Malignant bone tumors.

Malignant bone tumors represent a small percentage of cancers nationwide and also are much less common than malignant soft-tissue tumors. The rarity of the condition makes it imperative that orthopaedic surgeons in nononcologic practices are able to recognize the symptoms that suggest a possible bony malignancy to avoid inappropriate or delayed treatment. The most common primary malignant bone tumors, osteosarcoma and Ewing's sarcoma, occur in childhood. Chondrosarcoma occurs more frequently in older adults. Rare tumors such as chordoma and adamantinoma have anatomic predilections for the sacrum and tibia, respectively. The primary symptom of a patient with a malignant bone tumor is pain, which often occurs at rest or at night. There are also characteristic findings on physical examination such as swelling or decreased joint range of motion. Patients with a likely malignancy require thorough staging to determine the extent of disease and a well-planned biopsy for accurate diagnosis. The biopsy can be an image-guided needle biopsy or an open incisional biopsy. Knowledge of specific tumor characteristics and treatment options for osteosarcoma, Ewing's sarcoma, chondrosarcoma, malignant fibrous histiocytoma, chordoma, and adamantinoma is important. Patients with osteosarcoma and resectable Ewing's sarcoma are treated with chemotherapy followed by surgical resection. Secondary sarcomas can occur in previously benign bone lesions and require aggressive treatment. Specific techniques are available for the resection of malignant bone tumors from the upper extremities, lower extremities, pelvis, and spine. Reconstruction options include the use of allografts, megaprostheses, and vascularized autografts. There has been a trend toward more prosthetic reconstructions because of early complications with allografts. The care of patients with primary malignant bone tumors requires a multidisciplinary approach to treatment. The orthopaedic oncologist is a vital member of a team composed of musculoskeletal radiologists and pathologists, radiation oncologists, medical and pediatric oncologists, and microvascular surgeons.