Adult Medical-Surgical Adult Medical-Surgical NursingNursing

Musculo-skeletal Module: Musculo-skeletal Module:

Bone Tumours Bone Tumours

Bone Tumours: ClassificationBone Tumours: Classification

BenignBenign

Malignant primary (rare)Malignant primary (rare)

MetastasesMetastases

Benign Bone TumoursBenign Bone Tumours

Benign Bone TumoursBenign Bone Tumours

Osteochondroma: a projection at the end Osteochondroma: a projection at the end of a long bone (arising at the knee or of a long bone (arising at the knee or shoulder) shoulder)

Enchondroma: hyaline cartilage found in Enchondroma: hyaline cartilage found in hand, femur, tibia, humerushand, femur, tibia, humerus

Rhabdomyoma (muscle); fibroma (fibrous)Rhabdomyoma (muscle); fibroma (fibrous) Osteoclastoma (giant cell tumour): may Osteoclastoma (giant cell tumour): may

become malignantbecome malignant Bone cystBone cyst

Benign Tumours: PathophysiologyBenign Tumours: Pathophysiology

Benign bone tumours have a Benign bone tumours have a symmetric controlled growth patternsymmetric controlled growth pattern

Increase pressure on the adjacent Increase pressure on the adjacent bone tissue causing pain and bone tissue causing pain and deformitydeformity

Occur spontaneously within localised Occur spontaneously within localised bone tissuebone tissue

Do not spread to other tissues as Do not spread to other tissues as malignant tumours (but some benign malignant tumours (but some benign tumours may become malignant)tumours may become malignant)

Malignant Bone TumoursMalignant Bone Tumours

Primary Malignant Bone TumoursPrimary Malignant Bone Tumours

Sarcoma (malignant growth of Sarcoma (malignant growth of connective tissue):connective tissue):

Osteosarcoma is most common Osteosarcoma is most common (metastasises to lungs)(metastasises to lungs)

Chondrosarcoma (hyaline cartilage): Chondrosarcoma (hyaline cartilage): slow-growing in adults (femur, slow-growing in adults (femur, humerus, spine, scapula, tibia)humerus, spine, scapula, tibia)

Multiple myeloma (bone marrow) Multiple myeloma (bone marrow)

Bone MetastasesBone Metastases

Bone metastases are more common Bone metastases are more common than a primary tumourthan a primary tumour

Malignancy spreads from kidneys, Malignancy spreads from kidneys, prostate, lung, breast, ovary, thyroidprostate, lung, breast, ovary, thyroid

Metastases found in skull, spine, Metastases found in skull, spine, pelvis, femur, humeruspelvis, femur, humerus

Often more than one siteOften more than one site

Malignant Bone Tumours: Malignant Bone Tumours: PathophysiologyPathophysiology

Whether primary or metastatic, Whether primary or metastatic, malignant tumour cells:malignant tumour cells:

Cause localised bone destructionCause localised bone destruction May cause reactive bone overgrowthMay cause reactive bone overgrowth Invade and destroy adjacent bone Invade and destroy adjacent bone

tissuetissue Weaken bone structureWeaken bone structure May lead to pathological fracture May lead to pathological fracture

Bone Tumours: Bone Tumours: Clinical ManifestationsClinical Manifestations

Bone Tumours: Bone Tumours: Clinical ManifestationsClinical Manifestations

Pain: mild or severePain: mild or severe May be disabilityMay be disability May be visible/ palpable bony growthMay be visible/ palpable bony growth If spinal tumour, spinal cord compression If spinal tumour, spinal cord compression

may occur → neuropathy (paraplegia)may occur → neuropathy (paraplegia) If If malignant:malignant: Other disease symptoms: weight loss, Other disease symptoms: weight loss,

fever, malaise. Pathological fracture may fever, malaise. Pathological fracture may occuroccur

Bone Tumours: DiagnosisBone Tumours: Diagnosis

Diagnosis of Bone Tumours: Diagnosis of Bone Tumours: Xrays and ScansXrays and Scans

Patient history and clinical picturePatient history and clinical picture XrayXray CT scanCT scan Bone scanBone scan MRIMRI Biopsy (assists staging of malignant Biopsy (assists staging of malignant

tumour) tumour) MyelographyMyelography ArteriographyArteriography

Diagnosis of Bone Tumours: Diagnosis of Bone Tumours: Blood/ Urine Biochemistry Blood/ Urine Biochemistry

Serum alkaline phosphatase (raised in Serum alkaline phosphatase (raised in osteosarcoma)osteosarcoma)

Serum acid phosphatase (raised if Serum acid phosphatase (raised if metastases from prostate cancer)metastases from prostate cancer)

Serum calcium (raised if bone metastases Serum calcium (raised if bone metastases from breast, lung, kidney primary). May from breast, lung, kidney primary). May lead to symptoms of hypercalcaemia lead to symptoms of hypercalcaemia

Management of Benign Bone Management of Benign Bone TumoursTumours

Benign Bone Tumours: Benign Bone Tumours: ManagementManagement

Surgery to relieve symptoms and Surgery to relieve symptoms and restore functionrestore function

If potential to become malignant If potential to become malignant treat as primary malignanttreat as primary malignant

Management of Primary Malignant Management of Primary Malignant TumoursTumours

Primary Malignant Bone Tumours: Primary Malignant Bone Tumours: Management Management

Aims to destroy or remove the Aims to destroy or remove the tumour and prevent metastases:tumour and prevent metastases:

Surgical wide-bloc excision (with Surgical wide-bloc excision (with restorative grafting)restorative grafting)

Amputation may be requiredAmputation may be required Radiotherapy if radio-sensitiveRadiotherapy if radio-sensitive Chemotherapy pre-op, intra-op and Chemotherapy pre-op, intra-op and

post-operatively to prevent post-operatively to prevent metastases. *Adequate analgesia*metastases. *Adequate analgesia*

Management of Metastatic Bone Management of Metastatic Bone TumoursTumours

Metastatic Bone Tumours: Metastatic Bone Tumours: ManagementManagement

There is no cureThere is no cure

The aim of management is palliative:The aim of management is palliative:

To relieve symptomsTo relieve symptoms

To promote optimum quality of life To promote optimum quality of life

Metastatic Bone Tumours:Metastatic Bone Tumours:Pain ReliefPain Relief

Pain assessmentPain assessment DrugsDrugs: opioids, adjuvant therapy: opioids, adjuvant therapy Radiation therapy: Radiation therapy: External beamExternal beam Bone-seeking isotopesBone-seeking isotopes Hormonal therapy:Hormonal therapy: Appropriate where tumour is hormone-Appropriate where tumour is hormone-

dependentdependent These therapies are used to reduce These therapies are used to reduce

tumour mass and alleviate paintumour mass and alleviate pain

Metastatic Bone Tumours: Metastatic Bone Tumours: Promoting Quality of LifePromoting Quality of Life

Stabilisation of weakened bone to prevent Stabilisation of weakened bone to prevent pathological fracturepathological fracture

Monitor for and treat hypercalcaemia Monitor for and treat hypercalcaemia (from bone destruction)(from bone destruction)

Monitor effects on bone marrow (blood/ Monitor effects on bone marrow (blood/ blood products to replace loss)blood products to replace loss)

Prevent wound infection, delayed healing, Prevent wound infection, delayed healing, osteomyelitis: asepsis/ antibiotics/ osteomyelitis: asepsis/ antibiotics/ nutritionnutrition

Metastatic Bone Tumours: Spiritual/ Metastatic Bone Tumours: Spiritual/ Emotional SupportEmotional Support

Support coping skills, self-esteemSupport coping skills, self-esteem Provide support and access for family Provide support and access for family

members to share their experiencemembers to share their experience Encourage nutrition, fluids, fresh air, Encourage nutrition, fluids, fresh air,

exercise as tolerated, change of exercise as tolerated, change of sceneryscenery

Address spiritual and emotional need Address spiritual and emotional need appropriately. Respect the patient’s appropriately. Respect the patient’s wishes wishes

Bone Tumours: Bone Tumours: Nursing ConsiderationsNursing Considerations

According to the type of tumourAccording to the type of tumour Patient education about the conditionPatient education about the condition Provide support to patient and familyProvide support to patient and family Ensure adequate pain relief and Ensure adequate pain relief and

general comfort general comfort Encourage nourishing diet and fluidsEncourage nourishing diet and fluids Monitor and report any complicationsMonitor and report any complications