Adult Bone Cancer: Diagnosis and Tests

This page is for adults being checked for a primary bone cancer, and the people supporting them. It explains the tests, why the biopsy matters, how the exact type changes treatment, and what to ask.

Primary bone cancer means cancer that begins in bone. That is different from cancer that started elsewhere and later spread to bone. Pain is the most common symptom of bone cancer, but not all bone cancers cause pain. Other signs can include swelling, a lump, unexplained fever, or a bone that breaks without a clear reason.

To help diagnose bone cancer, the doctor asks about your personal and family medical history and does a physical exam. Some histories raise the odds:

• Osteosarcoma risk is higher after earlier radiation therapy.
• It is also higher after treatment with certain anticancer drugs called alkylating agents.
• People over 40 with Paget disease of bone are at increased risk of osteosarcoma.
• Families with Li-Fraumeni syndrome, an inherited condition that raises cancer risk, have increased risk of osteosarcoma and chondrosarcoma.

Tell your team about these histories directly. Do not assume the chart already shows them.

• X-ray is one of the imaging tests NCI lists.
• Bone scan, CT scan, MRI, PET scan and angiogram may also be used. Ask your team which ones are planned and why.

Blood tests may measure levels of the enzymes alkaline phosphatase and lactate dehydrogenase. NCI says large amounts of these enzymes may be present in the blood of people with osteosarcoma or Ewing sarcoma. They are not a diagnosis on their own.

A biopsy is the removal of a tissue sample from the bone tumor. There are three kinds:

• A needle biopsy makes a small hole in the bone and removes tissue with a needle-like instrument.
• An excisional biopsy removes the entire lump.
• An incisional biopsy cuts a sample from the tumor.

One point from NCI is worth acting on before the procedure, not after. Biopsies are best done by an orthopedic oncologist, a doctor experienced in the treatment of bone cancer. The reason is that where the biopsy cut is placed can affect what surgery is possible later. If a biopsy is being scheduled by someone who does not routinely treat bone tumors, that is a fair thing to raise.

The three main types of primary bone cancer behave differently and are treated differently.

Osteosarcoma often forms in the arm and shoulder or the leg and knee. Risk is highest among children and adolescents ages 10 to 19. It is more common in males.

Ewing sarcoma most often forms in the pelvis, legs, or ribs, though it can form in any bone. Risk is highest in children and adolescents younger than 19.

Chondrosarcoma begins in cartilage tissue. It forms mainly in the pelvis, upper leg, and shoulder. It occurs mainly in adults over age 40 and is usually slow growing.

That difference shows up directly in treatment. Patients with Ewing sarcoma, newly diagnosed or recurrent, usually receive a combination of anticancer drugs before surgery. So do patients with newly diagnosed osteosarcoma. So the type on your pathology report can affect whether drug treatment comes before surgery. NCI says most patients who have limb-sparing surgery need reconstructive surgery to regain limb function.

• What exact type of bone cancer is this, and did pathology confirm it?
• Who will perform the biopsy, and are they an orthopedic oncologist?
• Will the biopsy incision be placed so it does not limit later surgery?
• Given this type, would chemotherapy come before surgery?
• Is limb-sparing surgery possible here, and would reconstruction be needed?
• What were my alkaline phosphatase and lactate dehydrogenase levels?
• Which results are still pending, and who will call me?

You can call NCI's Cancer Information Service at 1-800-4-CANCER (1-800-422-6237) for information about clinical trials for treatment of bone cancer.

• National Cancer Institute, Bone Cancer fact sheet.