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Symptoms and diagnosis

Symptoms of primary bone cancer

The most common symptoms of bone cancer are:

Pain or tenderness in the area of the tumour This may start as an ache that doesnít go away. It may be made worse by exercise or feel worse at night when the muscles are relaxed. In children this symptom may be mistaken for a sprain or Ďgrowing painsí.

Swelling around the affected area of bone The swelling may not show up until the tumour is quite large. It isnít always possible to see or feel a lump if the affected bone is deep within body tissues.

Reduced movement If the cancer is near a joint, this can make it more difficult to move the joint and affect movement of the whole limb. If the affected bone is in the leg it may cause a limp. If the tumour is in the spine it may press on nerves, causing weakness or numbness and tingling in the limbs.

Broken bone Bone cancer is sometimes discovered when a bone that has been weakened by cancer breaks after a minor fall or an accident.

Generalised symptoms in the body These may include tiredness, a high temperature or sweats and weight loss. These symptoms are uncommon but sometimes occur in people with Ewingís sarcoma.

Many of the symptoms described above can be caused by conditions that happen much more often than bone cancer. Because of this, it sometimes takes a long time for bone cancer to be diagnosed. Anyone with bone pain that lasts longer than a few weeks should be referred to a bone specialist (orthopaedic doctor) or a cancer specialist (oncologist).

How bone cancer is diagnosed?

Usually you begin by seeing your family doctor (GP). She will examine you and arrange any tests or x-rays that may be necessary.

Your GP may refer you to a local surgeon who specialises in bone diseases (an orthopaedic surgeon), or to a bone cancer specialist or bone tumour centre.

If tests suggest you may have a primary bone tumour you should always be referred to a specialist hospital, or bone tumour centre. This is important because some tests for diagnosing bone tumours, particularly taking a bone sample (bone biopsy), need to be done by a person with very specialised experience.

Children may be referred to a childrenís (paediatric) hospital for some of their care. If you are a teenager you 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 help support teenagers.

At the hospital

The specialist will ask you about your symptoms. They will also want to know about your general health and any previous medical problems. They will then examine the affected bone to check for any swelling or tenderness. You will probably have a blood sample taken to check your general health. You may have some of the following tests.

Bone x-rays

Bone x-rays can help to 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).

Sometimes, how the bone looks on an x-ray can help the doctor to diagnose what type of bone cancer someone has. This is often the case for osteosarcoma.

Bone scan

This test looks at all the bones in the body. It shows if there are signs of cancer in any other bones away from the main tumour.

A small amount of a radioactive substance is injected into a vein in your hand or arm. Abnormal bone absorbs more of the substance than normal bone. This allows areas of abnormal bone to be highlighted by the scanner as 'hot spots'. The level of radioactivity used in the scan is very small and doesnít cause any harm to your body.

You will need to wait for 2Ė3 hours between having the injection and the scan, so you may want to take a magazine, book or MP3 player with you to pass the time.

It isnít always clear if 'hot spots' on a bone scan are caused by cancer or by other conditions such as arthritis. Sometimes an MRI (see below) or CT scan may help the doctors to decide whether the changes seen on a bone scan are caused by bone cancer or by another condition.

MRI (magnetic resonance imaging) scan

This test is similar to a CT scan but uses magnetism instead of x-rays to build up a detailed picture of areas of your body. In primary bone cancer itís used to look in detail at the area around the tumour. It allows the doctors to see how far the tumour has grown and how much of the bone is affected.

In some centres an MRI scan of the whole skeleton may be done, instead of a bone scan, to check for signs of cancer in any other bones away from the main tumour.

Before the scan you may be asked to complete and sign a checklist. This is to make sure that itís safe for you to have an MRI scan, because the scanner is a powerful magnet. The checklist asks about any metal implants you may have, for example a pacemaker, surgical clips, bone pins etc. You should also tell your doctor if you have 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 itís likely that you wonít be able to have an MRI scan. In this situation another type of scan can be used.

Before having the scan, youíll be asked to remove any metal belongings including jewellery. Some people are given an injection of dye into a vein in the arm, which doesnít usually cause discomfort. This is called a contrast medium and can help the images from the scan to show up more clearly.

During the test you will be asked to lie very still on a couch inside a long cylinder (tube) for about 30 minutes. It is painless but can be slightly uncomfortable, and some people feel a bit claustrophobic during the scan. Itís also noisy, but youíll be given earplugs or headphones. You will be able to hear, and speak to, the person operating the scanner.

Bone sample (bone biopsy)

A bone biopsy is a specialised test and should only be done by a radiologist or surgeon with specialist expertise in bone cancers.

A sample of bone is often needed to diagnose bone cancer. This is because x-rays and bone scans canít always show if a tumour is non-cancerous (benign) or cancerous. The sample is sent to a specialist doctor, called a pathologist.

The pathologist uses a microscope to look at the cells that make up the bone sample. They can tell from how these cells look whether the tumour is cancer or not. If there is a cancer, your doctors may arrange for further tests on the sample to find out what type of bone cancer it is. It can take up to ten days to get all the results back from a biopsy.

There are two ways of taking a bone biopsy:

Core needle biopsy

For a core needle biopsy the doctor uses a special needle to take a sample from the bone. Before the biopsy, the doctor will give you an injection of local anaesthetic into your skin and around your bone to numb it. They will then put the biopsy needle into the bone to take the sample. You may have several samples taken.

If the lump is near the surface of your body and can be felt easily, the doctor will probably just feel to guide the needle in.

If the lump is in a bone deep within the body or is harder to feel, the doctor will use images from an ultrasound or CT scanner (see page 19) to 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, particularly in children, the biopsy is done under a general anaesthetic.

For most people, a core needle biopsy will show if the lump is a cancer. Sometimes it doesnít provide enough cells to give a clear answer and an open, or surgical biopsy is needed.

Open biopsy

This type of biopsy is done less often than a core needle biopsy. It may be needed if a core biopsy is unable to get enough cells for a diagnosis.

For an open biopsy the surgeon uses a surgical knife (scalpel) to open the area and remove a sample from the lump. If the lump is small enough, all of it may be removed. An open biopsy may be done under a local or a general anaesthetic. This depends on the position of the lump and how deep it is within the body.

Waiting for the results of tests

This can be a worrying time for you, but it is important that an accurate diagnosis is made. It may help to talk about your worries with a partner or close friend, or you may wish to contact our cancer support specialists or other specialised organisations for emotional support.

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