Osteosarcoma Cancer: When to Seek a Bone Specialist

In regular check-ups, family doctors see a lot of teenagers who have bone pain, sports injuries and aches and pains in their muscles and bones. Most of these get better on their own, or improve with simple treatment, and don’t need a specialist to be seen. But there are some things doctors should find that mean a patient should be sent straight away to a bone cancer specialist, instead of being watched by their family doctor. 

Families often aren’t sure when pain that doesn’t go away needs a specialist, and when it’s just normal growing pains that need time. Osteosarcoma starts subtly, and seems like common problems that don’t usually need a lot of treatment. Knowing what to look for – the signs which show a serious problem, as opposed to harmless pain – allows doctors to send patients to specialists appropriately, without causing needless worry about the usual pains children get. 

Symptoms Which Need a Specialist to be Seen Immediately 

There are several things which should cause a doctor to send a patient to a bone specialist instead of simply waiting to see what happens. Pain that goes on for more than two weeks, even with enough rest and anti-inflammatory drugs, is the most worrying sign and needs looking at further. This is very different to growing pains, which get better in a few days or respond well to painkillers. 

Osteosarcoma pain usually gets steadily worse, not better and worse like injuries normally do. Pain at night that wakes children is especially worrying, because harmless problems very rarely cause pain at night which is bad enough to wake a sleeping child. 

Any lump or swelling near a joint needs to be looked at quickly, as the cancer spreading into soft tissue means a serious problem which needs to be dealt with at once. 

Unexplained fractures when doing everyday things which shouldn’t cause a bone to break show that the bone is pathologically weak and needs investigation. Osteosarcoma cancer destroys normal bone, and replaces it with abnormal tissue which can’t stand normal stress. These fractures caused by the disease may be the first sign of the problem, before anything else is noticed. 

Why Family Doctors Send Patients to Specialist Centres 

Family doctors know that they don’t have the knowledge to deal with rare cancers in children, which need very specialised ways of being diagnosed and treated. Fewer than 1,000 children get osteosarcoma in a whole country each year, so doctors don’t often see this in their careers. Because of this, patients need to be sent to centres which have a lot of experience in treating bone sarcomas. 

Finding out what is wrong needs complicated imaging to be interpreted, and biopsy techniques which inexperienced teams may not be able to do well. Poorly done biopsies can damage the tissue, and make it harder to remove the cancer in surgery, and make things much worse in the long term. Specialist centres use bone cancer doctors who are specifically trained in biopsy techniques which get enough tissue to diagnose the problem, and also keep as many options open for surgery as possible. 

Planning treatment needs doctors who specialise in children’s cancers, bone surgeons, doctors who use radiotherapy, people who study tissues and cells, and radiologists, all working together. These teams make complete plans to deal with the causes of osteosarcoma, what stage the cancer is at, whether the limb can be saved, when to use chemotherapy, and what rehabilitation is needed. No single doctor can do all of this, however good they are generally. 

What to Expect at the First Appointment with a Bone Cancer Specialist 

The first appointment will usually involve taking a detailed history, asking about when the symptoms started, how they have changed, what they stop the patient doing, and what treatment they have already had. The specialists will ask specific questions about pain at night, weight loss, fever, and any injuries in the past which might explain the current problems. A physical examination will look at what the lump is like, how far the joint can move, the nerves and blood vessels, and the lymph nodes in the area. 

If the patient has already had imaging done, the specialist will look at it, but they will often order more imaging, using methods which are best for finding sarcomas. Normal X-rays show things like destruction of the bone, changes around the bone, and lumps in soft tissue when osteosarcoma is present. MRI scans give a detailed map of the cancer, which is essential for planning surgery, while CT scans of the chest find cancer in the lungs, which is present in about 20% of patients when they are diagnosed. 

Blood tests measure alkaline phosphatase and lactate dehydrogenase levels, which are often high in osteosarcoma, and give a base line for later tests. Complete tests to find out how far the cancer has spread are done before treatment starts, to find out whether it is localised or has spread, and what treatment is needed. All of these tests usually take several days to complete before a definite diagnosis can be made. 

Biopsy Techniques Which Keep Future Treatment Options Open 

Taking a core needle biopsy, under imaging, is the best way to diagnose suspected bone sarcomas when it is possible to do so. This minimally invasive technique gets enough tissue for a diagnosis, and also minimises damage to the areas around the cancer, which surgery will have to deal with later. Interventional radiologists and orthopaedic oncologists work together to make sure biopsy routes line up with where surgery is planned. 

An open biopsy is needed when needle biopsies aren’t good enough – or when a tumour’s position makes it unsafe to take a sample using needles. These procedures demand careful work, with cuts being put in just the right places so that, when the tumour is removed in later surgery, the whole biopsy route is included in the sample. If a biopsy scar isn’t in the correct position, it might not be possible to save the limb; amputation could become necessary, though good technique would have prevented this. 

Specialised centres – such as Fortis Memorial Research Institute, Gurgaon – have experienced teams doing hundreds of sarcoma biopsies each year, using standard methods to get the best possible diagnosis, whilst still leaving all options open for surgery. These teams, made up of different kinds of doctors, plan the biopsy together with the final treatment strategy, from the first assessment to care after treatment is finished. 

Composition of the Treatment Team and the Jobs of Each Person 

Paediatric medical oncologists are in charge of chemotherapy, dealing with osteosarcoma chemotherapy plans, changes to doses, help with side effects, and watching for toxicity during courses of treatment. These doctors have a very good understanding of drug mixes, when drugs should be given, and ways to work out if treatment is effective – knowledge built up over many years of clinical trials. They manage the whole of a patient’s care, whilst other specialists deal with particular parts of the treatment. 

Orthopaedic oncologists do the main surgeries to remove the tumour, after chemotherapy has made it small enough for the best possible removal. These surgeons are experts in saving limbs, using custom-made prostheses to bring back function whilst making sure that no cancer cells are left behind. In complicated cases, vascular surgeons, plastic surgeons, or neurosurgeons may be involved in removing tumours near vital areas. 

Radiation oncologists help when cancer cells are still present at the edges of the surgery, or when cancer has spread and needs to be eased. Pathologists give vital diagnostic services through looking at biopsies and samples from surgery, to work out how well chemotherapy is working. Radiologists guide the diagnostic process and monitor how well treatment is going using repeated scans. This joined-up approach deals with the causes and treatment of osteosarcoma fully, using the specific skills of each specialist. 

When Getting a Second Opinion is Useful, and When it Might Cause Delays 

It is reasonable to get a second opinion for rare cancers, where treatment can be different between centres that have different ideas. Osteosarcoma symptoms needing urgent treatment don’t usually allow for long delays whilst getting many consultations, though short delays for an expert to review the case are usually acceptable. Most paediatric oncology centres are happy to receive requests for second opinions, and often arrange quick assessments when families are worried. 

Virtual tumour boards allow experts to review cases without families having to travel to centres further away, using technology to help with making decisions together. Reviewing pathology slides by sarcoma pathologists sometimes changes diagnoses, showing why expert advice is useful for unusual cases. Families should tell their main team if they want a second opinion, who can speed up the process whilst keeping treatment going.