Diagnosis of primary bone cancer

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1 This information is an extract from the booklet Understanding primary bone cancer. You may find the full booklet helpful. We can send you a free copy see page 9. Contents How bone cancer is diagnosed Further tests Grading and staging How bone cancer is diagnosed Usually you begin by seeing your family doctor (GP). They will examine you and arrange any tests or x-rays you need. Your GP may refer you to a local surgeon who specialises in bone diseases (an orthopaedic surgeon), or to a bone cancer specialist. If tests show that you may have primary bone cancer, you should be referred to a specialist hospital or bone tumour treatment centre (sarcoma unit). Children are referred to a children s (paediatric) hospital for some of their care. Teenagers may be referred to a teenage cancer unit. These units have specialist doctors with experience in diagnosing and treating young people with cancer. They also have a team of people to support teenagers. The specialist at the hospital or bone treatment centre will ask you about your symptoms. They will want to know about your general health and any previous medical problems. They will examine the affected area to check for any swelling or tenderness. You will have a blood sample taken to check your general health. You ll also have some of the tests listed over the following pages. Bone x-rays Bone x-rays may help show whether the cancer has started in the bone (primary bone cancer), or has spread into the bone from a cancer elsewhere in the body (secondary bone cancer). Questions about cancer? Ask Macmillan Page 1 of 9

2 Sometimes the way the bone looks on an x-ray can help the doctor tell which type of bone cancer it is. This is often true for osteosarcoma. However, you will need other tests before the doctor can definitely say whether it s a primary or secondary bone cancer and which type of cancer it is. MRI (magnetic resonance imaging) scan An MRI scan is used to assess the extent of the primary tumour so that the doctors can plan the best treatment. This test uses magnetism to build up a detailed picture of areas of your body. The scanner is a powerful magnet, so you may be asked to complete and sign a checklist to make sure it s safe for you. The checklist asks about any metal implants you may have, for example a pacemaker, surgical clips or bone pins. You should also tell the doctor if you ve ever worked with metal or in the metal industry, as very tiny fragments of metal can sometimes lodge in the body. If you do have any metal in your body, you probably won t be able to have an MRI scan. In this situation, another type of scan can be used. Before the scan you ll be asked to remove any metal belongings, including jewellery. Some people are given an injection of dye into a vein in the arm, which doesn t usually cause discomfort. This is called a contrast medium. It can help the images from the scan to show up more clearly. During the scan, you ll lie very still on a couch inside a long tube for about 30 minutes. It s painless but can be slightly uncomfortable, and some people feel a bit claustrophobic. It s also noisy, but you ll be given earplugs or headphones. You can hear, and speak to, the person operating the scanner during the scan. Bone sample (bone biopsy) A sample of bone is always needed to diagnose bone cancer. This is because x-rays and scans can t always show whether or not a tumour is cancer. If it is cancer, the bone biopsy should show which type of bone cancer it is. A bone biopsy is a specialised test. It should only be done by a radiologist or surgeon who s an expert in bone cancers. There are two ways of taking a bone biopsy: Page 2 of 9 Questions about cancer? Ask Macmillan

3 Core needle biopsy Before the biopsy, the doctor will give you an injection of local anaesthetic into your skin and around your bone to numb it. Then they will pass the biopsy needle through the skin into the bone to take the sample. They use a special needle to do this. They may take several samples. If the doctor can t feel the bone lump or if it s deep inside the body, the doctor may use an ultrasound or CT scanner (see pages 5) to help them guide the needle into the right place. You will usually be awake during a core needle biopsy, although you may be given a sedative to make you feel more relaxed and drowsy. Sometimes the biopsy is done under a general anaesthetic, particularly for children. For most people, a core needle biopsy will show whether the lump is cancer. However, sometimes it doesn t provide enough cells to give a clear diagnosis. In this case, you will need a surgical biopsy. Surgical biopsy This type of biopsy is done less often than a core needle biopsy. A surgeon uses a surgical knife (scalpel) to open the affected area and remove a sample from the lump. You will be given a local or a general anaesthetic before a surgical biopsy. This depends on your general health, the size of the tumour and how deep it is inside your body. The bone sample or samples are then sent to a specialist doctor (pathologist). The pathologist can tell whether the tumour is a cancer or not by examining cells from the sample under a microscope. If it is a cancer, your doctors may do further tests on the sample to find out which type of bone cancer it is. Waiting for test results Waiting for test results can be a difficult time. It may take from a few days to a couple of weeks for the results of your tests to be ready. You may find it helpful to talk to a partner, family member or close friend. Your specialist nurse can also provide support. You can also talk to one of our cancer support specialists on Questions about cancer? Ask Macmillan Page 3 of 9

4 Further tests If your tests show that you have bone cancer, the doctor may want to do some further tests to see whether the cancer has spread outside the bone. CT (computerised tomography) scan Most patients with bone tumours will have a CT scan of their lungs. They might also have a CT scan of the affected bone. A CT scan takes a series of x-rays, which build up a threedimensional picture of the inside of the body. The scan takes minutes and is painless. The CT scan uses a small amount of radiation, which is very unlikely to harm you and will not harm anyone you come into contact with. You might be asked not to eat or drink for at least four hours before the scan. You may be given a drink or injection of a dye, which allows particular areas to be seen more clearly. This may make you feel hot all over for a few minutes. It s important to let your doctor know if you are allergic to iodine or have asthma, because you could have a more serious reaction to the injection. You ll probably be able to go home as soon as the scan is over. Bone scan This scan looks at all the bones in the body. It s more sensitive than an x-ray, and it shows up any abnormal areas of bone more clearly. A small amount of a radioactive substance is injected into a vein in your hand or arm. Abnormal bone absorbs more radioactivity than normal bone, so these areas are highlighted and picked up by the scanner as hot spots. The level of radioactivity used in the scan is very small and doesn t cause any harm to your body. After you have the injection, you will need to wait 2 3 hours before you have the scan. You may want to take a magazine, book or MP3 player with you to help pass the time. Page 4 of 9 Questions about cancer? Ask Macmillan

5 A bone scan is very similar to any other scan. It s not an unpleasant experience. Liesel If hot spots do show up on a bone scan, it isn t always clear whether they re caused by cancer or by other conditions, such as arthritis. Sometimes a CT scan or MRI scan may help the doctors decide whether changes on a bone scan are caused by bone cancer or by another condition. Some hospitals or treatment centres may do an MRI scan of the whole skeleton instead of a bone scan. This is to check for signs of cancer in any other bones away from the main tumour. Bone marrow sample You will only need this test if you have, or are likely to have, Ewing s sarcoma. Very occasionally, a Ewing s sarcoma can spread to the bone marrow. The test involves a doctor taking a small sample (biopsy) of bone marrow from the hip bone. Taking a bone marrow sample Questions about cancer? Ask Macmillan Page 5 of 9

6 Before the test, adults will be given a local anaesthetic injection into the area around the bone to numb it. Children will usually have a general anaesthetic. The doctor will then pass a special needle through the skin into the bone. When the needle is in position, the doctor will draw a small liquid sample from the bone marrow into a syringe. You may feel some discomfort when this is being done, but it should only last for a few seconds. You can have painkillers if you need them. The test is usually done in the outpatient department and takes about minutes. Sometimes the doctor needs to take a small core of bone marrow. In this case they will do a procedure called a trephine biopsy, which takes a few minutes longer than a bone marrow sample. A special type of needle is passed through the skin to the bone marrow. The needle has a tip that can cut out a sample of the bone marrow. You may feel bruised after the test and have an ache for a few days. Taking mild painkillers will help ease it. Sometimes the bone marrow and trephine biopsies are done at the same time. Your bone marrow samples will be sent to a laboratory to be looked at under a microscope. It may take 7 10 days to get the results. PET/CT scan This is a combination of a CT scan and a PET (positron emission tomography) scan. A PET scan uses low-dose radiation to measure the activity of cells in different parts of the body. PET/CT scans give more detailed information about the part of the body being scanned. You may have to travel to a specialist centre to have one. You can t eat for six hours before the scan, although you may be able to drink. Before the scan, a mildly radioactive substance is injected into a vein, usually in your arm. The radiation dose used is very small. After having the injection you ll have to wait at least an hour before the scan. The scan usually takes minutes. You should be able to go straight home afterwards. Chest x-ray For people with primary bone cancer, the most common place for the cancer to spread to is the lung. A chest x-ray can show whether the lungs have been affected. Page 6 of 9 Questions about cancer? Ask Macmillan

7 Other tests If you re going to have chemotherapy, you will also have tests to check your hearing, kidneys and heart. Some chemotherapy drugs can affect how well you hear highpitched sounds. So you may have hearing tests (audiograms) before and during your course of chemotherapy. To check how well your kidneys are working, you may have a small amount of mildly radioactive liquid injected into a vein in your hand or arm. This is carried through your kidneys then passed out in your urine. A few hours after the injection, a nurse will take blood samples from you. These show how well your kidneys are working. You may also have an electrical trace taken of your heartbeat (an ECG), an ultrasound scan of your heart (an echocardiogram), or a MUGA (multiple-gated acquisition) scan. A MUGA scan shows the movement of the heart and is used to check your heart function. If you need a MUGA scan, your doctors will tell you more about it. Grading and staging Knowing the grade and stage of the cancer affects the decisions you and your doctors make about your treatment. Grading Grading describes what the cancer cells look like under a microscope. The grade gives an idea of how quickly the cancer may develop. The most common grading system for primary bone cancer uses two grades: low-grade and high-grade. Low-grade means the cancer cells look very similar to normal bone cells. They are usually slow-growing and are less likely to spread. In high-grade tumours, the cells look very abnormal. They are likely to grow more quickly and are more likely to spread. All Ewing s sarcomas and most osteosarcomas and spindle cell tumours are high-grade. Questions about cancer? Ask Macmillan Page 7 of 9

8 Staging The stage of a cancer describes its size and whether it has spread. The stages of primary bone cancer are also based on the grade of the cancer. There are two different staging systems used for primary bone cancer. This is the Enneking staging system, which is commonly used to stage primary bone cancers: Stage 1 The cancer is low-grade and hasn t spread beyond the bone. Stage 1 is divided into: Stage 1A The cancer is low-grade and is still completely inside the bone it started in. The cancer may be pressing on the bone wall and causing a swelling, but it has not grown through it. Stage 1B The cancer is low-grade and has grown through the bone wall. Stage 2 The cancer is high-grade and has not spread beyond the bone. Stage 2 is divided into: Stage 2A The cancer is high-grade and is still completely inside the bone it started in. Stage 2B The cancer is high-grade and has grown through the bone wall. Stage 3 The bone cancer may be any grade and has spread to other parts of the body, such as the lungs. Page 8 of 9 Questions about cancer? Ask Macmillan

9 More information and support More than one in three of us will get cancer. For most of us it will be the toughest fight we ever face. And the feelings of isolation and loneliness that so many people experience make it even harder. But you don t have to go through it alone. The Macmillan team is with you every step of the way. To order a copy of Understanding primary bone cancer, visit be.macmillan.org.uk or call We make every effort to ensure that the information we provide is accurate and up to date but it should not be relied upon as a substitute for specialist professional advice tailored to your situation. So far as is permitted by law, Macmillan does not accept liability in relation to the use of any information contained in this publication, or thirdparty information or websites included or referred to in it. Macmillan Cancer Support Registered charity in England and Wales (261017), Scotland (SC039907) and the Isle of Man (604). Registered office 89 Albert Embankment, London, SE1 7UQ REVISED IN APRIL 2014 Planned review in 2016 Questions about cancer? Ask Macmillan Page 9 of 9

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