CANCER

What is Tumor ?

A 'Tumor' is technically any enlarged area of the body that is abnormal. The term tumor is usually used to refer to a neoplasm or a growth of abnormal tissue. Tumors can be benign or malignant. A benign tumor is one that may grow to very large proportions if left untreated yet will not spread to other parts of the body and should not kill the patient. Many benign tumors do not grow significantly and do not require any treatment at all. Benign bone tumors are seen in children (most common are osteochondromas, hemangiomas, unicameral bone cysts, aneurysmal bone cysts, osteoid osteomas, and chondroblastomas) and in adults (most common are giant cell tumors and enchondromas). There are many other types of benign bone lesions and other causes of abnormalities seen on radiographs such as bone islands, bone infarcts and degenerative cysts that usually do not require surgery or a biopsy for treatment. Malignant bone tumors (bone cancers) include bone sarcomas, lymphoma of bone, multiple myeloma, and metastatic carcinoma. The main types of bone sarcomas are Osteosarcoma (see link on Osteosarcoma), Ewing's Sarcoma (see link on Ewing's Sarcoma), Chondrosarcoma and malignant fibrous histiocytoma of bone. Osteosarcoma and Ewing's occur mostly in adolescents and young adults while chondrosarcoma and malignant fibrous histiocytoma occur in adults.These malignant sarcomas require aggressive management with surgery, chemotherapy (exception is chondrosarcoma) and sometimes radiation (especially Ewing's). Cure is possible and is more likely in patients without metastatic spread of disease and when the tumors are small and surgically resectible. If untreated these tumors will spread to vital organs and kill the patient. Despite our best treatment modalities, almost half of patients with high grade sarcomas will progress and die of their disease. Research is being focused on improving our understanding of metastatic potential, mechanisms and prevention. 

What is MRI ?

MRI (Magnetic Resonance Imaging) is a great imaging technique that allows the physician to 'see what the tumor looks like' in relation to normal tissue planes. The MRI uses a magnetic field to create pictures of the body as if the subject was cut in sections. In order to have a MRI, the patient must lie flat and motionless in a confined space like a tube that is open on each end. The MRI is very loud and takes about one and one half hours to complete. Newer 'open' MRI scanners can create images that are almost as good as traditional scanners and are easier for the patient. Occasionally a contrast material is given to the patient by IV to improve the quality of the scan. Otherwise MRIs do not cause any pain. 

        If a patient has a symptomatic tumor the best way to know the diagnosis is to undergo a biopsy. A biopsy requires that a piece of the tumor is looked at under the microscope by a pathologist. By examining the cells under the microscope and by performing special tests on the tissue, the pathologist usually can tell what the diagnosis is and direct the appropriate treatment. Biopsies can be done as a 'fine needle aspiration,' 'cutting needle/trocar needle biopsy,' an 'incisional biopsy,' or an 'excisional biopsy.' A fine needle is usually performed by a pathologist and can only be used for soft tumors. The pathologist is gathering individual cells and is limited by a small amount cellular material to look at. It is an easy technique and relatively painless. A cutting needle biopsy is usually performed by a surgeon or radiologist who gives the pathologist small strips of tissue and is more likely to lead to an accurate diagnosis. Both types of needle biopsies are generally performed with the patient awake and with a numbing shot beforehand. The best chance to make the correct diagnosis is an incisional biopsy. This requires an anesthetic and has more risk for the patient. An incision is made and larger pieces of tissue are give to the pathologist. The tumor is contaminated with this technique and only qualified surgeons with a good understanding of the future treatment of the tumor (especially if it ends up being cancerous) should perform the biopsy. Any place the biopsy incision touches, contaminates those tissues with tumor cells. An excisional biopsy is where the surgeon removes the tumor completely before a diagnosis is established. This is a dangerous method even though at first thought it may seem like a logical approach.'If the tumors got to come out why not just take it out and find out what it is later'? is a common question. The problem with this approach is that if the tumor ends up being cancerous and especially if it is larger than a few centimeters, the cancer is very difficult to treat after such an excision. The entire surgical incision is contaminated with tumor cells and the cells may be more prone to spread. Excisional biopsies are best limited to the diagnosis of small superficial lesions of soft tissues. 

What is Sarcoma ?

A Sarcoma is a cancer of bone, cartilage, nerve, fat, muscle, or tendons. They usually occur in the arms and legs but can occur any where there is bone or muscle tissue. Osteosarcoma, Ewing's sarcoma, Chondrosarcoma and Malignant fibrous histiocytoma are the most common bone sarcomas. The most common soft tissue sarcomas are Malignant fibrous histiocytoma, Liposarcoma, Neurosarcoma, Synovial sarcoma, Fibrosarcoma, and Rhabdomyosarcoma. These are aggressive malignancies that require radical surgical resections or occasionally amputation and depending on which type of sarcoma, radiation and/or chemotherapy. The most important factor is early diagnosis and treatment. 


What is Osteosarcoma ?

Osteosarcoma is a cancer that usually occurs in the thigh or shin bone near the knee. They can occur in the shoulder region or several other less common locations. The typical patient is between ten and twenty-five years old and is diagnosed after a few months of deep, ill-defined pain and swelling in the leg or shoulder. Rarely, the patient breaks the bone before it is diagnosed. A radiograph (x-ray) will usually show the tumor and is highly characteristic in most cases. CAT scans and MRI studies will help define the lesion and a bone scan and chest CAT scan are performed to look for metastases. This is then followed by a carefully planned biopsy to confirm the diagnosis. Typically chemotherapy is given to the patient which is highly toxic. The patient will lose their hair and have nausea from the treatment. Long term problems of heart damage and hearing loss as well as other nerve damage can occur. Sterility is possible. After the initial treatment is completed, surgical removal of the tumor is required. Most patients today are able to have a limb sparing or 'salvage' operation where amputations are not necessary. Unfortunately, some patients have tumors are too large or aggressive and do require an amputation. (see link 'Surgical Management of Osteosarcoma'). Currently 60-70% of patients with non-metastatic osteosarcoma are cured (live without recurrence of disease). If a patient lives more than five years after the diagnosis with an osteosarcoma, they have a very high chance of never having a relapse of disease. (see link 'Limb Salvage Compared to Amputation for Osteosarcoma of the Distal End of the Femur.') 


What is Ewing's sarcoma ?

Ewing's sarcoma is an aggressive cancer of bone that is usually diagnosed in children and young adults. It is less common than osteosarcoma but has many similarities in treatment. Ewing's sarcoma are sensitive to chemotherapy and radiation. Surgery is usually employed as well and may be used to replace radiation. Cure rates are related to the size of the mass and the location in the body. Patients with metastatic disease can be cured, but not as often.