Ortho - Oncology
What is Ortho - Oncology
Oncology is a branch of medicine that specialises in the study, treatment, and management of cancer. It covers the entire scope of treatment from the diagnosis of cancer to all the different treatments of cancer and palliative care. A doctor who specialises in oncology is called an oncologist. Ortho oncology or orthopedic oncology is the speciality that deals with musculoskeletal cancers. This speciality deals with the diagnosis and treatment of bone cancers, soft tissue sarcomas, other cancers that have spread to the bones and conditions that occur due to another cancer or a side effect of treatment.
Since bone cancer treatment involves many different aspects of oncology, the Narayana Health team takes a multi-disciplinary approach to ortho oncology. An orthopedic oncology team consists of dedicated Orthopaedic Cancer Surgeons, Nuclear Medicine Specialist, Musculoskeletal Radiologists, Interventional Radiologists, Pathologists, Medical Oncology Consultants and Radiation Oncology Consultants.
Narayana Health as a leading bone cancer hospital in India also performs limb salvage surgery in collaboration with plastic and reconstructive surgeons who specialise in musculoskeletal oncology.
Treatment of bone and soft tissue cancer patients at Narayana Health Cancer Institutes have a multidisciplinary approach similar to other disciplines in Oncology, wherein a multidisciplinary team consisting of dedicated Orthopaedic Cancer Surgeons, Musculoskeletal Radiologists, Nuclear Medicine Specialist, Interventional Radiologists, Pathologists, Medical Oncology Consultants and Radiation Oncology Consultants administer the treatment. Limb salvage surgery, a need of the hour treatment, is routinely done here in collaboration with plastic and reconstructive surgeons trained in Musculoskeletal Oncology.
Types of Ortho Oncology Cancers
Bone cancers can occur in any part of the bone. When there is abnormal growth it is called a tumour, which is benign or cancerous. A tumour that is benign is likely to grow but not spread to other parts of the body. It can, however, grow and weaken the bone leading to fracture. When a bone tumour is malignant or cancerous it can destroy the cortex of the bone and spread to the other parts of the body.
The most common types of bone cancers are osteosarcoma and Ewing sarcoma. These two types usually occur in children and adolescents.
Cancer that develops in the connective tissues of the body is called sarcoma. They are very rare and can affect the muscles, fat, tendons, bones, cartilage, nerves, and blood vessels. Though they can occur in any part of the body they are most common in the limbs. A sarcoma that grows in the bone tissue is called osteosarcoma. It usually starts in the legs near the knee joint or in the upper arm close to the shoulder. It can, however, occur in any bone in the body and very rarely in the soft tissue outside the bone. When osteosarcoma grows in the bone it is called a central tumour or medullary tumour and when it is on the surface it is called a surface tumour or peripheral tumour.
- Ewing Sarcoma
This type of sarcoma can occur in the bone or in the soft tissue near the bone. When they are in the bone they are most commonly found in the leg, pelvis, arm, rib or spine of the patient. When Ewing sarcomas are in the soft tissue they are usually found in the chest wall, spine, thigh, pelvis or foot.
The other common types of bone cancers are:
- Chondrosarcoma: This is a cancer of the cartilage tissue and is more commonly found in adults.
- Chordoma: A cancer of the bone that usually starts in the lower spine.
Other soft-tissue sarcomas that start in the bone are:
- Undifferentiated Pleomorphic Sarcoma (UPS). UPS is a very rare bone cancer that is most often found in the knee joint area in adults.
- Fibrosarcoma: This is a soft tissue sarcoma that begins in the thigh bone. It is more common amongst middle-aged people.
- Sarcoma Of Paget’s Disease Of The Bone: This is a condition where there is an overgrowth of the bony tissues, especially around the skull area. It is more commonly found in older people and can rarely develop into bone cancer such as osteosarcoma.
An orthopaedic oncologist will perform a physical examination of the affected area and then further investigate using various diagnostic tests such as :
- Blood tests: In some patients, there is a higher than normal level of certain tumour markers or biomarkers that indicate tumours. For example, higher alkaline phosphatase and lactate dehydrogenase levels are found in patients with osteosarcoma or Ewing sarcoma. However, a blood test alone cannot be used to diagnose bone cancers as such high levels may be present when bone tissue is active due to other reasons such as a healing fracture or in growing children.
- X-rays: X-rays are the most common way to study the bony structures.
- Bone Scans: Bone scans involve the usage of a radioactive substance called a tracer being injected into the bloodstream of a person. This is then detected through a scan which will show where more of the tracer is collected.
- CT Scan: A computed tomography scan uses X-rays and sometimes a dye that is injected into the patient to produce two-dimensional images of the body tissues. These images show any tumours or abnormalities if they are present. There is a small amount of radiation that the patient is exposed to. In cases where exposure to radiation is not recommended, an MRI scan may be preferable.
- MRI: Magnetic resonance imaging obtains images of the body tissues by using magnetic fields and can be used to study tumours or measure their size. They are also used to study the soft tissues. Sometimes a contrast dye is used to get clearer pictures. Since MRI uses strong magnetic fields it cannot be used for patients who have implanted devices.
- PET-CT Scan: A Positron Emission Tomography scan combined with a CT scan is used to get highly detailed images of the inside of a person’s body.
- Biopsy: Imaging techniques are used to detect tumours and abnormalities in the body. However, the diagnosis of cancer can be made only after a sample of the tissue is studied. This is possible through a biopsy where a tissue sample is obtained through a needle or surgically. It involves making a small hole in the bone to get a sample. Depending on where the tumour is located, in some cases, a biopsy may not be possible.
Treatment & Preventions
When an oncologist has confirmed the diagnosis of cancer the tumour is studied for severity depending on various factors and they are assigned a stage. The bone cancer treatment that is chosen will be the most appropriate for the type and stage of cancer. Some of the most common treatments are:
Cancer is treated through chemotherapy by the infusion of drugs that are harmful to cancer cells usually into the bloodstream. It may involve the usage of one or more drugs that can be repeated in cycles.
Targeted therapy takes place when the genes, proteins or tissue environment of the cancer is specifically targeted. This limits the damage to healthy cells while effectively targeting the cancerous cells. The target can be determined by tests that help to identify the best target for the specific patient’s tumour.
Radiation therapy uses the targeted application of radiation such as X-rays or other particles to the cancerous cells to destroy them. Narayana Health bone cancer hospital in India uses the latest in technology to very precisely deliver radiation to make the bone cancer treatment time as short as possible. Radiation therapy can be given before or after surgery depending on the nature of cancer.
Surgical bone cancer treatment removes cancerous tissue as well as some marginal tissue that surrounds it. The oncologist will usually team it with chemotherapy or radiation therapy. At Narayana Health we strive to preserve most of the limb, this is called limb salvage. In some cases, however, amputation may be the only option. New techniques of surgery attempt to spare as much of the limb as possible using prosthesis, bone grafts and other reconstructive surgery techniques. Soft tissue such as muscle is then used to cover the area. Recovery from surgery will also include other rehabilitation and therapy for the patient to recover physical abilities and any emotional issues.
In some patients, especially those with osteosarcoma, cancer will have spread to other parts of the body despite surgery; it usually spreads to the lungs. To avoid such a possibility, surgery is often followed by chemotherapy too.
Though there is no prevention of bone cancers it is important that it be detected as early as possible. Early detection improves the outcome of treatment. When a patient has risk factors such as genetic predisposition to cancers, especially sarcomas, a history of radiation therapy or chemotherapy and benign bone tumours or other bone conditions they should be regularly monitored. Regular check-ups are advised to catch any problems early.
Ortho - Oncology FAQs
When tumours are fast-growing the chemotherapy may be given before surgery. This is called neoadjuvant chemotherapy, preoperative chemotherapy or induction chemotherapy. This prevents cancer from spreading and also shrinks the tumour prior to surgery.
Cancer is usually staged using the TNM system that grades cancer-based on the following factors
- Tumour (T): Size and location of the tumour
- Node (N): Whether cancer has spread to the lymph nodes?
- Metastasis (M): Whether cancer has spread to any other parts of the body?
These results are then combined and a stage assigned with the earliest bone cancer being assigned stage ) and the most severe IV (4).
Staging cancer gives an easy way of referencing and describing it and choosing the best treatment for it.
Orthopaedic oncologists specialize in:
- diagnosis of primary bone cancers
- determining the best possible method to treat or remove the cancer
- performing surgical procedures to treat the cancer
- performing reconstructive surgeries
- overseeing follow-up treatment with chemotherapy and radiation therapy
- helping the patient manage the pain in the complete course of cancer treatment
- coordinate patient care with other specialists
Diagnosing bone and soft tissue cancers include the following.
- Medical history and physical examination: The diagnosis begins with asking questions about your medical history and the presence of any visible symptoms, such as pain, swelling or new lumps that have developed under the skin.
- Imaging tests: They are used to determine the location, type and extent of bone and soft tissue cancers. Some of the imaging tests used are PET scans, CT scans and MRI scans.
- Biopsy: It can be of two types – needle biopsies and open biopsies. Needle biopsies use a needle-like instrument to obtain a tissue sample from the tumour, whereas in open biopsies, a surgeon makes an incision on the skin and removes a piece of tissue or the entire tumour if it’s small.
The most common symptom of bone cancer is pain. Initially, the pain may be occasional but eventually becomes more frequent. Other symptoms of bone cancer include swelling, fractures, numbness or tingling sensation if the cancer affects the bones of the spine.
In case of soft tissue cancers, the first sign may be the formation of a lump under the skin which may or may not be painful. Usually, soft tissue cancers begin in an arm or leg, but they can also occur in the chest, abdomen, head and neck.
The treatment options for bone and soft tissue can include the following.
Surgery is the most common treatment for both bone and soft tissue cancers. The surgical procedures followed for treatment are
- Wide excision – the tumour is removed along with some of the healthy surrounding tissue.
- Limb-sparing surgery – the tumour is removed from an arm or leg without amputating the part. The part of the bone removed is replaced by bone grafts or internal prostheses.
- Amputation – it is used as the last resort if limb-sparing surgery is not possible.
- Reconstructive surgery
It is usually performed after the primary surgery to kill any remaining cancer cells. Radiation therapy is also used as a treatment for patients who can’t undergo surgery. It is also helpful to reduce symptoms caused by bone and soft tissue cancers.
It is used to shrink a tumour before the surgery. It is also used if the cancer has spread from a patient’s bones to other parts of the body.
Targeted therapies are designed to specifically act on the cancer cells by attacking the mechanisms that cause them to grow and spread or engaging the immune system to kill the cancer cells.