
herbs such as sheep sorrel (Rumex acetosella), burdock root (Arctium
lappa), slippery elm inner bark (Ulmus fulva), turkey rhubarb
(Rheum palmatum), red clover (Trifolium pratense), and watercress
(Nasturtium officinale) may be helpful. A usual dose is one cup tea bid,
or 2 tbs. formula bid for six months.
- Combine equal parts of coneflower (Echinacea angustifolia),
poke root (Phytolacca americana), red clover (Trifolium pratense),
plantain (Plantago lanceolata), gotu kola (Centella asiatica), and
yellowdock (Rumex crispus). Take 30 to 60 drops tincture tid, or drink
three to four cups tea daily for up to six weeks at a time.
- Combine equal parts of astragalus (Astragalus membranaceus),
schizandra berry (Schizandra chinensis), licorice root (Glycyrrhiza
glabra), lomatium root (Lomatium dissectum), barberry (Berberis
vulgaris), and queen's delight (Stillingia sylvatica). Take 30 drops
tincture bid for four to six months.
- For vascular support, consider including hawthorn (Crataegus
monogyna): 200 mg bid and/or ginkgo (Ginkgo biloba): 120 mg
standardized extract bid.
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Homeopathy |
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An experienced homeopath evaluates an individual's symptoms and
constitutional type before prescribing a specific treatment regimen. Some of the
most common acute remedies used in treating symptoms that may be associated with
bone cancer are listed below. Acute dose is three to five pellets of 12X to 30C
every one to four hours until symptoms resolve.
- Arnica for bruised sensation and restlessness
- Bryonia for easy fractures with stitching pains that are worse
with the slightest movement
- Eupatorium for excruciating bone pains with aching, stiffness,
and chills, that worsens with motion
- Symphytum for fractures with persistent pain and poor
healing
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Acupuncture |
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May aid in immune support, increasing overall sense of well-being and
stamina, as well as minimizing side effects from conventional
therapies. |
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Patient Monitoring |
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Patients will need support for recurring and multiple
complications. |
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Other
Considerations |
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Prevention |
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Multiple myeloma:
- Prompt treatment of complications
- Intense hydration may help minimize renal
damage
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Complications/Sequelae |
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Multiple myeloma:
- Myocardial infarction
- Lung disease
- Diabetes
- Stroke
- Hyperviscosity syndrome
- Skeletal instability
Bone sarcomas:
- Arising from resection
- Lung metastasis
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Prognosis |
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Multiple myeloma:
- Serum beta2-microglobulin—< 0.004 g/L
median survival 43 months; > 0.004 g/L,12 months
- Labeling index—> 1%, strongest
predictor
- Chronic course—15 months to 5 years, followed
by acute terminal phase
Bone sarcomas:
- Response to chemotherapy—best outcome
predictor; increases with wide surgical margins
- Surgery alone—survival < 2
years
- Long-term survival 60% to 70%
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Pregnancy |
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Many of the chemotherapy drugs and radiation are contraindicated during
pregnancy. Bone sarcomas can become progressively worse during
pregnancy. |
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References |
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Boik J. Cancer & Natural Medicine: A Texbook of Basic Science and
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Cecil RI, Plum F, Bennett JC, eds. Cecil Textbook of Medicine.
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Dambro MR. Griffith's 5-Minute Clinical Consult. 1999 ed. Baltimore,
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De Vita VT, ed. Cancer: Principles and Practice of Oncology.
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Navis I, Sriganth P, Premalatha B. Dietary curcumin with cisplatin
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Pharmacol Res. 1999; 39(3):175-179.
Pizzo PA, Poplack DG. Principles and Practice of Pediatric Oncology.
3rd ed. Philadelphia, PA: Lippincott-Raven Publishers; 1997.
Morrison, R. Desktop Guide to Keynotes and Confirmatory Symptoms.
Albany, Calif: Hahnemann Clinic Publishing; 1993.
Rakel RE, ed. Conn's Current Therapy. 51st ed. Philadelphia, PA: W.B.
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Scalzo R. Naturopathic Handbook of Herbal Formulas. 2nd ed.
Durango, Colo: Kivaki Press; 1994: 35-36.
Ziegler TR, Bye RL, Persinger RL, Young LS, Antin JH, Wilmore DW. Effects of
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315(1):4-10. |
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |