Bone tumors

Orthopedic oncology deals with the management of cancers of the musculoskeletal system, whether primary or secondary, benign or malignant, through both surgical and nonsurgical interventions.

In recent years, due to the complexity and specificity of these diseases, orthopedic oncology has emerged as a separate specialty within orthopedics.

The main goal of this discipline is to remove the bone segments involved by tumors and, at the same time, reconstruct them to enable the patient to preserve mobility, daily functions, and social life as much as possible, thus ensuring the best possible quality of life. Of course, this is all accompanied by the goal of gaining control of the disease.

The choice of the most appropriate therapeutic strategy, including reconstructive techniques, always arises from multidisciplinary discussion among the specialists involved. In some cases, it may be useful to postpone surgery in favor of medical or radiation therapies; in others, surgery should be performed early, for example, to reduce the risk of fractures or because of the proximity of the lesion to critical anatomic structures.

Only through collaboration between different specialists is it possible to optimize outcomes, control pain, and preserve the organs involved, all of which are critical to ensuring the patient’s quality of life.

Radiation therapy consists of the use of high-energy radiation To destroy cancer cells. Treatment is performed at the Division of Radiotherapy in consecutive daily sessions, Monday through Friday, in cycles that can last from a single session up to 10 to 15 sessions depending on the intent and dose to be administered.

Radiation therapy is widely used in the case of bone metastases because of its known antalgic power.

It is also used in the case of prevention of pathological fractures by resorting to its recalcifying power and in cases of compression by neoplastic tissue of critical and vital organs (e.g., the spinal cord).

It may have a postoperative role after a decompressive laminectomy, a surgical procedure aimed at decompressing the spinal cord and/or spinal roots, in which case radiation therapy will be responsible for sterilizing the affected territory from any residual tumor tissue.

Radiation therapy can have curative intent In the case of situations where the number of bone localizations is limited and disease recovery is still being pursued. In the latter case, special techniques such as the stereotactic radiotherapy. This is a high-dose, highly collimated radiation therapy that makes use of a limited number of sessions, from one to five.

Interventional radiology is an operative branch of medical radiology that uses radiologic guidance (ultrasound, CT, fluoroscopy) to perform minimally invasive procedures, alternatives to surgery, to diagnose and treat various pathologies including bone diseases.

The main procedures in interventional bone radiology are as follows:

• Bone biopsy: consists of the harvesting, under ultrasound or CT guidance, of bone tissue suspected of tumor involvement. The procedure is generally outpatient and is performed using local anesthesia; it involves harvesting using a special cannula that removes a small whip of tissue without the need for surgical incisions;
• Vertebroplasty and osteoplasty: These procedures allow, through the use of cannulas of a few mm introduced under radiological guidance, to inject resins into fractures or bone lesions in order to prevent their worsening and to reduce pain in association with radiotherapy and medical therapy. In some cases, these procedures may be combined with percutaneous insertion of screws or prostheses. Vertebroplasty can also be performed in fractures that are not directly caused by the tumor but need to be treated to reduce pain;
• Thermoablation and Cryoablation: consist of targeted destruction of cancer cells by probes emitting high or very low temperatures that are introduced under radiological guidance. These procedures are performed in patients with few neoplastic lesions in whom radiotherapy is not feasible and may be combined with vertebroplasty and osteoplasty.

Pain from bone metastasis is the most common among cancer patients, involving about one-third of cases. This type of pain significantly affects quality of life, reducing walking ability and increasing the risk of neurological deficits and pathological fractures.

Bone pain typically has three components: baseline pain, spontaneous pain, and motion-induced pain.

Treatment is multimodal and may include systemic analgesics, bisphosphonates, chemotherapy, radiation therapy, orthopedic interventions, and neuromodulation techniques.

There are no specific pharmacological guidelines for bone metastases; therefore, pain treatment follows World Health Organization (WHO) and European Society for Medical Oncology (ESMO) guidelines.

Evaluation of the effectiveness of therapies should be based on subjective measures of pain, quality of life, and patient judgment.

According to WHO, drug treatment is divided into a three-step ladder:

• Step one: mild pain medications (acetaminophen, NSAIDs), with or without adjuvant drugs;

• Second step: weak opioids for mild-to-moderate pain (codeine, tramadol, tapentadol), with or without adjuvant drugs;

• Third step: strong opioids for moderate-to-severe pain (morphine, methadone, fentanyl, buprenorphine, oxycodone, hydromorphone), with or without adjuvant drugs.

The ladder can be extended to a fourth step, involving rotation or change of route of administration (subcutaneous or intravenous elastomers), and a fifth step, reserved for invasive interventions such as intrathecal pumps, spinal cord stimulators, or chordotomies, in patients refractory to other therapies.

Medications, non-opioids or opioids, may be combined with corticosteroids, antiepileptics, local anesthetics, antidepressants, anti-nausea or anti-stipsia, depending on the intensity and type of pain and side effects. Anti-inflammatories are recommended either as a first step or in combination with opioids for severe pain, but their use must consider the patient’s clinical condition.

Effective analgesic therapy, according to WHO, must:

• prevent pain by taking medications at regular times (“as needed” administration is reserved for breakthrough pain);

• Be easy to take, favoring the oral route;

• be changed promptly when the analgesic loses effectiveness;

• Be customized in dosage, drug type and route of administration.

A proper pharmacological approach can control pain in more than 90% of patients with bone metastases.

The cancer patient is a person with complex needs that requires multidisciplinary support not only for the cancer disease, but also for all related issues.

At the Candiolo Institute, patients who need or require it have access to specialists in different areas to receive nutritional support, physical therapy, pain therapy and management of other associated conditions.

Treatment for bone tumors often involves side effects that impact quality of life more or less severely. However, they can be mitigated and in some cases prevented by specific treatments and/or appropriate lifestyle.

At the Candiolo Institute, the doctors and nurses of the multidisciplinary team are available to provide the patient with all the support he or she needs to manage the various side effects he or she will face in the course of treatment.

The impact of cancer in a person’s life also affects the psychological sphere: falling ill with cancer is in fact always a traumatic event that affects all dimensions of the person and can generate anxiety, fear, anger, depression.

At the Candiolo Institute, alongside cutting-edge therapies, the treatment and care pathway always includes a qualified psycho-oncological support that helps the patient cope positively not only with treatment but also with the delicate phase of physical and psychological recovery.

It is also possible to participate in support groups psychological to compare with other people who have gone through or are going through the same experience.

The cancer patient is often a fragile patient, who needs help and support in his or her disease journey: when he or she experiences an ailment, whether related to the disease or a side effect of therapy, he or she should be able to receive a specialist’s opinion quickly, through a “fast track.”

For this reason, at the Candiolo Institute there is an assistance service every day, Monday through Friday from 8 a.m. to 5 p.m.: just call the secretary of the Oncology Day Hospital (011 993 3775) reporting the need for an urgent consultation, and the patient is quickly contacted by his or her specialist doctor.

The Social Service Department of the Candiolo Institute conducts information and orientation interviews to patients and their families on how to access services in the area and how to obtain welfare and social security benefits provided by law (disability, benefits for aids and prostheses, work leave, etc.).

The service operates on Wednesdays and Fridays from 9 a.m. to 1 p.m. (phone: 011 9933059).

Due to the high number of cases treated each year, the Candiolo Institute is a national reference for taking care of esophageal cancer. Our experience enables us to deal with even the most complex situations, always with a personalized approach built on the clinical and personal profile of each patient.

Establishing the treatment plan always starts with an accurate and timely diagnosis. Patients have access to state-of-the-art imaging technologies that allow accurate assessment of the extent of the disease.

In addition, the Institute offers advanced and sophisticated laboratory investigations, including molecular and genomic analyses, which are critical for identifying biological features of cancer and guiding therapeutic decisions.

When indicated, surgery is performed with minimally invasive techniques (laparoscopic or thoracoscopic), which reduce operative trauma, promote faster recovery, and improve postoperative quality of life. Every treatment choice is defined within the GIC, ensuring a consistent and integrated approach.

As an IRCCS, the Candiolo Institute combines clinical practice with a strong vocation for scientific research. Patients can be evaluated for inclusion in active clinical trials, which represent a real chance to access innovative therapies not yet available in standard practice. Collaboration between care and research is a distinctive value that translates into concrete opportunities for the patient.

The Interdisciplinary Care Group takes care of the person at every stage: from diagnosis to treatment to follow-up, with attention to nutritional support, psychological health, and reintegration into daily life. The organization of checkups, visits and treatment is designed to ensure continuity and serenity, always valuing the human dimension of care.