Symptoms and causes

By Mayo Clinic Staff

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Symptoms
Signs and symptoms of bone cancer include:

Bone pain

Swelling and tenderness near the affected area

Broken bone

Fatigue

Unintended weight loss

When to see a doctor
Make an appointment with your doctor if you or your child develops signs and
symptoms that worry you.

Causes

Osteosarcoma

Ewing's sarcoma
It's not clear what causes most bone cancers. Doctors know bone cancer begins as an
error in a cell's DNA. The error tells the cell to grow and divide in an uncontrolled way.
These cells go on living, rather than dying at a set time. The accumulating mutated cells
form a mass (tumor) that can invade nearby structures or spread to other areas of the
body.
Types of bone cancer
Bone cancers are broken down into separate types based on the type of cell where the
cancer began. The most common types of bone cancer include:

Osteosarcoma. Osteosarcoma begins in the bone cells. Osteosarcoma occurs

most often in children and young adults, in the bones of the leg or arm.

Chondrosarcoma. Chondrosarcoma begins in cartilage cells. It usually occurs in

the pelvis, legs or arms in middle-aged and older adults.

Ewing's sarcoma. It's not clear where in bone Ewing's sarcoma begins, but the
tumors most commonly arise in the pelvis, legs or arms of children and young
adults.

Risk factors
It's not clear what causes bone cancer, but doctors have found certain factors are
associated with an increased risk, including:

Inherited genetic syndromes. Certain rare genetic syndromes passed through

families increase the risk of bone cancer, including Li-Fraumeni syndrome and
hereditary retinoblastoma.

Paget's disease of bone. Most commonly occurring in older adults, Paget's

disease of bone can increase the risk of bone cancer developing later.

Radiation therapy for cancer. Exposure to large doses of radiation, such as

those given during radiation therapy for cancer, increases the risk of bone cancer
in the future.

Bone Cancer
Key Points

1.

Cancer that starts in the bone is uncommon.

Pain is the most common symptom of bone cancer.

Surgery is the usual treatment for bone cancer.

With modern surgical techniques, 9 out of 10 people who have bone cancer
in an arm or leg may not need amputation.

Because bone cancer can come back after treatment, regular follow-up visits
are important.

People with bone cancer are encouraged to enroll in clinical trials (research
studies) that explore new treatments.

What is bone cancer?

Bone cancer is a malignant (cancerous) tumor of the bone that destroys normal
bone tissue (1). Not all bone tumors are malignant. In fact, benign (noncancerous) bone
tumors are more common than malignant ones. Both malignant and benign bone tumors
may grow and compress healthy bone tissue, but benign tumors do not spread, do not
destroy bone tissue, and are rarely a threat to life.
Malignant tumors that begin in bone tissue are called primary bone cancer. Cancer that
metastasizes (spreads) to the bones from other parts of the body, such as the breast, lung,
orprostate, is called metastatic cancer, and is named for the organ or tissue in which it
began. Primary bone cancer is far less common than cancer that spreads to the bones.

2.

Are there different types of primary bone cancer?

Yes. Cancer can begin in any type of bone tissue. Bones are made up of osteoid (hard or
compact), cartilaginous (tough, flexible), and fibrous (threadlike) tissue, as well as elements
ofbone marrow (soft, spongy tissue in the center of most bones).
Common types of primary bone cancer include the following:
o

Osteosarcoma, which arises from osteoid tissue in the bone. This tumor occurs
most often in the knee and upper arm (1).

Chondrosarcoma, which begins in cartilaginous tissue. Cartilage pads the ends of

bones and lines the joints. Chondrosarcoma occurs most often in
the pelvis (located between the hip bones), upper leg, and shoulder. Sometimes a
chondrosarcoma contains cancerous bone cells. In that case, doctors classify the
tumor as an osteosarcoma.

The Ewing Sarcoma Family of Tumors (ESFTs), which usually occur in bone but
may also arise in soft tissue (muscle, fat, fibrous tissue, blood vessels, or other
supporting tissue). Scientists think that ESFTs arise from elements of
primitive nerve tissue in the bone or soft tissue (2). ESFTs occur most commonly
along the backbone and pelvis and in the legs and arms (3).

Other types of cancer that arise in soft tissue are called soft tissue sarcomas. They are not
bone cancer and are not described in this resource.

3.

What are the possible causes of bone cancer?

Although bone cancer does not have a clearly defined cause, researchers have identified
several factors that increase the likelihood of developing these tumors. Osteosarcoma occurs
more frequently in people who have had high-dose external radiation therapy or treatment
with certain anticancer drugs; children seem to be particularly susceptible. A small number
of bone cancers are due to heredity. For example, children who have
had hereditary retinoblastoma (an uncommon cancer of the eye) are at a higher risk of
developing osteosarcoma, particularly if they are treated with radiation. Additionally, people
who have hereditary defects of bones and people with metal implants, which doctors
sometimes use to repair fractures, are more likely to develop osteosarcoma (4). Ewing
sarcoma is not strongly associated with any heredity cancersyndromes, congenital
childhood diseases, or previous radiation exposure (2).

4.

How often does bone cancer occur?

Primary bone cancer is rare. It accounts for much less than 1 percent of all cancers. About
2,300 new cases of primary bone cancer are diagnosed in the United States each year (5).
Different types of bone cancer are more likely to occur in certain populations:
o

Osteosarcoma occurs most commonly between ages 10 and 19. However, people
over age 40 who have other conditions, such as Paget disease (a benign condition
characterized by abnormal development of new bone cells), are at increased risk
of developing this cancer.

Chondrosarcoma occurs mainly in older adults (over age 40). The risk increases
with advancing age. This disease rarely occurs in children and adolescents.

5.

ESFTs occur most often in children and adolescents under 19 years of age. Boys
are affected more often than girls. These tumors are extremely rare in African
American children.

What are the symptoms of bone cancer?

Pain is the most common symptom of bone cancer, but not all bone cancers cause pain (1).
Persistent or unusual pain or swelling in or near a bone can be caused by cancer or by other
conditions. It is important to see a doctor to determine the cause.

6.

How is bone cancer diagnosed?

To help diagnose bone cancer, the doctor asks about the patients personal and family
medical history. The doctor also performs a physical examination and may order laboratory
and otherdiagnostic tests. These tests may include the following (1):
o

X-rays, which can show the location, size, and shape of a bone tumor. If x-rays
suggest that an abnormal area may be cancer, the doctor is likely to recommend
special imagingtests. Even if x-rays suggest that an abnormal area is benign, the
doctor may want to do further tests, especially if the patient is experiencing
unusual or persistent pain.

A bone scan, which is a test in which a small amount

of radioactive material isinjected into a blood vessel and travels through
the bloodstream; it then collects in the bones and is detected by
a scanner.

A computed tomography (CT or CAT) scan, which is a series of

detailed pictures of areas inside the body, taken from different angles,
that are created by a computer linked to an x-ray machine.

A magnetic resonance imaging (MRI) procedure, which uses a

powerful magnet linked to a computer to create detailed pictures of areas
inside the body without using x-rays.

A positron emission tomography (PET) scan, in which a small amount

of radioactive glucose (sugar) is injected into a vein, and a scanner is
used to make detailed, computerized pictures of areas inside the body
where the glucose is used. Because cancer cells often use more glucose
than normal cells, the pictures can be used to find cancer cells in the
body.

7.

An angiogram, which is an x-ray of blood vessels.

Biopsy (removal of a tissue sample from the bone tumor) to

determine whether cancer is present. The surgeon may perform a
needle biopsy or an incisional biopsy. During aneedle biopsy, the
surgeon makes a small hole in the bone and removes a sample of
tissue from the tumor with a needle-like instrument. In an incisional
biopsy, the surgeon cuts into the tumor and removes a sample of
tissue. Biopsies are best done by an orthopedic oncologist (a doctor
experienced in the treatment of bone cancer) (1). Apathologist (a
doctor who identifies disease by studying cells and tissues under a
microscope) examines the tissue to determine whether it is cancerous.

Blood tests to determine the level of an enzyme called alkaline

phosphatase. A large amount of this enzyme is present in the blood
when the cells that form bone tissue are very activewhen children
are growing, when a broken bone is mending, or when a disease or
tumor causes production of abnormal bone tissue. Because high levels
of alkaline phosphatase are normal in growing children and
adolescents, this test is not a completely reliable indicator of bone
cancer (1, 6).

What are the treatment options for bone cancer?

Treatment options depend on the type, size, location, and stage of the cancer, as well as the
persons age and general health. Treatment options for bone cancer include
surgery,chemotherapy, radiation therapy, and cryosurgery.
o

Surgery is the usual treatment for bone cancer. The surgeon removes the entire
tumor with negative margins (no cancer cells are found at the edge or border of
the tissue removed during surgery). The surgeon may also use special surgical
techniques to minimize the amount of healthy tissue removed with the tumor.

Dramatic improvements in surgical techniques and preoperative tumor treatment have

made it possible for most patients with bone cancer in an arm or leg to avoid radical
surgical procedures (removal of the entire limb). However, most patients who undergo
limb-sparing surgery need reconstructive surgery to maximize limb function (1).
o

Chemotherapy is the use of anticancer drugs to kill cancer cells. Patients who
have bone cancer usually receive a combination of anticancer drugs. However,
chemotherapy is not currently used to treat chondrosarcoma (1).

Radiation therapy, also called radiotherapy, involves the use of high-energy xrays to kill cancer cells. This treatment may be used in combination with surgery.
It is often used to treat chondrosarcoma, which cannot be treated with

chemotherapy, as well as ESFTs (1). It may also be used for patients who refuse
surgery.
o

8.

Cryosurgery is the use of liquid nitrogen to freeze and kill cancer cells. This
technique can sometimes be used instead of conventional surgery to destroy the
tumor (1).

Is follow-up treatment necessary? What does it involve?

Yes. Bone cancer sometimes metastasizes, particularly to the lungs, or can recur (come
back), either at the same location or in other bones in the body (1). People who have had
bone cancer should see their doctor regularly and should report any unusual symptoms right
away. Follow-up varies for different types and stages of bone cancer. Generally, patients are
checked frequently by their doctor and have regular blood tests and x-rays. People who
have had bone cancer, particularly children and adolescents, have an increased likelihood of
developing another type of cancer, such as leukemia, later in life. Regular follow-up care
ensures that changes in health are discussed and that problems are treated as soon as
possible.

9.

Are clinical trials (research studies) available for people with bone cancer?
Yes. Participation in clinical trials is an important treatment option for many people with
bone cancer. To develop new treatments and better ways to use current treatments, NCI, a
part of the National Institutes of Health, is sponsoring clinical trials in many hospitals and
cancer centers around the country. Clinical trials are a critical step in the development of
new methods of treatment. Before any new treatment can be recommended for general use,
doctors conduct clinical trials to find out whether the treatment is safe for patients and
effective against the disease.
People interested in taking part in a clinical trial should talk with their doctor. Information
about clinical trials is available from NCIs Cancer Information Service (CIS) at 18004
CANCER (18004226237) and in the NCI booklet Taking Part in Cancer Treatment
Research Studies. This booklet describes how research studies are carried out and explains
their possible benefits and risks. More information about clinical trials is available on
NCIs Clinical Trials page, which offers detailed information about specific ongoing studies
by linking to PDQ, NCIs comprehensive cancer information database. The CIS also
provides information from PDQ.

Selected References
1. Malawer MM, Helman LJ, O'Sullivan B. Sarcomas of bone. In: DeVita VT,
Hellman S, Rosenberg SA, editors. Cancer: Principles and Practice of
Oncology. Vol. 2. 7th ed. Philadelphia: Lippincott Williams and Wilkins, 2004.

2. Pizzo P, Poplack DG, editors. Principles and Practice of Pediatric Oncology. 4th
ed. Philadelphia: Lippincott Williams and Wilkins, 2002.
3. Ries LAG, Smith MA, Gurney JG, et al., editors. Cancer Incidence and Survival
among Children and Adolescents: United States SEER Program 1975-1999.
Bethesda, MD: National Cancer Institute, 1999.
4. Miller RW, Boice JD, Curtis RE. Bone cancer. In: Schottenfeld D, Fraumeni JF,
editors. Cancer Epidemiology and Prevention. 2nd ed. New York: Oxford
University Press, 1996.
5. American Cancer Society (2008). Cancer Facts and Figures 2008
GA: American Cancer Society. Retrieved March 13, 2008.

. Atlanta,

6. Fischbach FT, Dunning MB. A Manual of Laboratory and Diagnostic Tests. 7th
ed. Philadelphia: Lippincott Williams and Wilkins, 2004.

Related Resources

Chemotherapy and You: Support for People With Cancer

Cryosurgery in Cancer Treatment: Questions and Answers

Follow-up Care After Cancer Treatment

Metastatic Cancer

Radiation Therapy and You: Support for People With Cancer

Taking Part in Cancer Treatment Research Studies

Bone Cancer

Clinical Trials Home Page

Reviewed: March 13, 2008

What is bone cancer?

Normal bone tissue
Bone is the supporting framework of your body. Most bones are hollow. The outer part of bones is a
network of fibrous tissue called matrix onto which calcium salts are laid down.

The hard outer layer of bones is made of compact (cortical) bone, which covers the lighter spongy
(trabecular) bone inside. The outside of the bone is covered with a layer of fibrous tissue
called periosteum. Some bones are hollow and have a space called the medullary cavity which contains
the soft tissue called bone marrow (discussed below). The tissue lining the medullary cavity is
called endosteum. At each end of the bone is a zone of a softer form of bone-like tissue called cartilage.
Cartilage is softer than bone but more firm than most tissues. It is made of a fibrous tissue matrix mixed
with a gel-like substance that does not contain much calcium.
Most bones start out as cartilage. The body then lays calcium down onto the cartilage to form bone. After
the bone is formed, some cartilage may remain at the ends to act as a cushion between bones. This
cartilage, along with ligaments and some other tissues connect bones to form a joint. In adults, cartilage is
mainly found at the end of some bones as part of a joint. It is also seen at the place in the chest where the
ribs meet the sternum (breastbone) and in parts of the face. The trachea (windpipe), larynx (voice box),
and the outer part of the ear are other structures that contain cartilage.

Bone itself is very hard and strong. Some bone is able to support as much as 12,000 pounds per square
inch. It takes as much as 1,200 to 1,800 pounds of pressure to break the femur (thigh bone). The bone
itself contains 2 kinds of cells. The osteoblast is the cell that lays down new bone, and the osteoclast is
the cell that dissolves old bone. Bone often looks as if it doesnt change much, but the truth is that it is
very active. Throughout our bodies, new bone is always forming while old bone is dissolving.
In some bones the marrow is only fatty tissue. The marrow in other bones is a mixture of fat cells and
blood-forming cells. The blood-forming cells produce red blood cells, white blood cells, and blood
platelets. Other cells in the marrow include plasma cells, fibroblasts, and reticuloendothelial cells.
Cells from any of these tissues can develop into a cancer.

Types of bone tumors

Most of the time when someone with cancer is told they have cancer in the bones, the doctor is talking
about a cancer that has spread to the bones from somewhere else. This is called metastatic cancer. It can
be seen in many different types of advanced cancer, like breast cancer, prostate cancer, and lung cancer.
When these cancers in the bone are looked at under a microscope, they look like the tissue they came
from. For example, if someone has lung cancer that has spread to bone, the cells of the cancer in the
bone still look and act like lung cancer cells. They do not look or act like bone cancer cells, even though
they are in the bones. Since these cancer cells still act like lung cancer cells, they still need to be treated
with drugs that are used for lung cancer.
For more information about metastatic bone cancer, please see our document called Bone Metastasis, as
well as the document on the specific place the cancer started (Breast Cancer, Lung Cancer, Prostate
Cancer, etc.).
Other kinds of cancers that are sometimes called bone cancers start in the blood forming cells of the
bone marrow not in the bone itself. The most common cancer that starts in the bone marrow and
causes bone tumors is calledmultiple myeloma. Another cancer that starts in the bone marrow
is leukemia, but it is generally considered a blood cancer rather than a bone cancer. Sometimes
lymphomas, which more often start in lymph nodes, can start in bone marrow. Multiple myeloma,
lymphoma, and leukemia are not discussed in this document. For more information on these cancers,
refer to the individual document for each.
A primary bone tumor starts in the bone itself. True (or primary) bone cancers are called sarcomas.
Sarcomas are cancers that start in bone, muscle, fibrous tissue, blood vessels, fat tissue, as well as some
other tissues. They can develop anywhere in the body.
There are several different types of bone tumors. Their names are based on the area of bone or
surrounding tissue that is affected and the kind of cells forming the tumor. Some primary bone tumors
are benign (not cancerous), and others are malignant (cancerous). Most bone cancers are sarcomas.

Benign bone tumors

Benign tumors do not spread to other tissues and organs and so are not usually life threatening. They are
generally cured by surgery. Types of benign bone tumors include:

Osteoid osteoma (OS-tee-oyd OS-tee-oh-ma)

Osteoblastoma (OS-tee-oh-blas-TOE-muh)
Osteochondroma (OS-tee-oh-kon-DROH-muh)
Enchondroma (en-kon-DROH-muh)
Chondromyxoid (kon-dro-MIX-oyd) fibroma.

These benign tumors are not discussed further in this document, which is limited to bone
cancers.

Malignant bone tumors

Osteosarcoma: Osteosarcoma (also called osteogenic sarcoma) is the most common primary bone
cancer. This cancer starts in the bone cells. It most often occurs in young people between the ages of 10
and 30, but about 10% of osteosarcoma cases develop in people in their 60s and 70s. It is rare in middleaged people, and is more common in males than females. These tumors develop most often in bones of
the arms, legs, or pelvis. This cancer is not discussed in detail in this document, but is covered in our
document called Osteosarcoma.
Chondrosarcoma: Chondrosarcoma (KON-droh-sar-KOH-muh) is a cancer of cartilage cells. It is the
second most common primary bone cancer. This cancer is rare in people younger than 20. After age 20,
the risk of getting a chondrosarcoma goes up until about age 75. Women get this cancer as often as men.
Chondrosarcomas can develop anywhere there is cartilage. Most develop in bones such as the pelvis, leg
bone or arm bone. Occasionally, chondrosarcoma will develop in the trachea, larynx, and chest wall.
Other sites are the scapula (shoulder blade), ribs, or skull.
Benign (non-cancerous) tumors of cartilage are more common than malignant ones. These are
called enchondromas. Another type of benign tumor that has cartilage is a bony projection capped by
cartilage called an osteochondroma. These benign tumors rarely turn into cancer. There is a slightly
higher chance of cancer developing in people who have many of these tumors, but this is still not
common.
Chondrosarcomas are classified by grade, which measures how fast they grow. The grade is assigned by
the pathologist (a doctor specially trained to examine and diagnose tissue samples under a microscope).
The lower the grade, the slower the cancer grows. When a cancer is slow growing, the chance that it will
spread is lower and so the outlook is better. Most chondrosarcomas are either low grade (grade I) or
intermediate grade (grade II). High-grade (grade III) chondrosarcomas, which are the most likely to
spread, are less common.

Some chondrosarcomas have distinctive features under a microscope. These variants of

chondrosarcoma can have a different prognosis (outlook) than usual chondrosarcomas.

Dedifferentiated (DEE- dih-feh-REN-shee-AY-ted) chondrosarcomas start out as typical

chondrosarcomas but then some parts of the tumor change into cells like those of a high-grade
sarcoma (such as high grade forms of malignant fibrous histiocytoma [HIS-tee-oh-sy-TOH-muh],
osteosarcoma, or fibrosarcoma). This variant of chondrosarcoma tends to occur in older patients
and is more aggressive than usual chondrosarcomas.
Clear cell chondrosarcomas are rare and grow slowly. They rarely spread to other parts of the

body unless they have already come back several times in the original location.
Mesenchymal (meh-ZEN-kih-mul) chondrosarcomas can grow rapidly, but like Ewing tumor, are
sensitive to treatment with radiation and chemotherapy.

Ewing tumor: Ewing tumor is the third most common primary bone cancer, and the second most
common in children, adolescents, and young adults. This cancer (also called Ewing sarcoma) is named
after the doctor who first described it in 1921, Dr. James Ewing. Most Ewing tumors develop in bones, but
they can start in other tissues and organs. The most common sites for this cancer are the pelvis, the
chest wall (such as the ribs or shoulder blades), and the long bones of the legs or arms. This cancer is
most common in children and teenagers and is rare in adults older than 30. Ewing tumors occur most
often in white people and are very rare among African Americans and Asian Americans. More detailed
information about this cancer can be found in our document called Ewing Family of Tumors.
Malignant fibrous histiocytoma: Malignant fibrous histiocytoma (MFH) more often starts in soft tissue
(connective tissues such as ligaments, tendons, fat, and muscle) than in bones. This cancer is also
known as pleomorphic undifferentiated sarcoma, especially when it starts in soft tissues. When MFH
occurs in bones, it usually affects the legs (often around the knees) or arms. This cancer most often
occurs in elderly and middle-aged adults and is rare among children. MFH mostly tends to grow locally,
but it can spread to distant sites, like the lungs.
Fibrosarcoma: This is another type of cancer that develops more often in soft tissues than it does in
bones. Fibrosarcoma usually occurs in elderly and middle-aged adults. Bones in the legs, arms, and jaw
are most often affected.
Giant cell tumor of bone: This type of primary bone tumor has benign and malignant forms. The benign
(non-cancerous) form is most common. Giant cell bone tumors typically affect the leg (usually near the
knees) or arm bones of young and middle-aged adults. They dont often spread to distant sites, but tend
to come back where they started after surgery (this is called local recurrence). This can happen several
times. With each recurrence, the tumor becomes more likely to spread to other parts of the body. Rarely,
a malignant giant cell bone tumor spreads to other parts of the body without first recurring locally.
Chordoma: This primary tumor of bone usually occurs in the base of the skull and bones of the spine. It
develops most often in adults older than 30, and is about twice as common in men as in women.
Chordomas tend to grow slowly and often do not spread to other parts of the body, but they often come

back in the same area if they are not removed completely. The lymph nodes, the lungs, and the liver are
the most common areas for secondary tumor spread.

Other cancers that develop in bones

Non-Hodgkin lymphomas
Non-Hodgkin lymphoma generally develops in lymph nodes but sometimes starts in the bone. Primary
non-Hodgkin lymphoma of the bone is often a widespread disease because multiple sites in the body are
usually involved. The outlook is similar to other non-Hodgkin lymphomas of the same subtype and stage.
Primary lymphoma of the bone is given the same treatment as lymphomas that start in lymph nodes it is
not treated like a primary bone sarcoma. For more information see our document Non-Hodgkin
Lymphoma.

Multiple myelomas
Multiple myeloma almost always develops in bones, but doctors do not consider it a primary bone cancer
because it develops from the plasma cells of the bone marrow (the soft inner part of some bones).
Although it causes bone destruction, it is no more a bone cancer than is leukemia. It is treated as a
widespread disease. At times, myeloma can be first found as a single tumor (called a plasmacytoma) in a
single bone, but most of the time it will spread to the marrow of other bones. For more information see our
document Multiple Myeloma.

Last Medical Review: 03/21/2014

Last Revised: 02/25/2015