Neoplasms of the musculoskeletal system are of various types, including osteogenic, chondrogenic, fibrogenic, muscle (rhab-domyogenic), and marrow (reticulum) cell tumors as well as nerve, vascular, and fatty cell tumors. They may be primary tumors or metastatic tumors from primary cancers elsewhere in the body (eg, breast, lung, prostate, kidney). Metastatic bone tumors are more common than primary bone tumors.
Types
Benign Bone Tumors
Benign bone tumors are slow growing, well circumscribed, and encapsulated. They produce few symptoms and do not cause death. Benign primary neoplasms of the musculoskeletal system include osteochondroma, enchondroma, bone cyst (eg, aneurys-mal bone cyst), osteoid osteoma, rhabdomyoma, and fibroma.
Benign tumors of the bone and soft tissue are more common than malignant primary bone tumors.
Osteochondroma, the most common benign bone tumor, may become malignant. Enchondroma is a common tumor of the hyaline cartilage of the hand, femur, tibia, or humerus.
Osteoid osteoma is a painful tumor that occurs in children and young adults. Osteoclastomas (giant cell tumors) are benign for long periods but may invade local tissue and cause destruc-tion. These tumors may undergo malignant transformation and metastasize. Bone cysts are expanding lesions within the bone (eg, aneurysmal and unicameral).
Malignant Bone Tumors
Primary malignant musculoskeletal tumors are relatively rare and arise from connective and supportive tissue cells (sarcomas) 92 Bone Tumors
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Bone Tumors 93 or bone marrow elements (myelomas). Malignant primary mus-
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culoskeletal tumors include osteosarcoma, chondrosarcoma, Ewing’s sarcoma, and fibrosarcoma. Soft tissue sarcomas include liposarcoma, fibrosarcoma, and rhabdomyosarcoma. Metastasis to the lungs is common. Osteogenic sarcoma (osteosarcoma) is the most common and is often fatal owing to metastasis to the lungs. It is seen most frequently in children, adolescents, and young adults (in bones that grow rapidly); in older people with Paget’s disease of the bone; and in persons with a prior history of radiation exposure. Common sites are distal femur, the prox-imal tibia, and the proxprox-imal humerus.
Chondrosarcoma, the second most common primary malig-nant bone tumor, is a large, bulky tumor that may grow and metastasize slowly or very fast, depending upon the charac-teristics of the tumor cells involved. Tumor sites may include pelvis, femur, humerus, spine, scapula, and tibia. Tumors may recur after treatment.
Metastatic Bone Disease
Metastatic bone disease (secondary bone tumors) is more com-mon than any primary malignant bone tumor. The most common primary sites of tumors that metastasize to bone are the kidney, prostate, lung, breast, ovary, and thyroid. Metasta-tic tumors most frequently attack the skull, spine, pelvis, femur, and humerus and often involve more than one bone.
Clinical Manifestations
Bone tumors present with a wide range of associated problems:
• Asymptomatic or pain (mild, occasional to constant, severe).
• Varying degrees of disability; at times, obvious bone growth.
• Weight loss, malaise, and fever may be present.
• Spinal metastasis results in cord compression and neurologic deficits (eg, progressive pain, weakness, gait abnormality, paresthesia, paraplegia, urinary retention, loss of bowel or bladder control).
Assessment and Diagnostic Findings
• May be diagnosed incidentally after pathologic fracture
• CT scan, bone scan, myelography, MRI, arteriography, x-ray studies
• Biochemical assays of the blood and urine (alkaline phos-phatase levels are frequently elevated with osteogenic sar-coma; serum acid phosphatase levels are elevated with metastatic carcinoma of the prostate; hypercalcemia is pres-ent with breast, lung, and kidney cancer bone metastases)
• Surgical biopsy for histologic identification; staging based on tumor size, grade, location, and metastasis
Medical Management
The goal of treatment is to destroy or remove the tumor. This may be accomplished by surgical excision (ranging from local excision to amputation and disarticulation), radiation, or chemotherapy.
• Limb-sparing (salvage) procedures are used to remove the tumor and adjacent tissue; surgical removal of the tumor may, however, require amputation of the affected extremity.
• Chemotherapy is started before and continued after surgery in an effort to eradicate micrometastatic lesions.
• Soft tissue sarcomas are treated with radiation, limb-sparing excision, and adjuvant chemotherapy.
• Metastatic bone cancer treatment is palliative; therapeutic goal is to relieve pain and discomfort as much as possible while promoting quality of life.
• Internal fixation of pathologic fractures, arthroplasty, or methylmethacrylate (bone cement) minimizes associated disability and pain in metastatic disease.
Nursing Management
• Ask the patient about the onset and course of symptoms;
assess the patient’s understanding of the disease process, how the patient and the family have been coping, and how the patient has managed the pain.
• Gently palpate the mass and note its size and associated soft tissue swelling, pain, and tenderness.
• Assess patient’s neurovascular status and range of motion of the extremity to provide baseline data for future compar-isons; evaluate the patient’s mobility and ability to perform activities of daily living (ADLs).
• Nursing care similar to that of other patients who have had skeletal surgery: Monitor vital signs; assess blood loss; observe 94 Bone Tumors
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Bone Tumors 95 and assess for the development of complications such as deep
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vein thrombosis (DVT), pulmonary emboli, infection, con-tracture, and disuse atrophy; elevate affected part to reduce edema; and assess the neurovascular status of the extremity.
• Teach patient and family about the disease process and diag-nostic and management regimens; explain diagdiag-nostic tests, treatments (eg, wound care), and expected results (eg, decreased range of motion, numbness, change of body con-tours) to help patient deal with the procedures and changes and comply with the therapeutic regimen.
• Assess pain and provide pharmacologic and nonpharmaco-logic pain management techniques to relieve pain and increase comfort level; work with the patient to design the most effective pain management regimen.
• Prepare the patient and provide support during painful pro-cedures.
• Prescribe intravenous (IV) or epidural analgesics to be used during the early postoperative period; later, oral or trans-dermal opioid or nonopioid analgesics are indicated to alle-viate pain; external radiation or systemic radioisotopes may be prescribed.
• Support and handle the affected extremities gently; provide external supports (eg, splints) for additional protection.
• Ensure any prescribed weight-bearing restrictions are fol-lowed; with help of physical therapist, teach the patient how to use assistive devices safely and how to strengthen unaf-fected extremities.
• Encourage the patient and family to verbalize their fears, concerns, and feelings; refer to psychiatric advanced prac-tice nurse, psychologist, counselor, or spiritual advisor if nec-essary.
• Assist the patient in dealing with changes in body image due to surgery and possible amputation; provide realistic reassurance about the future and resumption of role-related activities and encourage self-care and socialization.
• Encourage the patient to be as independent as possible.
For more information, see Chapter 68 in Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner and Suddarth’s textbook of medical-surgical nursing (12th ed.). Philadelphia:
Lippincott Williams & Wilkins.