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.

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

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

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

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

Multiple myeloma:

• Bony lesions; possibly palpable
• Pallor, bone pain, weakness, fatigue

Bone sarcomas:

• Complaints of pain
• Fractures; possibly palpable

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

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

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

Bone sarcomas:

• Core-needle or open biopsy must not compromise later limb-sparing resection
• Angiography assesses response to preoperative chemotherapy

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:

• Surgical resection

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

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

Nutrients and herbs may be helpful in enhancing conventional treatments, optimizing detoxification, and supporting immune function.

• 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.

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.

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

May aid in immune support, increasing overall sense of well-being and stamina, as well as minimizing side effects from conventional therapies.

Patients will need support for recurring and multiple complications.

Multiple myeloma:

• Prompt treatment of complications
• Intense hydration may help minimize renal damage

Multiple myeloma:

• Myocardial infarction
• Lung disease
• Diabetes
• Stroke
• Hyperviscosity syndrome
• Skeletal instability

Bone sarcomas:

• Arising from resection
• Lung metastasis

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%

Many of the chemotherapy drugs and radiation are contraindicated during pregnancy. Bone sarcomas can become progressively worse during pregnancy.

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